Every finding on record at Axiom Healthcare of Rosiclare

Based on observation, interview, and record review, the facility failed to establish and maintain effective infection prevention while performing perineum care for 1 of 3 residents (R2) reviewed for infection control in sample of 5. Findings include: R2's admission record documents an admission date of 12/9/2025 and includes diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Hyperlipidemia, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Hydronephrosis with Renal and Ureteral Calculous Obstruction, and Obstructive and Reflux Uropathy and Dysphagia.R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 12 suggesting moderate cognition impairment. Section H (Bowel and Bladder) documents R2 is frequently incontinent and occasionally incontinent of bowel. Section GG (functional abilities) documents R2 is dependent for toileting hygiene, personal hygiene, and requires substantial/maximal assistance with toilet transfers.R2's care plan documented R2 has renal insufficiency related to stage 3 chronic kidney disease. R2 had a cerebral vascular accident CVA/Stoke) affecting left dominant side. Intervention includes monitor/document bladder and bowel function. If incontinent monitoring/document for appropriate bowel and bladder training program implement.R2's Physician Orders dated July 2026 documents Macrodantin, Macrocrystal oral capsule 100mg. Give 100mg by mouth one time a day for abnormal urinalysis with start date of 7/20/2026 and stop date of 7/23/2026. On 7/23/2026 Macrocrystal oral capsule 100mg, give 100mg by mouth twice a day for abnormal urinalysis for 1 week with start date of 7/23/2026. R2's Medication Administration Record dated July 2026 documents the last date of Macrodantin was administered at 8:00AM on 7/30/2026.Document titled Local Laboratory dated 7/22/2026 urinalysis resulted with greater than 100,00 CFU/ml of Eschierichia Coli and greater than 100.00 CFU/ml of Psuedomonas aeruginosa.On 8/2/2026 at 10:05PM observation was made of signage outside of R2's room for contact isolation. V11 was present and stated R2 is on isolation due to recent urinary tract infection. V11 stated R2 had completed the treatment for the urinalysis but continued isolation until repeat urinalysis resulted. Proper Person Protective Equipment (PPE) was present.On 8/2/2026 at 10:10PM, V11 (Assistant Director of Nursing/ADON), V12 (Certified Nurse Assistant /CNA) and V13 CNA entered R2's room to provide peri care to R2. Proper PPE was donned by all staff that entered the room. From standing at the foot of the bed, V12 was on the right side of R2's bed and V13 was noted to be on the left side of R2's bed. V11 was standing at the foot of the bed. V12 had a basin on the bedside table with a towel in the base of the basin and disposable peri wipes stacked on top of the towel. V12 stated the peri wipes had peri wash on them. There were also gloves and another towel noted on the table. V12 and V13 donned gloves and pulled R2's covers back and removed R2's depends. V12 then reached into the basin and pulled out a peri wipe and with his right hand, he cleaned the left side of R2's peri area while holding onto R2's left leg with his left hand. V12 then threw that wipe in a trash bag and then V12 reached back in the basin and grabbed another clean wipe and wiped the left side of the labia. V12 then turned and threw that wipe away and reached back in the clean basin and removed another wipe. Up to that time there had been no glove changes. At this point V12 wanted to start the peri care over so V11 went outside the room and brought back new disposable peri wipes. V11 had on gloves and placed the peri wipes in the basin. V12 then reached in with clean gloves and grabbed the peri wipes and laid them down on the bedside table without a barrier. V12 then picked up the wipes and handed them to V13 to hold. V12 then grabbed a clean peri wipe off of V13's hand and began washing the left side peri area of R2. V12 then grabbed another peri wipe out of V13's hand and cleaned the left side of labia. V13 told V12 at this time to change his gloves. V12 changed his gloves and finished peri care with proper glove changes. V12 was asked if the initial demonstration of peri care was the way he always does peri care and V12 stated yes. V12 was asked if he has received education on peri care and hand hygiene and V12 stated yes. The demonstration was witnessed by V11. On 8/2/2026 at 11:05AM, V11 presented a document title Incident Investigation Form dated 7/21/2026 at 8:10AM. Person being interviewed is V12 CNA, location ADON office and type is marked as other. Describe documents: Concerns reported from midnight nurse V14 Licensed Practical Nurse (LPN) regarding V12 CNA not using gloves and providing care to residents. V12 denies not using gloves while providing hands on care/peri care. V12 was educated on proper glove use and hygiene at this time. V12 stated understanding and assured V11 and V2 (Director of Nursing) that proper protocol would be followed. Document signed by V11 and V12. V11 stated observations and training on Infection control would be initiated for V12 immediately.On 8/2/2026 at 11:00AM, R2 stated she has always had urinary tract infections because she has a lot of issues with her kidneys. R2 stated it has been this way for a long time. R2 was asked if staff wear and change gloves during incontinence care and R2 stated I see them with gloves but I am not sure about anything else I don't watch.Policy titled Infection Prevention and Control Program dated 12-5-2024 document under purpose, to comply with a system for preventing, identifying, reporting, investigating and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Under the heading of Guidelines, # 15 documents, all facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. Employees disregarding the facility's policies and procedures shall be retrained as necessary, disciplined, and may be discharged for repeated non-compliance.

Based on interview and record review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. The failure has the potential to affect all 29 residents residing in the facility. Findings include:On 7/8/2026 at 8:22AM, V10 (Certified Nurse Assistant/CNA) stated there is usually always 3 CNAs on the dayshift and she feels like with 3 CNAs the residents get good care, and showers can get done as scheduled. V10 was asked if she was working on 6/28/2026. V10 stated she came in at 6:00AM on 6/28/2026 and there were only 2 CNAs scheduled for that shift, so the night shift CNA had to stay over 4 hours because he was the dot for that day. The dot means if there is not enough staff for on oncoming shift then the person with the dot by their name must stay over. V10 stated so from 6:00AM-7:00AM there were 3 CNAs until the other dayshift CNA (V8) started vomiting and was sick, so she had to go home. V10 stated the nightshift CNA that had to stay over had to leave at 10:00AM because he had already worked 12 hours before staying over. V10 stated so between 10AM and 1:00PM she was the only CNA working on the floor. V10 stated the lunch meal was a little tough but the nurses helped feed and pass trays. V10 stated the nurses tried to help as much as they could but they had their own jobs to do as well. V10 stated she knows the nurses helped give a few showers. V10 was asked if any showers were missed due to low staffing and V10 stated yes I know there were some missed, and I know for sure 2 residents did not get their showers and there may have been more. V10 was asked if she felt like resident care was affected by the low staffing and V10 stated yes it was but I did the best I could do. V10 stated I know the DON (Director of Nursing) was notified but she never came in to help. V10 stated it was the first and only time that I have ever been the only CNA on the floor. On 7/8/2026 at 2:56PM, V8 (CNA) stated she was scheduled for dayshift on 6/28/2026. V8 stated she came in sick, and she vomited at the nurse's station, and the nurses sent her home. V8 stated that at the time she left there were 2 CNAs left on the floor and one of those had stayed over from the night shift. V8 stated she left at 7:00AM. V8 stated we normally have 3 CNAs on dayshift and with 3 CNAs we are able to provide good patient care and get all the showers completed. V8 stated some days are harder than others but we manage to get everything done.On 7/8/2026 at 12:01PM, V7 (Licensed Practical Nurse/LPN) stated she was working on 6/28/2026. V7 stated at 6AM there were 2 CNAs at the facility for dayshift. V7 stated V8 (CNA) became sick and started vomiting so V8 had to leave so this left 1 CNA for dayshift. V7 stated a nightshift CNA stayed over until 10AM to help on the floor. V7 stated from 10AM to shortly before 2PM there was only 1 CNA on the floor, but the nurses did try to help on the floor in between medication passes and other duties. V7 stated she was able to help with 3 showers on that day. V7 stated she and the other nurse also helped feed residents on that day. V7 stated that staffing is rough and when someone has to go home sick when you are already short is a problem. V7 stated she was texting V2 (DON) but V2 would not come in because she had plans for the day. V2 stated we did the best we could for the residents. On 7/7/2026 at 11:22AM R1 was observed sitting up in her wheelchair in her room. R1 was alert and oriented. R1 stated she feels like there are days when there are not enough staff. R1 stated she remembers a Sunday when there was only one CNA working for part of that day. R1 stated that 1 CNA was trying but there are just too many for one person. R1 stated she had an episode of incontinence because they just could not get to her in time. Call lights were going off for quite a while. Residents needing assistance were having to wait to include myself. R1 stated she had the night shift CNA who stayed over a little while, get her up that morning before he left. R1 stated even though when there are 3 CNAs it is sometimes 8:00AM before she is getting up out of bed. R1 stated her showers are supposed to be on Wednesdays and Saturdays and she did not get a shower either day last week but it is because they did not have time.On 7/9/2026 at 2:40PM reviewed R1's shower sheets and the electronic medical record documentation and documents show R1 received showers twice a week from 6/1/2026- 7/1/2026. R1 was scheduled for a shower on 7/8/2026 but decided to wait until 7/9/2026 because it was storming per interview with R1 on 7/8/2026 at 2:50PM.On 7/7/2026 at 11:38AM, R2 who was alert and oriented stated she is not happy with her care. R2 stated she does not get showers like she is supposed to. R2 stated her dirty clothes had been lying on the other bed for over a week. R2 stated they do not have enough staff, and it takes a long time for the staff to answer call lights. R2 was asked if there has ever been a time when staffing was low and she felt like she didn't get the help she needed. R2 stated, yes there was one day recently that there was not hardly any staff here and we did not get the help we needed. The staff that were here were trying but there was just not enough help. R2 could not recall the exact day. R2 stated she does require assistance with showers and sometimes with cleaning herself after using the bathroom. On 7/7/2026 at 11:47AM, R3 who was alert and oriented, stated quiet often they only have 2 CNAs on dayshift and 2 CNAs on evenings and nights. R3 stated there are usually 2 nurses on days, 1 nurse on evenings, and 1 nurse on night shift. R3 stated she knows that recently there was a day that there was only one CNA and at least the night shift stayed until around 10AM and then someone else came in before 2:00PM. R3 stated she could hear call lights going off for a while waiting for help that day. R3 stated she is dependent on staff to turn and reposition her and she does not get turned or checked on every 2 hours. R3 stated she may get turned once during the evening shift. R3 stated she has never been turned every 2 hours on any shift. R3 stated she is paralyzed from the waist down and she can't use her hands and arms to help because they have very little use. On 7/7/2026 at 1:02PM, V12 (Assistant Director of Nursing/MDS Coordinator) stated she was unsure of who the manager on duty was for 6/28/2026. V12 was shown the manager on duty schedule that was provided, and it documented V12 was manager on duty on 6/28/26. V12 stated she was unable to do that shift because of family plans. V12 stated she was not sure who actually took her spot on 6/28/2026. V12 was asked who was on call for nursing for 6/28/2026. V12 stated we are all basically on call all the time and this included V2 (Director of Nursing). V12 stated she was notified by the facility that staffing was low so she tried to call people in to work without success and she was unable to come in due to family plans. V12 stated she does know that the nurses were trying to help. V12 was asked if one or two CNAS on the dayshift was acceptable, V12 stated no and we normally always run 3 CNAs on the dayshift. On 7/7/2026 at 1:08PM, V2 (DON) stated she was made aware of the staffing circumstances that occurred on 6/28/2026. V2 stated she was made aware but she was unable to come to the facility and help because she had made arrangements with her family. V2 stated she knew V6 (CNA) did come in to help at some point. V2 was asked if she felt like 1 CNA and 2 nurses could provide the care the residents need. V2 stated they did work together but there should always be 3 CNAs on the dayshift. V2 stated 1 CNA is not enough to provide care for the residents. On 7/8/2026 at 3:00PM, V1 (Administrator) stated she was not made aware of the staffing issues on 6/28/2026 until later in the morning and she immediately started calling staff and had a CNA to come to the building as soon as possible which that CNA got to the building around 1:00PM. V1 stated this was not a good situation and she has already put corrective measures in place and the nurse managers that are on call will be expected to come to the facility and fill the void for nurse staffing until the issue is resolved. V1 stated they have the dot system in place and that helps cover so the residents' care is adequate, but there may need to be some changes to that system to have another back-up in place as well. V1 stated she has been at the facility for about 15 months, and she has never had this type of staffing issue, and it will not happen again because they will have staff back up in place.Certified Nursing Assistance (CNA) schedules for the period of 6/1/2026 through 7/9/2026 were reviewed. The schedule reflects 3 CNAs for day shift (6AM-2PM) scheduled regularly, 3 CNAs for evening shift (2PM-10PM) and 2 CNAs for night shift (10PM-2PM). The schedule does reflect that on 6/28/2026 there were only 2 CNAs scheduled for the dayshift with 1 open spot. V8 (CNA) was scheduled for 6AM-2PM but was marked as 6AM-7AM.Time sheets reviewed for 6/28/2026 document V8 had 1 hour worked and 7 hours sick. V9 (night shift CNA) worked until 10AM and V10 (CNA) worked 8.30 hours starting at 6:00AM. V6 (CNA) worked 1.3 hours starting at 12:45PM.Policy titled Nurse Staffing with no date documents, it is the policy of facility to provide sufficient licensed and unlicensed staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based on resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. Facility Census sheet dated 7/7/26 documents there are 29 residents living in the facility.

Based on interview, and record review the facility failed to ensure they used the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 29 residents living in the facility. Findings include:The 'Facility Assessment dated 9/16/2025 documents current census average of 31-36 residents. The assessment documents there are 3 wings all double occupancy. The staffing plan on this Facility Assessment documents Licensed Nurses providing direct care total number needed or average or range is 6AM-6PM 1RN and 1LPN or 2 LPNs, and 6PM-6AM 1 RN or LPN. On 7/7/2026 at 11:00AM, V1 (Administrator) was asked if the Director of Nursing is usually in the building 8 hours a day throughout the week. V1 stated well usually she is but sometimes she is weekend manager, so she is off a day through the week. V1 stated V2 does take vacation days sometimes and has most holidays off. Requested the working schedules for 6/1/2026-7/31/2026. Schedules presented.On 7/7/2026 at 1:08PM, V2 (Director of Nursing/DON) was asked if she understood the facility assessment and the need for 8 hours of RN coverage per day, V2 stated she understood some of it. V2 stated she does come in when she can if needed for coverage.On 7/1/2026 the schedule documents no RN scheduled. V2's payroll sheet documents a clock in at 9:18 ([NAME])-4:30PM. Only 6.75 hours of RN coverage.On 7/6/2026 the schedule documents no RN scheduled. V2's payroll sheet documents absent/holiday. Leaving the facility with 0 RN hours.Reviewed Nurses schedules dated 6/1/2026- 7/9/2026. The schedule documents the DON is scheduled Monday through Fridays 8:00AM-4:30PM.On 6/1/2026 the schedule documents there were not 8 consecutive hours of RN coverage. Only 7.5 hours of RN coverage. No RN scheduled and DON [NAME] at 8:36AM-4:30PM.On 6/9/2026 the schedule documents there were 0 RN hours. DON absent/vacation and no RN scheduled.On 6/19/2026 the schedule documents there were not 8 consecutive hours of RN coverage. Only 7.75 hours. No RN scheduled and DON clock in was 8:11AM ([NAME])- 4:30PM.Facility Census Sheet dated 7/7/26 documents there are 29 residents living in the facility.Policy titled Nurse Staffing with no date documents, it is the policy of facility to provide sufficient licensed and unlicensed staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based on resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health.

Based on interview and record review, the facility failed to staff a Director of Nursing (DON). The facility also failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 33 residents residing in the facility. The Findings Include:On 12/2/25 at 10:00 AM, V1 (Administrator) stated that they do not have a Director of Nursing at this time. V1 stated that the position is posted, and they are actively seeking qualified candidates. At this same time, V1 stated that they do not have a Registered Nurse (RN) on the schedule 7 days a week, 8 consecutive hours a day. Nursing schedules were reviewed from May 2025 through December 2025. There was no documentation of RN coverage on the following dates: May 2025: 3rd and 10thJune 2025: 3, 5, 7, 9, 13, 17,18, 28, 30 and 31stJuly 2025: 5thSeptember 2025: 1, 2, 8, 9, 17, 25, and 29thOctober 2025: 2, 9,10,11,15,17, 23, and 28thNovember 2025: 5, 22, and 27thDecember 2025: 3rdOn 12/2/25 at 3:00 PM, V1 stated that they do not have a policy on staffing, they just adhere/follow the regulations. On 12/5/25 at 10:00 AM, V1 stated that the previous DON's last day on the job was 11/6/25. The Long Term Care Facility Application for Medicare and Medicaid Services dated 12/2/25, documents 33 residents reside in the facility.

Based on observation, interview and record review the facility failed to follow the recipe for the scheduled menu item. This has the ability affect all 33 residents that reside in the facility. The Findings Include: On 12/3/25 the planned lunch menu was for a barbeque riblette, pasta salad and fruit cup. During the lunch observation on 12/3/25 it was observed that the residents receiving a regular diet received a barbeque riblette that did not have sauce on it and residents receiving mechanical soft diets received ground meat with a squirt/drizzle of ketchup on top. The recipe for the barbeque pork riblette is as follows: Ingredients: pork pattie, rib shaped boneless, 3 oz (ounces) frozen and sauce, barbeque. Instructions for cooking: 1. Place frozen riblettes on a sheet pan sprayed with nonstick cooking spray. 2. bake 15-18 minutes or according to package directions and until desired internal temperature is reached 3. Remove from oven and place riblettes in a steam table pans sprayed with nonstick cooking spray. Add barbeque sauce, cover, and bake until desired internal temperature is reached .The recipe for the barbeque pork riblette mechanical soft is as follows: .4. placed prepared riblettes in a washed and sanitized food processor. Pulse/grind to size and texture of ground beef 5. place in steam table pan and add barbeque sauce or prepared broth to keep moist . The recipe for the barbeque pork riblette pureed is as follows: Ingredients: barbeque riblette, water, chicken base. Method of preparation: dissolve chicken base in water to make chicken broth. Place prepared meat in a sanitized food processor. Gradually add broth, blend until smooth On 12/3/25 at 2:00 PM, V2 (Dietary Manager) stated that they did not have barbeque sauce available to cook the barbeque riblets in. V2 stated that on the mechanical soft diet trays they added some ketchup to the top of the meat and the pureed was a plain riblette that was pureed with the chicken broth. V2 stated that the riblette was barbeque flavored only and did not have any barbeque sauce as the recipe indicated. The Long term Care Facility Application for Medicare and Medicaid dated 12/2/25, documents 33 residents reside in the facility.

Based on observation, interview and record review the facility failed to prepare the mechanical soft diet per resident needs for 5 of 5 (R2, R15, R17, R22 and R25) residents reviewed for a mechanical soft diet, in a sample of 23. The Findings Include:On 12/3/25 at 12:15 PM, during a lunch observation it was noted that the barbeque riblets did not have barbeque sauce. During this time, it was observed that the mechanical soft meal trays had dry ground barbeque riblets with a small drizzle of ketchup on top.1. R2's admission profile sheet documents an admission date of 12/1/2020 and includes the following diagnosis: cerebral infarction, unspecified dementia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. A diet type report dated 12/3/25 provided by V1 (Administrator) documents that R2 is to receive a Mechanical soft/nectar thickened liquid diet with extra sauce/gravy.2. R15's admission profile sheet documents an admission date of 10/17/23 and includes the following diagnosis: dysphagia, mild intellectual disability, and mood disorder. The diet type report for R15 documents that he is to receive a No Added Salt diet with ground moist meat and thin liquids.3. R17's admission profile sheet documents an admission date of 7/21/12 and includes the following diagnoses: anxiety, depression, unspecified dementia and hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The diet type report documents that R17 is to receive a No Added Salt/Ground meat/thin liquid diet with minced and moist meats.4. R22's admission profile sheet documents an admission date of 1/11/2019 and includes the following diagnosis: unspecified dementia, epilepsy, and muscle wasting/atrophy. The diet type report documents that R22 is ordered a Controlled Carbohydrate Diet, mechanical soft with thin liquids. 5. R25's admission profile sheet documents an admission date of 8/16/19 and includes the following diagnosis: depression, anxiety, and dysphagia.The diet type report documents that R25 is to receive a regular mechanical soft diet with thin liquids. The ground barbeque pork riblette with sauce recipe is as follows:Ingredients: Pork pattie, rib shaped boneless, 3 oz (ounce) frz (frozen), Sauce, barbecue. The instructions for preparation .4. placed prepared riblettes in a washed and sanitized food processor. Pulse/grind to size and texture of ground beef 5. place in steam table pan and add barbeque sauce or prepared broth to keep moist . On 12/3/25 at 2:00 PM, V2 (Dietary Manager) stated that they did not have barbeque sauce available to cook the barbeque riblettes in. V2 stated that on the mechanical soft diet trays they added some ketchup to the top of the meat. On 12/4/25 at 2:30 PM, V4 (Speech Language Pathologist) stated on a phone interview that the mechanical soft diet meats need the gravy/sauce on top or mixed, rather than just dry minced meat to assure the resident is safe from aspiration while eating. V4 stated that the sauce/gravy will assist in safely chewing and swallowing the food. On 12/4/25 at 2:34 PM, V3 (Entree Representative) stated that the mechanical soft lunch meal on 12/3/25 was not prepared as it should have been per the recipe. V3 stated that the barbeque riblette meat for the mechanical soft diets was served too dry.

Based on observation, interview and record review, the facility failed to maintain a full time Director of Nursing and to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 34 residents living in the facility. Findings Include: The Long Term Care Facility Application For Medicare and Medicaid document dated 11/19/2024, documents 34 residents residing in the facility. The facility's nursing schedules document there was no RN on shift for coverage on the following dates: 9/3/2024, 9/7/2024, 9/21/2024, 9/25/2024, 9/26/2024, 9/30/2024, 10/5/2024, 10/9/2024, 10/10/2024, 10/14/2024, 10/15/2024, 10/19/2024, 10/21/2024, 10/22/2024, 10/23/2024, 10/28/2024, 10/29/2024, 11/6/2024, 11/13/2024,11/14/2024, 11/18/2024, 11/19/2024 and 11/21/2024. On 11/21/2024 at 10:45 AM, V1 (Administrator) and V3 (Regional Manager) both stated that the facility currently did not have the services of a Director of Nurses (DON) or a Registered Nurse (RN) eight hours a day, seven days a week. V2 and V3 stated the facility was actively in the process of trying to hire a full time RN. At this time, V1 stated that they had been without a DON since 4/29/2024. V1 further stated that they are really trying to recruit an RN to work here so they can accept more residents, but with the lack of coverage they are limited on what they can accept. On 11/20/2024 at 12:30 PM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated that there has not been a DON since she started working here in June of 2024. On 11/21/2024 at 2:00PM, V4 (Licensed Practical Nurse) stated that there are many days when no RN is on shift. V4 stated that currently they do not have any residents requiring treatments that only RN's can do, like IV (Intravenous) antibiotics. The Personnel Policy, dated September 2024, documents: To define basic staffing requirements and patterns for all facility personnel 1. The facility operates in compliance with applicable federal, state, and local laws, regulations and codes with accepted professional standards and principles that apply to professionals. Standards for individual positions may be found with the appropriate department staffing patterns in the departmental manuals

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R27) of 1 resident reviewed for PASRR Screening in the sample of 18. Findings Include: 1. R27's Admission Record documented an initial admitted to the facility of 1/23/23. The current admitted is listed as 05/10/2024 and included a diagnosis of psychotic disorder with delusions due to known physiological condition with onset date of 05/10/2024. R27's Notice of PASRR Level I Screen Outcome dated 5/7/24 documented a PASRR Level I Determination of No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability/RC (Related Condition). In the section titled Diagnoses under Mental Health Diagnoses this document noted No mental health diagnosis is known or suspected. Under the section titled Mental Health Medications it is noted that R27 was currently prescribed: Zyprexa pill, 2.5mg/day for a diagnosis of Altered Mental Status. Under the section titled Ascend Outcome it's documented No Level II Required - No SMI/ID/RC. Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an Intellectual/developmental disability or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. R27's Minimum Data Set, dated dated dated [DATE] in Section I - Active Diagnoses documented a diagnosis of psychotic disorder (other than schizophrenia). On 11/22/24 at 9:01 AM, V7 (Business Office Manager) stated she was responsible for ensuring residents' PASRR screenings were completed. V7 said R27's admission was prior to V7 being hired, and V7 was not sure why a PASRR Level II screening was not completed for R27. V7 said she would make a referral to have R27's PASRR Level II screening completed. On 11/22/24 at 10:44 AM, V1 (Administrator) acknowledged the error in the PASRR screening of R27 and stated R27 will be referred to have the Level II completed. V1 said she expected staff would follow the facility's PASRR policy. V1 said the facility would conduct an audit to ensure no other residents were also eligible to have a Level II screening. The facility's 11/13/18 Preadmission Screening and Annual Resident Review (PASARR) policy documented in part . Procedure . 1. Admission and Readmission . a. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder . intellectual disability . or related condition . b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will refer the potential admission to the State PASARR representative for the Level II screening process .

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 2 (R5, R24) of 5 residents reviewed for Gradual Dose Reductions (GDR) in a sample of 18. Findings Included: 1. R5's Admission Record documented an admitted [DATE] and included diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance, depression unspecified and anxiety. R5's current Medication Administration Record (MAR) for November 2024 documented R5 is prescribed the following psychotropic medications: Duloxetine 30mg (milligrams) take one capsule by mouth once daily at 8 AM, Alprazolam (sub for Xanax) .25mg tablet take 1/2 tablet (.125) by mouth twice daily at 8 AM and 5 PM, Risperidone .25mg tablet take 1 tablet by mouth twice daily at 8 AM and 5 PM, Trazodone 50mg tablet take 1/2 tablet (25mg) by mouth daily at 5 PM, and Zoloft (Sertraline) 25mg 1 tablet by mouth daily at 5 PM. A Pharmacy Consultation Report dated 4/29/2024 documented the following: Under Comment: R5 has received an antidepressant, sertraline 25 mg daily for management of depressive symptoms since 11/2023. Under Recommendation: documents, If this therapy is to continue at the current dosage, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., appetite changes, falls), and check DECLINE below .Alternatively, please attempt a gradual dose reduction (GDR) of sertraline to 25mg QOD (every other day) X (times) 2 weeks, then discontinue. Under Rationale for recommendation: documents Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated. This consultation report with pharmacist recommendations was signed by the Consultant Pharmacist on 4/29/24. Under the Physician's Response, V6 (Physician) checked the section that documented I decline the recommendation above because GDR is CLINICALLY CONRAINDICATED for this individual as indicated below. (NOTE: Please check option #1 or #2 AND provide patient specific rationale on the lines below). #1 is checked on this report, which documents Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition of psychiatric disorder AS DOCUMENTED BELOW. Under the section that states Please provide CMS (Centers for Medicare and Medicaid Services) REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, V6 left this section blank, with no patient specific rationale provided to explain why the recommendation for reduction was being declined. Additionally, V6 did not signed this 4/29/24 recommended consultation report until 7/11/24. On 11/21/2024 at 10:59 AM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated she had not been employed with the facility at the time of the 4/29/24 pharmacy consultation report for R5, and she was not aware of why the GDR form had not been followed up on prior to 7/11/2024 by V6 (Physician). 2. R24's Admission Record documented an admitted [DATE] and included diagnoses of unspecified dementia, unspecified severity, with other behavior disturbance, and depression. R24's current MAR for November 2024 documented R5 is prescribed Risperidone .25mg tablet, take one tablet twice daily (DX (diagnosis): Dementia w/ (with) behavioral disturbance). The most recent pharmacy Consultation Report provided by the facility was dated 8/07/2023 and documented the following: Under Comment: R24 receives Risperidone 0.25mg BID (twice per day) for expressions or indications of distress related to dementia (e.g., BPSD (behavioral and psychological symptoms of dementia), dementia with psychosis). Under Recommendation: documented Please attempt a gradual dose reduction (GDR) of Risperidone to 0.25mg HS (night) while concurrently monitoring for reemergence of symptoms and/or withdrawal symptoms. Under Rational for Recommendation documented CMS requires that antipsychotics, being used to treat expressions or indications of distress related to dementia be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated). Under Physician Response V6 (Physician) checked the box I accept the recommendation(s) above, please implement as written and signed the form on 8/9/23. There was no Pharmacy Consultation Report available or provided by the facility for August of 2024, when the next GDR would have been due. During the survey (11/19/24 - 11/22/24) however, the facility provided a Pharmacy Consultation Report dated 11/19/24, with a fax stamp showing the form was faxed to the provider/physician (V6) on 11/20/24. This Consultation Report documented the following recommendations from the pharmacist: Under Comment R24 receives Risperidone 0.25mg BID for expressions or indications of distress related to dementia with psychosis) since 8/17/23. According to the charting during this time period, she tolerated the medication reduction well. There are a couple notes of increased confusion, however she does have dementia and BIMS score was 4 on 9/20/23. She is also taking Mirtazapine 7.5mg HS for depression since 4/1/22. Under Recommendation documents Please attempt a gradual dose reduction (GDR) of Risperidone to 0.25mg daily. Under Rational for Recommendation: CMS requires that antipsychotics, being used to treat expressions or indications of distress related to dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated). This document was signed by the consultant pharmacist on 11/19/24, however the section for the physician to sign had not yet been completed. On 11/20/24 at 1:30 PM, V2 stated she received the GDR form for Risperidone 0.25mg on 11/19/2024 and faxed it to V6 (Physician) for review, acceptance, or declining recommendation. V2 stated, she does not know why she received this GDR form in November 2024 and not within the year time frame of August 2023 to August 2024. On 11/21/24 at 9:52 AM, V3 (Regional Consultant) stated the facility does not have a specific GDR policy. V3 stated, the facility follows the regulations for GDR of psychotropic medications. On 11/21/24 at 10:11 AM, V1 (Administrator) stated her expectations for GDR psychotropic medications would be to follow the facility policy and/or the regulation guidelines that document to attempt reductions within the specified timeframes. V1 stated, the previous owners of the facility did not have a GDR policy and she was unaware if the new owners have a policy. V1 stated, she understands that if a medication review is not completed within the timeframe guidelines, then the resident would not be free from unnecessary medication.

Based on observation, interview, and record review the facility failed to assist dependent residents with repositioning and incontinence care for 2 of 3 residents (R5 and R 15) reviewed for Activities of Daily Living (ADL's) in a sample of 18. The findings include: 1. R5's New Admission Information sheet in the medical record documents and admitted [DATE]. R5's Physician Order Sheet dated 9/1/2024, documents diagnoses including Physical Debilitation, Hypertension, Anxiety, Osteoarthritis, Psychosis, and Moderate to Severe Dementia. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 2, indicating R5 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R5 is totally dependent on staff for all functional abilities. Section H, Bladder and Bowel, documents R5 is always incontinent of bowel and bladder. R5's Care Plan documents a Focus area of the risk for alteration in skin integrity related to decreased mobility. Documents interventions, with revision date of 8/27/2024, include peri care and barrier cream as needed after incontinent episodes. The same Care Plan also documents a Focus area dated 5/16/2024 of R5 requiring staff assist with ADL's (Activity of Daily Living). Intervention dated 8/27/2024, assist with bed mobility. Focus dated 8/28/2024, documents R5 is incontinent of Bowel and Bladder. Documented interventions, dated 8/28/2024, include change every 2 hours and as needed per staff and clean peri area with each incontinence episode. On 9/26/2024 at 12:15 PM, upon entering the facility, R5 was observed sitting in the day area in a geriatric recliner, positioned on left hip with a pillow observed behind the right hip. From 12:30PM through 3:18PM R5 was observed to be remaining in the same position in the geriatric recliner, on the left hip with a pillow placed under the right hip. R5 remained in the same location in the day room area. On 9/26/2024 at 3:20PM, V2 (Licensed Practical Nurse/ Minimum Data Set Director) stated that R5 should be repositioned and have peri/incontinence care every 2 hours. V2 stated R5 had been in day room area since lunch. On 9/26/2024 at 3:30PM, V5 (Certified Nursing Assistant/CNA) was asked how often R5 should be checked and repositioned and V5 stated every 2 hours at least. V5 stated she works 2PM -10PM and she assumes R5 was checked and repositioned around 1:00PM. V5 stated R5 is always incontinent of bowel and bladder and is dependent on the staff for incontinence care and repositioning. V5 stated R5's skin always looks red. On 9/26/2024 at 3:30PM, V5 and V6 (CNAs) took R5 to her room per the geriatric recliner and transferred R5 to the bed with the mechanical lift. R5 was provided incontinence care with noted redness to peri area and thighs. A new disposable undergarment was placed on R5 and R5 was transferred back to the geriatric recliner with the mechanical lift. 2. R15's New Admission Information sheet in the medical record documents an admitted [DATE]. R15's Physicians Order Sheet dated 9/1/2024 documents diagnoses including Left Middle Cerebral Cardiovascular Accident, Right Sided Hemiparesis, Aphasia, Hypertension, and Depression. R15's MDS dated [DATE] documents a BIMS score of 1, indicating R15 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R15 requires substantial/maximal assistance for toileting and dressing and R15 requires partial/moderate assist for turning and repositioning and showers. Section H, Bladder and Bowel, documents R15 is always incontinent of bowel and bladder and is not on a toileting program. R15's Restorative Nursing Program Documentation documents that R15 is involved in a dressing program, transfer program, bed mobility program, and passive range of motion program. R15's Care Plan documents a Focus area, with a revision date 8/29/2024, of Bowel and Bladder incontinence. Documented interventions for this focus area, dated 8/29/2024, include check resident every 2 hours and assist with toileting as needed and provide peri care after each incontinence episode. R15's Care plan also documents a Focus area, with a revision date of 6/11/24, of alteration in skin integrity related to decreased mobility with documented interventions including staff assistance with peri care and toileting. On 9/26/2024 at 12:15 PM, upon entering the facility, R15 was observed sitting in the day area in a standard wheelchair. From 12:30PM through 3:18PM, R15 was observed to remained in the wheelchair with periods of leaning over and sleeping. Throughout this time, R15 remained in the same location in the day room area. On 9/26/2024 at 3:20PM, V2 (Licensed Practical Nurse /Minimum Data Set Director) stated R15 should be repositioned and have peri/incontinence care every 2 hours. V2 stated R15 had been in Day Room since lunch. On 9/26/2024 at 3:50PM, V5 (CNA) was asked how often R15 should be checked and repositioned. V5 stated every 2 hours at least. V5 stated she came in to work at 2 PM and she assumes R15 was checked and repositioned by the day shift on the 1:00PM rounds. V5 stated R15 is always incontinent of bowel and bladder and dependent on the staff for transfers and incontinence care. On 9/26/2024 at 3:50PM, R15 was taken to her room via wheelchair by V5. V5 transferred R15 using a gait belt. V5 provided incontinence care with urine noted to disposable undergarment. A new disposable undergarment was placed on R15 and R15 was left in bed to rest. The facility policy titled Preventative Skin Care, dated 1/18, documents It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to rid the facility of flies and roaches. This failure has the potential to affect all 40 residents currently residing at the facility. Findings Include: The facility Nurses Midnight Census report provided to this surveyor on 7/8/24 document 40 residents currently reside at the facility. On 7/8/24 at 10:32 AM, there was a live roach crawling under the three-compartment sink and in the dry food storage area. There were multiple flies seen in the food preparation area. V8 (Dietary Manager) stated the roaches are better now. V8 stated the exterminator came in and is due back anytime now. On 7/8/24 and 7/9/24 between 10:00 AM and 4:00 PM, each time this surveyor walked through the dining room there were multiple flies observed. The dining room was located between the room this surveyor was sitting in and the nurse's station, the resident rooms, and the administrator's office. This surveyor made multiple trips each day through the dining room area. On 7/8/24 at 11:05 AM, R11, an alert and oriented resident, observed lying in bed and stated they have flies like crazy. A single fly was observed flying around her head and over the bed table. R11 stated she hadn't seen as many roaches lately. On 7/9/24 at 10:49 AM, R8, an alert and oriented resident, stated he had seen roaches in his room, and he stomps them when he sees them. On 7/8/24 at 1:03 PM, V26 (Cook/Dietary Aid) stated the exterminator came in last month and it has knocked the population of roaches down significantly. When asked about the flies seen in the kitchen V26 stated they are waiting on fly traps. On 7/8/24 at 1:12 PM, V27 (Cook/Dietary Aid) stated they had been seeing some roaches and had been letting V4 (Maintenance Director) know, and he had been spraying. V27 stated she had been told they were waiting for fly traps for the flies they had. On 7/8/24 at 1:18 PM, V18 (Cook) stated they had seen roaches and had let V4 know, and he had sprayed. V18 stated he thought they were getting fly traps for the flies. On 7/9/24 at 3:26 PM, when asked what they had done about the roaches, V4 (Maintenance Director) stated they had gotten the pest control company back to the facility and were trying to be a little cleaner. When asked what a little cleaner meant, V4 stated they aren't leaving stuff laying around. V4 stated they also leave the light on in the kitchen at night. V4 stated they are trying to keep them knocked down the best they can until the exterminator can get them under control. On 7/9/24 at 3:46 PM, V1 (Administrator) stated the pest control company came in on 6/5/24 and should be coming back soon. V1 stated the June service was an extra visit and they are only coming once a month. V1 stated no one had called the pest control company to let them know they had seen more roaches because the company was aware they had an infestation. V1 stated they told them it would take 6 months to a year to eradicate them. When asked about the flies V1 stated, they are horrible. V1 stated they can't spray anything or have fly tape, so they are trying the little buckets of solution to try to attract them outside. The facility undated Insect and Pest Control Policy documents, It is the policy of (name of company) to contract with a duly licensed exterminating service to protect and/or control against infestations of insects and rodents. A preventative treatment, both interior and exterior, shall be applied at least monthly. Treatments will be applied more often if required. Chemical, materials and equipment used to control insects and rodents will be provided by the Vendor and will be in accordance with current Federal and State specifications for use in nursing homes. Methods of applications shall be in accordance with current Federal and State regulations and manufacturer's recommendations. Policy Interpretation and Implementation .4. Any employee observing insects or rodents shall inform their supervisor giving the exact location and type of infestation .6. The maintenance person shall contact the contracted pest control company for eradication.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and maintain floors, walls, and equipment in a safe and sanitary condition. This failure has the potential to affect all 40 residents residing in the facility. Findings Include: The facility Nurses Midnight Census provided to this surveyor on 6/3/24 documents 40 residents currently reside at the facility. On 6/3/24 at 11:16 AM, this surveyor opened the refrigerator door in the kitchen and observed fruit in individual bowls sitting on the shelf, uncovered and undated. On 6/3/24 at 11:20 AM, this surveyor showed V8 (Dietary Manager) the uncovered, undated fruit in the refrigerator and V8 told V6 (Cook) that all food should be covered and dated. On 6/3/24 at 11:20 AM, a roach crawled out from underneath the freezer and crawled towards this surveyor's feet. At that time V8 (Dietary Manager) stated they have been without pest control services. V8 stated she was aware of the roaches and there had been an uptick and them since they hadn't had pest control services. On 6/4/24 at 10:22 AM, this surveyor walked into the kitchen and observed a trash bag with what appeared to be dirty linens sitting on the floor by the door. The ice machine was sitting to the left and had scaly white and rust colored residue on the side, down the side, and on the front around the rim of the lid and on the inside of the lid. A soiled wet blanket was spread out in the middle of the floor between the ice machine and the dishwasher. V6 (Cook) stated the blanket was on the floor because the drain kept backing up and they had to order a new tool to snake the drain. The trays sitting on the dishwasher drain with clean silverware in it was covered with a black and scaly appearing residue. The kitchen floors were dirty, the walls behind and under the three-compartment sink and the stove was dirty with a greasy appearing residue. There was a black residue on the wall behind the dishwasher and garbage disposal that ran the length of the wall and was near the caulk above the sink. V8 (Dietary Manager) stated the black residue behind the sink/disposal area was a buildup of grease and stuff. V8 stated the residue on the food trays is calcium from the local water. V8 took her fingernail and scraped a layer of the residue off. V8 stated they run the trays through the dishwasher with bleach. V8 stated the ice machine has calcium build up on it also, from years of leaking and maintenance is responsible for cleaning it monthly. On 6/5/24 at 11:07 AM, V4 (Maintenance Director) stated he hadn't worked at the facility long so he hadn't cleaned the ice machine yet but will be cleaning it this month. V4 stated he was aware of the black substance behind the dishwasher/disposal. V4 stated he wasn't sure what it was, but he was planning to take the caulk out, clean it, and apply new caulk. On 6/5/24 at 11:08 AM, V18 (Laundry/Housekeeping/Dietary Aid) stated the black substance behind the dishwasher/disposal was gone. V18 stated he cleaned the area with bleach and a wire brush, and it took the substance off. V18 stated he cleaned under everything but hadn't had the opportunity to deep clean. V18 stated they hadn't done anything with the dish crates and thought they may have to power wash them to get the scaly substance off. On 6/3/24 at 3:17 PM, V1 (Administrator) stated they had not had pest control services since 12/2023. V1 stated at one point the company told them to purchase something at a local store, but she told them she didn't think that would work and she was concerned about using the chemicals. V1 stated the facility had not put anything in place to mitigate pests. On 6/5/24 at 1:32 PM, V1 (Administrator) stated pest control had been called and was supposed to be at the facility on 6/1/24 and 6/4/24 and hadn't come. V1 stated the pest control company was supposed to come again on 6/5/24. On 6/5/24 at 1:32 PM, V1 (Administrator) stated food in the refrigerator should be covered and dated. V1 stated daily cleaning may prevent some of the calcium build up. V1 stated pest control has been called and was supposed to be at the facility on 6/1/24 and didn't come. The facility policy Kitchen Sanitation dated 10/20 documents, Policy: It is the policy of (name of company) to comply with public health standards and local and state sanitation regulations. Procedure: 1. The Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. 2. The Dietary Sanitation QA (Quality Assurance) Review (see attached form) shall be used as a tool to monitor compliance with sanitation standards and identify which areas need corrective action. 3. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. 4. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment should be used for each task. 5. In-service training should be scheduled periodically to review sanitation standards. The facility policy Refrigerator and Freezer Storage dated 10/14 documents, It is the policy of (name of company that any item placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable food

Based on observation, interview, and record review the facility failed to implement interventions to prevent the development of new pressure ulcers for a resident at high risk and failed to timely identify a new pressure ulcer for 1 of 3 (R13) residents reviewed for pressure ulcers in the sample of 17. This failure resulted in R13 developing an unstageable pressure ulcer to her right heel. Findings Include: R13's New Admission Record undated, documented R13's initial admitted to the facility as 11/05/2014. R13's POS (Physician Order Sheet) dated 6/1/2024, documents diagnosis to include Dementia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Degenerative Joint Disease, Cyclic Neutropenia, and Depression. R13's POS includes orders for Skin Prep to Left Heel twice a day with order date of 4/25/2024, and float heels while in bed as tolerated with order date of 3/13/2024. R13's MDS (Minimum Data Set) dated 1/2/2024 includes a BIMS (Brief Interview for Mental Status) score of 00 indicating Severely Cognitively Impaired. The same MDS documented in section GG, R13 requires total dependence of staff for Activities of Daily Living. R13's Braden Scale for Predicting Pressure Ulcer Risk assessments dated 4/13/24 and 5/9/24 both document a total score of 14 indicating R13 is at a high-risk level for developing pressure ulcers. The section of Wound Review indicates R13 currently has an unresolved pressure ulcer. Under the section of Skin Treatment Review indicates mattress type is Foam, and heel protectors. R13's current Plan of Care documented a date of April 2024. Focus category of Skin Integrity with Focus Information of Potential for impaired skin integrity r/t (related to) dx (diagnoses): Diabetes Mellitus and decreased mobility. The section for Goal documents resident will be free of skin breakdown thru the next 90 days, goal start date is documented a 1/12/2015 with goal date documented as 7/24. Section of Plan of Care for Intervention/Task documents all interventions with start date of 1/12/2015. There were no interventions listed to float heels while in bed as tolerated. On 6/4/2024 at 10:05am, V13 (Licensed Practical Nurse/LPN) administered treatment to R13's Left Heel. V13's heels were both flat on the bed and were not floated off the bed at time of entering the room. R13's mattress was noted to be a standard mattress. V13 removed the sock to R13's left heel and applied skin prep, then placed the sock back on her left foot. V13 then stated, I always apply it to the right heel as well. V13 then removed the sock off R13's right foot and started applying skin prep to right heel and V13 stated, Oh wow look at this heel, it is really red, looks worse than the left heel. V13 then stated, I am not saying anymore. V13 then replaced the sock to the right foot, covered R13's feet back up, left R13's heels flat on the bed without floating the heels off the bed and left the room. On 6/4/2024 at 2:10pm, this surveyor observed V3 (MDS Coordinator/Infection Preventionist) assess R13's heels. Upon entering room R13's heels were not floated off the bed. V3 assessed R13's right heel and stated, this heel injury area is bigger than the one on the left heel. V3 stated this heel is very red and mushy. V3 stated these heels should be floated or have boots on them. V3 stated I will get treatment orders for the right heel and add the right heel to the weekly/monthly logs. On 6/5/2024 at 9:10am, observation was made of R13 in bed resting on her back with a pillow wedged under her thighs and both heels flat on the bed. On 6/5/2024 at 11:06am observation was made of R13 in bed resting on her back without the pillow under her thighs with both heels flat on the bed. On 6/5/2024 at 2:00pm R13 was resting in bed positioned on right side with pillow between knees and heels flat on the bed. R13's Monthly Wound Tracking Report dated 5/2024 documents R13 has a wound to left heel. This document includes a description of R13's wound to Left Heel as: Stage is Unstageable, Measurements are 0.2cm (centimeters) length, 0.2 cm width and 0 cm depth, no drainage, acquired in facility, and no odor. This same document does not include date of onset of wounds. R13's Monthly Wound Tracking Report does document a pressure ulcer to R13's right heel that is being assessed and tracked. On 6/4/2024 at 9:55am, V13 (LPN/Licensed Practical Nurse) provided R13's Facility Weekly Wound Tracking log which documents on Mondays for the month of May 2024, weekly descriptions of left heel wounds for R13. This record documents assessments of left heel on 5/6/2024 measuring 0.3cm length, 0.3 cm width, 0 cm depth, no odor, no drainage, pink in color, on 5/13/2024 measuring 0.2cm length, 0.2 cm width, 0 cm depth, no odor, no drainage, pink in color, on 5/20/2024 measuring 0.1cm length, 0.1cm width, 0 cm depth, no odor, no drainage, pink in color, on 5/27/2024 measuring 0.1cm length, 0.1cm width, 0 cm depth, no odor, no drainage, and pink in color. At that time V13 stated wound assessments were not done as of this time for this week, and they should have been done yesterday. There was no documentation on the log that R13 had a pressure ulcer to the right heel. On 6/4/2024 at 3:45pm, V3 (MDS Coordinator/Infection Preventionist) presented a copy of the Facility Weekly Wound Tracking log. The log documents R13 has Area #1 Left Heel with no documentation of assessment and Area # 2 Right Heel includes documentation of Date of Assess: 6/4/2024, Type: P (Pressure), Stage: U (Unstageable) Measurements: 3.3cm Long, 2cm Width, 0cm depth, Drainage: none, Odor: none, Wound color: red, Date of Onset: 6/4/2024, MD/Family notified marked Yes. On 6/5/2024 at 1:05pm, V12 (Certified Nurse Assistant/CNA) stated she takes care of R13. V12 stated we are supposed to keep her heels floating while in bed, she also has a boot to wear sometimes too. V12 stated I try to keep her on her side most of the time. V12 stated R13 is total care and is incontinent of bowel and bladder. V12 stated R13 doesn't communicate normally, and she must have assistance in turning and repositioning. On 6/5/2024 at 1:10pm, V10 (CNA) stated she provides care to R13. V10 stated R13 is totally dependent on staff for all needs. V10 stated I know we are to float her heels while she is in bed. V10 stated she had not noticed the area to her right heel before. V10 stated it has been a while since she gave R13 a shower. V10 stated if she would have noticed the area, she would have reported it to the nurse immediately. V10 stated R13 depends on the staff for proper turning and repositioning. V10 stated we are not assigned specific residents we work together. On 6/4/2024 at 10:55am, V1 (Administrator) stated the floor nurses do the monitoring of the wounds in the facility and the treatments. The floor nurses make sure the interventions are in place too. V1 then stated V3 is our MDS Coordinator and Infection Preventionist, she also keeps up with all the wounds and makes wound logs since we don't have a Director of Nurses. V1 stated she is the one that orders the specialized mattresses and the only specialized mattresses they use are the air loss mattresses. V1 stated the delivery time is very quickly and she has not had any issues with ordering. On 6/4/2024 at 1:50am, V3 stated my duties are MDS, Infection Preventionist and I make the wound logs but that is all I do with wounds, and I get the information from the floor nurses for the wound log. V3 stated the Director of Nurses (DON) always kept up with the wounds like assessing the wounds weekly, assuring the interventions are in place including prevention, assuring the treatments are getting done and the wounds are healing. V3 stated I am not doing all that a DON would do, I am only here on Mondays, Tuesdays, and Wednesday from 2pm to 10pm and I don't have time to do the wound stuff with doing MDS and Infection Preventionist. V3 stated the IDT (Interdisciplinary Team) decides the interventions. V3 explained she was aware that R13 was on a standard mattress and should be on a specialized air loss mattress. On 6/6/2024 at 10:03 am, V19 (Physician), stated he expected the facility to follow his orders for wound care and prevention such as floating the heels. V19 also stated he expects the facility to follow their policy and procedure for Wound Care and Prevention. V19 stated he was aware of the issues with R13's left heel. V19 was asked if he was aware of the unstageable right heel pressure and V19 stated I am going to call the facility and discuss treatments and the need for pressure relief for R13. V19 said there is a need for an air loss mattress for R13. R13's POS (Physician Order Sheet) dated 6/1/2024 documents on 6/4/24 there is a handwritten order to apply skin prep to right outer heel each shift and PRN (as needed). The facility document titled (Company name) Preventative Skin Care. Policy statement reads It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. The section of this document with subtitle of Equipment reads 1. Lotion, 2. Barrier Cream, 3. Special Mattresses (i.e., gel, foam, water, air, etc.), 4. Special chair cushion (i.e., gel, foam, air, etc.), 5. Pillows or positioning devices. The section of this document with subtitle of Procedure reads #6 Special mattresses and or chair cushions will be used on any resident identified as being high risk for potential skin breakdown.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program. This has the potential to affect all 40 residents residing at the facility. Findings Include: The facility Nurses Midnight Census provided to this surveyor on 6/3/24 documents 40 residents currently reside at the facility. On 6/3/24 at 11:20 AM, a roach crawled out from underneath the freezer and crawled towards this surveyor's feet. V8 (Dietary Manager) stated they have been without pest control services. V8 stated she was aware of the roaches and there had been an uptick in them since they hadn't had pest control services. On 6/3/24 at 11:46 AM, V4 (Maintenance Director) gave this surveyor a pest control summary dated 12/27/23. V4 stated that was the last report he had from a pest control company. V4 stated he was told the pest control company had been at the facility once since 12/2023 but he could not find any report documenting that. V4 stated he had worked at the facility about two weeks and had not had any reports of roaches in the kitchen. V4 stated he had been told he could call the pest control company and he called but they hadn't gotten back to him with a date of service. On 6/3/24 at 1:01 PM, V4 provided this surveyor with a pest control contract dated 10/2019. When asked why they hadn't had the pest control company in the facility since they had a contract, V4 stated he wasn't sure, but he thought it may be because of the company bankruptcy. V4 stated he was just given the ok to call the pest control company on 5/31/24. When asked if they were doing anything internally to mitigate the pests, V4 stated, I don't know. On 6/3/24 at 2:36 PM, R9 who was alert to person, place and time stated she had seen roaches and spiders in the facility. On 6/3/24 at 2:40 PM, R1 who was alert to person, place and time stated she had seen roaches, water bugs, and ants in the facility. On 6/4/24 at 11:58 AM, V17 (Family Member) was sitting at the dining room table with R12. This surveyor observed V17 swiping flies off R12's food. V17 stated there are a lot of flies. V17 stated they come in every time someone opens the door. V17 stated they need fly strips in the facility, but he doesn't think those are legal. On 6/4/24 at 1:56 PM, V10 (Certified Nursing Assistant/CNA) stated they have flies and roaches. V10 stated they use a fly swatter for the flies, and they have a roach man who comes in every so often and sprays. On 6/4/24 at 2:15 PM, V7 (CNA) stated they have flies and a few cock roaches here and there, but not like an infestation. On 6/4/24 at 2:23 PM, V15 (CNA) stated they have flies and a few roaches. On 6/3/24 at 3:17 PM, V1 (Administrator) stated they had not had pest control services since 12/2023. V1 stated at one point the company told them to purchase something at a local store, but she told them she didn't think that would work and she was concerned about using the chemicals. V1 stated the facility had not put anything in place to mitigate pests. On 6/5/24 at 1:32 PM, V1 (Administrator) stated pest control had been called and was supposed to be at the facility on 6/1/24 and 6/4/24 and hadn't come. V1 stated the pest control company was supposed to come again on 6/5/24. The facility undated Insect and Pest Control Policy documents, It is the policy of (name of company) to contract with a duly licensed exterminating service to protect and/or control against infestations of insects and rodents. A preventative treatment, both interior and exterior, shall be applied at least monthly. Treatments will be applied more often if required. Chemicals, materials and equipment used to control insects and rodents will be provided by the Vendor, and will be in accordance with current Federal and State specifications for use in nursing homes. Methods of applications shall be in accordance with current Federal and State regulations and manufacturer's recommendations.

Based on observation, interview, and record review the facility failed to ensure residents rights were protected when they failed to ensure their privacy by not providing a curtain or door to cover the commode stall area in the women's common area bathroom. This failure has the potential to affect 33 female residents currently residing at the facility. Findings Include: The facility Nurses Midnight Census report provided to this surveyor by the facility on 6/3/24 documents 33 female residents currently reside at the facility. The facility resident rooms were observed to have no private/semi-private bathrooms. There was only one women's shower/bathroom located at the end of the women's hall for the women to use. On 6/3/24 at 11:31 AM, the women's shower room/bathroom was observed by this surveyor and had three stalls with commodes in them. There was a curtain covering the entrance to one commode area, and no curtain or covering over the entrance to the other two commode areas. On 6/3/24 at 11:33 AM, V7 (Certified Nursing Assistant/CNA) stated she thought the curtains that covered the entrance to the two commode stalls were in laundry since they were normally hanging up. On 6/3/24 at 11:46 AM, V5 (Laundry) stated she thought she saw one of the curtains in the clean utility room, but she didn't know about the other one. V5 stated there are normally three curtains hanging. V5 left the interview and returned a few minutes later with one curtain and stated she found one of the curtains but not the other one. On 6/3/24 at 2:07 PM, R6 was interviewed and was alert and oriented at the time of this interview. R6 stated she used the women's bathroom/shower room, and she wasn't sure why they didn't have curtains over the commode stall entrances. R6 stated, Maybe they are washing them. On 6/3/24 at 2:34 PM, the women's bathroom/shower room was observed by this surveyor. There was one curtain covering one commode stall and a second curtain that was hanging over a second commode stall. This second curtain was missing 6 hanging hooks. Five of the six missing hooks were not able to be placed due to the curtain holes that held the hooks were ripped. This made the curtain drape down in a fashion that only half of the entrance to the commode stall could be covered. The third commode stall did not have a curtain. On 6/3/24 at 2:40 PM, R1 was interviewed and was alert and oriented at the time of the interview. R1 stated she had lived at the facility 3-4 years and as long as she can remember they have been missing one of the curtains in the women's bathroom/shower room. On 6/4/24 at 10:22 AM, the women's bathroom/shower room was observed and was still missing a curtain for one commode stall entrance, the second commode stall entrance curtain was still hanging with half the hooks missing. On 6/4/24 at 11:18 AM, V2 (Anonymous) stated the curtains in the women's bathroom/shower room have been missing for more than a month or two. On 6/4/24 at 1:56 PM, V10 (CNA) stated she thinks the curtains in the women's bathroom/shower room have been missing since she started working at the facility in 2/2024. On 6/4/24 at 2:06 PM, V14 (CNA) stated she knew one of the curtains in the women's bathroom/shower room had been missing for a while. On 6/4/24 at 2:23 PM, V15 (CNA) stated she had worked at the facility since 2/2024 and the curtains were missing all the time. V15 stated they would get soiled and when she first started working, they were gone for a while, then V1 (Administrator) asked about them and they were back up, but now they have taken them down to clean again. On 6/5/24 at 9:35 AM, the women's bathroom/shower room commode stalls were still missing one curtain and a second curtain is only half hanging. On 6/5/24 at 1:32 PM, V1 (Administrator) stated she had the laundry/housekeeping supervisor price check curtains, and she is planning to replace them. When asked for the facility Resident Rights policy this surveyor was provided with an undated packet titled, Illinois Long Term Care Ombudsman Program Resident's Rights for People in Long-Term Care Facilities. Under Your rights to dignity and respect, it documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Under, Your rights to privacy and confidentiality it documents, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on interview and record review the facility failed to ensure residents were able to choose what time they got up in the morning for 1 of 5 (R12) residents reviewed for resident's rights in the sample of 17. Findings include: R12's undated New Admission Information sheet documents R12 was admitted to the facility on [DATE]. R12's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R12 has diagnoses that include intractable seizures, debility, anxiety syndrome, and intermittent explosive disorder. R12's MDS (Minimum Data Set) dated 5/15/24 documents a BIMS (Brief Interview for Mental Status) score of 11 indicating R12 has a moderate cognitive deficit. This same MDS documents R12 is dependent on staff for chair/bed to chair transfers. R12's current Care Plan documents a Focus Category of Safety dated August 2019. This Focus Category includes the following interventions dated August 2024, Encourage resident to use call light and ask for help when feeling unsure of transfer/ambulation ability .Check every two hours when in bed for safety .Toilet per schedule and as needed when restless or agitated May use Hoyer lift for transfers prn (as needed) . R12's Care Plan does not address R12's preferences related to when she gets up and/or goes to bed. R12's Interview for Daily Preferences assessment dated [DATE] and 5/15/24 documents it is somewhat important for R12 to be able to choose her own bedtime. This assessment does not document information related to what time R12 prefers to get up in the morning. On 6/3/24 at 2:51 PM, when asked if staff had ever told a resident they had to get up early, R11 (R12's roommate) pointed to R12. R11 stated staff say they have to get R12 up before the morning shift arrives. R11's undated New Admission Information documents R11 was admitted to the facility on [DATE]. R11's MDS dated [DATE] documents a BIMS score of 15, which indicates R11 is cognitively intact. On 6/4/24 at 10:41 AM, V16 (Activities Director/Social Services Director) stated one wing of the facility is gotten up in the morning by midnight shift because it is too hard to get all of the residents up by 7:30 AM when breakfast is served. V16 stated V17 (Family Member) doesn't want R12 gotten up that early and he was told they do it to assist day shift. On 6/4/24 at 11:18 AM, V2 (Anonymous) stated V17 brought R1 getting up early in a care plan meeting and asked that R12 be allowed to sleep in the morning. V2 stated V1 (Administrator) told V17 it was better for staff to be able to get the residents up and ready for breakfast. On 6/4/24 at 11:58 AM, V17 (Family Member) stated R12 was having to get up really early and he told V1 (Administrator) he didn't want her to have to get up that early. V17 stated V1 told him she would see what they could do about it. On 6/4/24 at 1:56 PM, V10 (Certified Nursing Assistant/CNA) stated she gets to work at 6:00 AM and R12 is up when she gets to work. When asked why residents are up that early V10 stated midnight shift gets a few residents up for them to be helpful. V10 stated those residents like to get up that early. On 6/4/24 at 2:06 PM, V14 (CNA) stated she works day shift and gets to the facility at 6:00 AM. V14 stated there are residents up when she gets to the facility and R12 is one of them. V14 stated she wasn't sure why they were up before 6:00 AM. V14 stated none of the residents have said anything about getting up that early but sometimes R12 isn't up when she gets to the facility. On 6/4/24 at 2:15 PM, V18 (CNA) stated there is a list of residents that midnight shift gets up before day shift arrives. V18 stated R12 is on the list but will sometimes refuse to get up. On 6/5/24 at 10:20 AM, when asked what time she got up in the morning R12 stated, 5. When asked if she wanted to get up that early, she stated, No. when asked what happened if she told them she didn't want to get up that early R12 shrugged her shoulders. R12 was able to answer simple questions but was not able to have a full conversation. On 6/5/24 at 10:21 AM, R11 stated they get R12 up at 5:00 AM. When asked if R12 ever told staff she didn't want to get up and R11 stated R12 moans like she doesn't want to, and staff tell her she has to get up. On 6/5/24 at 1:32 PM, V1 (Administrator) stated R12 only gets up early when she wants to. V1 stated some days she gets up early and other days she doesn't. V1 then asked this surveyor if R12 had told this surveyor what time she wanted to get up. When asked for a resident rights policy this surveyor was provided with an undated packet titled Illinois Long Term Care Ombudsman Program Resident's Rights for people in Long-Term Care Facilities. This packet documents under, Your rights to participate in your own care You have the right to choose activities and schedules (including sleeping and waking times).

Based on interview and record review the facility failed to report an allegation of staff to resident abuse to the State Survey Agency for 1 of 3 (R3) residents reviewed for abuse in the sample of 17. Findings Include: On 6/3/24 at 3:17 PM, V1 (Administrator) stated this surveyor had been provided with all of the facility abuse/neglect investigations. When asked if she had any reports of a resident being forced down the hall and yelling, V1 stated, No. At this time this surveyor reported an allegation of abuse to V1 of an unknown resident being pushed down the hall, dragging their feet, while an unknown staff member yelled at the resident. On 06/04/2024 the facility provided this surveyor with a document titled; Incident Investigation Form dated 5/24/24. This form included the following. Newly admitted resident (R4), had her husband (V21) in visiting. (V21) stated on 5/24/24 that during his visit to see his wife on 5/23/24 that he did not like how a nurse talked to a resident. (V21) stated nurse yelled at resident on shift 2-10 PM. Nurse over the phone: V22 (RN/Registered Nurse) stated resident (R3) is the only resident he could think of regarding (V21) comment. Nurse stated (R3) is hard of hearing and will not tolerate a hearing device and you have to speak loudly so resident can hear. Nurse stated (R3) was trying to grab on a med-cart and nurse began to redirect (R3) away from med-cart and in a different direction. CNAs (Certified Nursing Assistants) over the phone: (V15) worked until 10 PM and did not hear or see anything. V14 worked until 6 PM and stated she did not hear anything like this. V23 worked 2 pm until 10 PM, she is no longer an employee and will not answer phone. V24 worked 2 PM to 10 PM and does not recall anything happening regarding that complaint. In conclusion, this facility is unable to substantiate (V21's) claim. On 6/4/24 at 11:18 AM, V2 (Anonymous) stated on an unknown date, V21 (Family Member) reported he was visiting with R4 on an evening shift, when he saw one of the female residents being pushed down the hall and being yelled at. V2 stated V21 reported the resident was being physically pushed and was dragging her feet. V2 stated V21 reported if that is happening when people are witnessing it what is happening when no one is around. V2 stated, V21 was not able to identify the staff member or the resident. V2 stated since V1 (Administrator) was there at the time V21 reported it she assumed it was investigated. On 6/5/24 at 1:32 PM, V1 (Administrator) stated she didn't believe the allegation this surveyor reported to her on 6/3/24 was the same allegation that was documented in the incident investigation dated 5/24/24, but stated it was the only one she could recall. V1 stated she spoke to the nurse regarding the allegation on 5/24/24 and he said R3 was the only resident it could have been because she was hearing impaired and wouldn't tolerate a hearing device. When asked if she reported the allegation from 5/24/24 to the State Survey Agency, V1 stated she didn't because they didn't have a specific resident name so there was no resident to report on. R3's undated New Admission Information sheet documents R3 was admitted to the facility on [DATE]. R3's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R3's diagnoses include left hip nailing, dementia, osteoarthritis, depression, and anemia. R3's MDS (Minimum Data Set) dated 5/22/24 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive deficit. This same MDS documents under Section J, R3 has a history of falls with injuries. R3's current Care Plan documents a Focus Category of Communication dated 5/2024. The interventions included for this care plan dated 2/22/24 are as follows: Use questions that require yes/no answers or one to two word responses when resident is experiencing problems with communicating. Validate response thru repeating answers. Establish eye contact and face resident prior to communication. Assure resident you are listening by maintaining eye contact throughout conversation. Acknowledge resident at each greeting. Reduce environmental distractions. Take to quiet area as needed. The facility Abuse Prevention Program policy dated 3/5/2009 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. 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. Under External Reporting the facility policy documents, 1. Initial Reporting of Allegations. If, during the course of an incident investigation, the administrator or designee has determined that there is a reasonable cause to suspect mistreatment has occurred, the resident's representative and the (State Survey Agency) shall be informed with 24 hours. (State Survey Agency) shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. A written report shall be sent to the (State Survey Agency) .2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the (State Survey Agency) .

Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident abuse for 1 of 3 (R3) residents reviewed for abuse in the sample of 17. Findings Include: On 6/3/24 at 3:17 PM, V1 (Administrator) stated this surveyor had been provided with all of the facility abuse/neglect investigations. When asked if she had any reports of a resident being forced down the hall and yelling, V1 stated, No. At this time this surveyor reported an allegation of abuse to V1 of an unknown resident being pushed down the hall, dragging their feet, while an unknown staff member yelled at the resident. On 06/04/2024 the facility provided this surveyor with a document titled; Incident Investigation Form dated 5/24/24. This form includes the following. Newly admitted resident (R4), had her husband (V21) in visiting. (V21) stated on 5/24/24 that during his visit to see his wife on 5/23/24 that he did not like how a nurse talked to a resident. (V21) stated nurse yelled at resident on shift 2-10 PM. Nurse over the phone: V22 (RN/Registered Nurse) stated resident (R3) is the only resident he could think of regarding (V21) comment. Nurse stated (R3) is hard of hearing and will not tolerate a hearing device and you have to speak loudly so resident can hear. Nurse stated (R3) was trying to grab on a med-cart and nurse began to redirect (R3) away from med-cart and in a different direction. CNAs (Certified Nursing Assistants) over the phone: (V15) worked until 10 PM and did not hear or see anything. V14 worked until 6 PM and stated she did not hear anything like this. V23 worked 2 pm until 10 PM, she is no longer an employee and will not answer phone. V24 worked 2 PM to 10 PM and does not recall anything happening regarding that complaint. In conclusion, this facility is unable to substantiate (V21's) claim. On 6/4/24 at 11:18 AM, V2 (Anonymous) stated on an unknown date, V21 (Family Member) reported he was visiting with R4 on an evening shift, when he saw one of the female residents being pushed down the hall and being yelled at. V2 stated V21 reported the resident was being physically pushed and was dragging her feet. V2 stated V21 reported if that is happening when people are witnessing it what is happening when no one is around. V2 stated, V21 was not able to identify the staff member or the resident. V2 stated since V1 (Administrator) was there at the time V21 reported it she assumed it was investigated. On 6/5/24 at 1:32 PM, V1 (Administrator) stated she didn't believe the allegation this surveyor reported to her on 6/3/24 was the same allegation that was documented in the incident investigation dated 5/24/24, but stated it was the only one she could recall. V1 stated she spoke to the nurse regarding the allegation on 5/24/24 and he said R3 was the only resident it could have been because she was hearing impaired and wouldn't tolerate a hearing device. When asked if she had interviewed any other staff or residents, V1 stated she had not. When asked if she had started an investigation on the allegation this surveyor reported on 6/3/24, V1 stated, I didn't do an investigation because I thought it was the same allegation. R3's undated New Admission Information sheet documents R3 was admitted to the facility on [DATE]. R3's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R3's diagnoses include left hip nailing, dementia, osteoarthritis, depression, and anemia. R3's MDS (Minimum Data Set) dated 5/22/24 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive deficit. This same MDS documents under Section J, R3 has a history of falls with injuries. R3's current Care Plan documents a Focus Category of Communication dated 5/2024. The interventions included for this care plan dated 2/22/24 are as follows: Use questions that require yes/no answers or one-to-two-word responses when resident is experiencing problems with communicating. Validate response thru repeating answers. Establish eye contact and face resident prior to communication. Assure resident you are listening by maintaining eye contact throughout conversation. Acknowledge resident at each greeting. Reduce environmental distractions. Take to quiet area as needed. The facility Abuse Prevention Program policy dated 3/5/2009 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. 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. Under Investigation Procedures the policy documents, Regardless of the specific nature of the allegation .the investigation shall consist of: a review of the initial written reports. Completion of a written report on the status of the investigation of the occurrence; An interview with the person (s) reporting the incident; Interviews with any witness to the incident; an interview with the resident; Where appropriate, an interview with the resident's attending physician or psychiatrist; A review of the medical records of any residents involved in the occurrence; If the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training; An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; Where appropriate, interviews with the resident's roommate, family members, visitors, or others who were in the vicinity of the incident; Interviews with other residents to which the accused individual has regular contact; Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; Obtain address, phone number, and social security number of the accused individual; an interview with the accused individual or individuals (with a witness present); and a review of all circumstances surrounding the incident.

Based on observation, interview, and record review the facility failed to provide timely incontinence care per current standards of practice for 2 of 3 (R12 and R16) residents reviewed for incontinence care in the sample of 17. Findings Include: 1. R12's undated New Admission Information sheet documents R12 was admitted to the facility on [DATE]. R12's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R12's diagnoses include intractable seizures, debility, depression, and anxiety. R12's current Care Plan documents a Focus Category dated 8/2019 of Continence. This Focus area includes the following interventions dated 8/2024, Allow brief when up. Assist to change PRN (as needed) .Consider scheduled toileting if pattern is evident. Set schedule per pattern. Include resident in decision making R12's MDS (Minimum Data Set) dated 5/15/24 documents a BIMS (Brief Interview for Mental Status) score of 11, which indicates R12 has a moderate cognitive impairment. This same MDS documents R12 is dependent on staff for toileting. On 6/5/24 at 10:21 AM, R11 stated R12 had been up since around 5:00 AM, had been taken to breakfast, brought back to the room and hadn't been checked or changed since she was gotten up. Intermittent observation of R12 began at this time. No staff were observed entering R12's room or providing care to R12. R11's undated New Admission Information documents R11 was admitted to the facility on [DATE]. R11's MDS dated [DATE] documents a BIMS score of 15, which indicates R11 is cognitively intact. On 6/5/24 continuous observations of R12 began at 11:15 AM. R12 was sitting next to her bed, in a reclined chair with footstool. Continuous observation continued until 11:51 AM with no staff entering R12's room and/or providing care. At 11:51 AM, V25 (CNA/Certified Nursing Assistant) entered R12's room and stood at the foot of her bed until V14 (CNA) entered the room. Neither V25 nor V14 took incontinence care supplies into R12's room with them. They shut the door to R12's room. This surveyor knocked on the door and asked R12 if care could be observed. At this time, V14 exited the room and returned with incontinence care supplies and V10 (CNA). R12 was transferred to bed by V10 and V25 using a gait belt. R12's pants were saturated with urine and the bed pad under R12 was saturated with urine. R12 was placed in bed and her pants were removed. V25 removed the incontinence brief that was saturated from front to back and was dark yellow/brown. R12 was dressed in a new incontinence brief and clean pants, then transferred to her chair. V10, V14, and V25 all stated they had checked and changed R12 when she was brought back from breakfast at approximately 8:45 AM. This indicates a discrepancy in the time frames as told to this surveyor by R11. Based on the interviews of R11, V10, V14, and V25, R12 had either not been changed since she was gotten up at approximately 5:00 AM or had not been changed since her return from breakfast at approximately 8:45 AM. 2. R16's undated New Admission Information sheet documents R16 was admitted to the facility on [DATE]. R16's Physician's Order sheet dated 6/1/24 to 6/30/24 documents R16's diagnoses include hypertension, dementia, and depressive disorder. R16's MDS dated [DATE] documents a BIMS score of 08, which indicates R16 has a moderate cognitive impairment. R16's bowel and bladder assessment dated [DATE] documents R16 requires supervision to find the bathroom, is continent of bladder with occasional incontinence. R16's current Care Plan documents a Focus Category of ADL (Activities of Daily Living) dated 5/2024. This Focus area includes the following interventions, .Assist Resident to toilet upon rising and hs (hour of sleep) and after all meals as tolerated. Place brief on when up. Pad on bed, change q (every) 2 hrs (hours) and prn (as needed) when repositioning. Cleanse peri-area after each incontinent episodes (sic). Barrier cream as needed upon cleansing. On 6/5/24 at 11:30 AM, R16 was walking down the hallway towards this surveyor. R16 was redirected back to the other hallway by V10 (CNA). When R16 turned around to walk the other way, the back of her pants was noted to be wet. R16 walked to the common area and started down the other hallway when V20 (RN/Registered Nurse) redirected R16 to the dining room. At 11:35 AM, R16 was observed in the dining room area, pants were soaked. At 12:04 PM, R16 walked to the bathroom by herself, exited the bathroom at 12:07 PM, R16's pants remained soaked. At 12:10 PM, R16 was assisted to the bathroom. On 6/5/24 at 12:15 PM, R16's room was observed by this surveyor. The rocking chair next to R16's bed had a cushion in it that was wet. This surveyor then saw R16 exiting the bathroom with V14 (CNA). V14 stated R16 takes herself to the bathroom all the time. When asked about the wet cushion in R16's rocking chair, V14 stated R16 probably went to her room and urinated in the rocking chair, then took herself to the bathroom. On 6/5/24 at 1:32 PM, V1 (Administrator) stated she would expect residents to be changed as needed and shouldn't be made to wait for care. V1 stated she would expect residents to get care timely to prevent skin breakdown and infections. V1 stated if the care plan says they should be assisted to toilet, then they should be assisted.

Based on observation, interview, and record review the facility failed to ensure interventions to prevent falls were implemented and followed for 1 of 3 (R3) residents reviewed for falls in the sample of 17. Findings Include: R3's undated New Admission Information sheet documents R3 was admitted to the facility on [DATE]. R3's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R3's diagnoses include left hip nailing, dementia, osteoarthritis, depression, and anemia. R3's MDS (Minimum Data Set) dated 5/22/24 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive deficit. This same MDS documents under Section J, R3 has a history of falls with injuries. R3's current Care Plan documents a Focus Category of Safety dated 5/2024. This focus area includes the following interventions. 4/24/24 rolled out of bed- unwitnessed, body pillow for comfort and positioning when in bed as tol (tolerated). R3's Fall Risk assessment dated [DATE] documents a score of 24, which indicates R3 is at high risk of falls. The facility Quality Improvement Review dated 4/24/24 documents, R3 rolled out of bed. Yelled for help. Staff noted her on floor. Bruise to (Rt-right) forehead and (Rt) elbow. Care plan status Comfort Care. Staff In-serviced: Using body pillow to help prevent rolling out of bed. Intervention: Body pillow to go along res (resident/R3) on bed for comfort/positioning as resident allows. On 6/4/24 at 1:20 PM and 3:36 PM, R3 was in bed sleeping, the foot board was padded, there was no body pillow observed on the bed. On 6/5/24 at 9:32 AM, R3 was in bed sleeping, covered with blanket, no body pillow observed. On 6/5/24 at 9:37 AM, V10 (CNA/Certified Nursing Assistant) walked with this surveyor to R3's room. There was no body pillow in R3's bed. V10 checked the closet and stated her body pillow may be in laundry. V10 placed a regular size pillow next to R3. On 6/5/24 at 1:32 PM, V1 (Administrator) stated she had been told R3 didn't have the body pillow in place after this surveyor observations. V1 stated staff told her it was in laundry, and she told them they needed to get another pillow and make sure R3 has a pillow where it is supposed to be. V1 stated she preferred the body pillow over a regular size pillow, and they should have at least one back up. The facility Fall Prevention Policy 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. Under Procedure the policy documents.5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on observation, interview, and record review the facility failed to provide assistance with eating for 1 (R30) of 4 residents reviewed for nutrition out of a sample of 38. This failure resulted in R30 having a significant weight loss of 14.8% in 6 months. The Findings Include: R30's Minimum Data Set (MDS) documents a most recent admitted [DATE]. The November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. R30's care plan with a goal date of 2/24 lists a goal that resident weight will be a proper Body Mass Index (BMI). Interventions with a start date of 3/15/23 is listed for the following: serve diet as ordered and tolerated, see orders/tray card for current diet, set up tray per resident preference, Ensure proper/comfortable positioning at table, record intake for each meal, and offer substitutes for foods not eaten, note any reporting chewing/swallowing difficulties or changes in habits or intake and notify nurse for follow up with physician, allow use of clothing protector per resident/family preference, encourage the resident to participate to the fullest extent possible with each interaction, praise all efforts for eating/nutritional care. An intervention with the start date 3/15/23 is to use lids on coffee cups to prevent spills. R30's report of monthly weight and vitals for the [AGE] year lists the following weights: June 2023 is 135 pounds, July 2023 is 131 pounds, August 2023 is 125 pounds, September 2023 is 123 pounds, October 2023 is 119 pounds, and November 2023 is 115 pounds. R30 has had a significant weight loss of 14.8% over the last 6 months. On 12/1/23 at 10:30 AM, V1 (Administrator) stated that R30 does not have current supplements ordered due to poor intake of those supplements. V1 stated that several different types had been trialed. R30's Skilled activities of daily living (ADL) reports that are filled out by the CNAs (Certified Nursing Assistants) for June and July for eating are coded daily as an 'S' which is described on the form to be: Set Up/Clean Up by helper but resident completes the ADL on own. The ADL assist report for June and July is coded as a '1' for all meals that is defined as '1' being supervision (oversight, encouragement or cueing). August ADL assist report documents R30 is coded as a '1' and '2.' A '2' is defined as being limited assistance (resident highly involved in activity and staff provide non-weight bearing assistance). The August ADL report lists R30 as an 'S' or a 'V' (verbal cueing/supervision/touching, helper may touch/steady/contact guard). The September skilled ADL report lists R30 as an 'S' all month except one meal she refused. The September ADL assist report documents R30 as being a '2' for eating. The October skilled ADL sheet documents that R30 is coded as an 'S' for eating and no skilled ADL assist report was provided. November 2023 skilled ADL report was coded as an 'S' for R30, and no skilled assist report was provided. R30's Minimum Data Set (MDS) dated [DATE] is a quarterly assessment and codes eating as R30 requiring set up or clean up assistance, set up or clean up provided, resident completes activity. The annual MDS with a 12/1/23 acceptance date is coded the same as the 8/30/23 quarterly. These documents also show that R30 has a BIMS (Brief Interview for Mental Status) score of 4, which indicates severe cognitive impairment. On 12/1/23 at 10:30 AM, V15 (Regional MDS Coordinator) stated that the MDS's are coded based on the CNA daily ADL report and ADL assist report. V15 stated that she is not in the building daily, as she is a regional MDS coordinator. V15 further stated that prior to taking on a regional position she was the floating MDS coordinator for this facility, so the facility has not had a full-time person in the MDS position for some time. V15 stated that she questions what can be done if many residents need assistance with eating because they do not have enough CNAs to do that and they are looking at reducing the nursing hours. On 11/29/23 at 11:50pm, R30 was in her room with lunch tray and drinks on the bedside table. R30's tray contained the regular diet of pulled pork, macaroni and cheese, butternut squash, and fruit cup (strawberries in juice/syrup and bananas). R30 was lying in bed with eyes closed. Observations of R30 conducted at approximately 15-minute intervals revealed R30 not attempting to eat, tray still untouched at bedside. No staff were observed going in the room to encourage her to eat or offer assistance. Housekeeping was noted entering in room at approximately 12:45PM cleaning up soda that R30 had spilled on the floor. R30 was awake and sitting up with bedside table & tray in front of her at this time but had still not taken any bites of food. At 12:52 PM, R30 started eating her fruit cup with her fingers, which contained cut up strawberries in a juice/syrup, despite having rolled up silverware in front of her. After finishing this, R30 did not attempt to eat any of the other food items on her tray. At approximately 12:58pm, V4 and V8 (CNAs) came to room. When asked at this time if R30 requires assistance with eating, V4 stated no she didn't. When asked about R30 eating the strawberries in juice/syrup with her fingers despite having silverware and pointing out the fact she did not attempt to eat any other meal items. V4 stated, yes R30 has been declining. R30 was not offered any alternative food items before her tray was picked up with only the fruit cup eaten. On 11/30/23 at 11:55PM, R30 was observed up to dining table with lunch meal of taco salad, rice, and vegetable being served at this time. From 11:55am to 12:20pm, R30 sat with meal in front of her, not eating, with no staff prompting or encouraging her to eat the taco salad meal. At 12:20pm, R30 was brought a peanut butter and jelly sandwich (which had been requested by staff for her tablemate (R5), but R30 still sat without eating it. At 12:29pm, V7 (Licensed Practical Nurse/LPN) began verbally prompting R30 to eat the sandwich, and she responded by taking bites of the sandwich until she finished it. On 12/01/23 at 11:30 AM, R30 was observed sleeping laying across her bed across, with her feet hanging over the side of the bed towards the floor and her head against the wall. On 12/01/23 at 12:15 PM, R30's lunch tray was delivered to her room. At this time, the tray was placed in her room on the bedside table while the resident remained asleep. At 12:47 PM, housekeeping was removing the untouched tray from R30's room. The cover was still on the food, the silverware was still wrapped in the napkin, and the drinks still had the covers on them. Intermittent observations of R30 were completed throughout the lunch service from 11:30AM -12:47PM and R30 remained in this position with an untouched tray without staff intervention or assistance. On 12/01/23 at 12:47 PM, V1 (Administrator) came to R30's room as housekeeping was removing R30's tray from the room and acknowledged that the tray had not been touched, the silverware remained wrapped, the cover was still on the plate as well as the lids on the drinks. R30 was still sleeping at this time. R30's nutritional assessment signed off on 11/17/23 by V16 (Regional Dietitian) documents the following: weight of 115.7 pounds is below acceptable BMI (Body Mass Index) range of (21.92)-underweight or age with significant weight loss noted for 6 months (15.55%). Resident diet/supplement prescription is noted above and resident feeds self. Oral intake is reported as approximately 25-50% of most meals per the November intake log. Varied oral intake may alter weights. R30's food and fluid intake sheet for November 2023 shows a varied intake of 0-100%, with the resident usually showing an intake of 25-50%. On 12/5/23 at 12:56 PM, V16 (Regional Dietitian) stated that when she is in the facility, she observes mealtimes, reviews charts, and speaks with residents. V16 stated that she had not witnessed the issues survey staff have observed this week with R30 not eating. V16 stated that what she had seen was that R30 was able to feed herself. V16 said that CNAs fill out the ADL sheets and that is how the care plan and MDS are filled out to determined how residents are to be assisted. V16 stated she trialed all the different supplements for R30 and said that she had not been made aware that R30 needed assistance and was not eating on her own anymore. V16 stated she was just told R30 had poor intake. V16 said she would expect staff to tell her if there were any issues with residents needing more assistance, then see if adding that as an intervention would improve intake and stabilize R30's weight loss. 43088

Based on interview and record review, the facility failed to ensure a gait belt was used when transferring/lifting a resident for 1 (R2) of 3 residents reviewed for accidents in a sample of 7. This failure resulted in R2 sustaining a right proximal humerus fracture and inferior subluxation of the humeral head as it relates to the glenoid. This past non-compliance occurred between 1/19/23 and 1/25/23. The findings include: R2's New Admission Information documents that R2 was admitted to the facility on [DATE]. R2's Physician's orders dated 2/1/23-2/28/23 document diagnoses including Acute Ischemic Left MCA (Middle Cerebral Artery) Stroke, CKD (Chronic Kidney Disease), IDDU (sic Insulin Dependent Diabetes Mellitus), dysphagia, dialysis, seizures, Proximal Right humerus fracture. R2's MDS (Minimum Data Set) dated 1/26/23, Section C documents a BIMS score of 06, which indicates that R2 has severe cognitive impairment. Section G of the same MDS documents for transfers, R2's self-performance is total dependence, and the support provided is two plus physical assist. R2's (undated) care plan documents a problem area of Self-care deficit - needs assist to complete quality care ADL's (Activities of Daily Living) with a corresponding intervention of (mechanical) lift for transfer with a start date of 12/5/18. A report titled Final Investigation dated 1/27/23 documents the following: On 01/19/2023 at approximately 2:30 PM, CNA's (V3) and (V4) were repositioning (R2) in preparation for her shower in a geri chair to get (R2) realigned with the (name of mechanical lift) sling that was underneath her. (R2) was sitting at an angle on the (name of mechanical lift) sling to where they couldn't get it properly around her and attached to (name of mechanical lift) lift. When they went to reposition (R2), (V3) heard a loud pop noise. At which point (V4) stayed with (R2) while (V3) went and notified nurses immediately. Ambulance was notified, and (R2) was sent over to ER (emergency room ) for X-rays and returned to facility at approximately 7:30 PM with immobilizer to right arm at all times except for care. The report continues to document X-ray results were obtained and revealed inferior subluxation of the humeral head as it relates to the glenoid and a proximal right humerus fracture .In conclusion, the facility was able to conclude that (R2's) injury resulted while being repositioned. QA (Quality Assurance) committee met, and new interventions were discussed, and her care plan has been updated to reflect her current status. On 2/16/23 at 9:15am, V1 (Administrator) said that they had a QA meeting on 1/20/23 after the incident when R2 was injured and placed a new intervention of gait belt training with staff. V1 said she conducted the in-service with all staff on 1/25/23. V1 said that R2 was sitting in her chair and the mechanical lift sling was underneath R2. V1 said the sling had slid down in an awkward position and that V3 (CNA/Certified Nurse Assistant) and V4 (CNA) lifted/repositioned R2 to get the sling under her right. V1 said V3 and V4 heard a pop sound after lifting/repositioning R2 and immediately got the nurse. V1 said that the two CNAs did not use a gait belt when repositioning/lifting R2. V1 said that staff are made aware of the gait belt policy upon hire and that gait belts are mandatory. On 2/16/23 at 1:15pm, V4 (CNA) said that she did not use a gait belt when repositioning R2. V4 said that V3 and herself each took a side a put their arms underneath R2's (arms) and lifted her enough to get sling straightened up. V4 said they then heard a pop and immediately went to get the nurse. V4 said that she was aware of the gait belt policy and did get in-serviced on use of belt after incident. V4 said she does not know why she did not use the gait belt but knows she should have. On 2/16/23 at 2:00pm, V3 (CNA) said she is still upset over R2 being injured and does not know why she didn't use a gait belt. V3 said R2's lift sling had slid underneath her and they needed to get it straightened up to lift her using the mechanical lift. V3 said that she and V4 lifted R2 by putting their arms under R2's arms and had another staff straighten the pad. V3 said while lifting R2, they heard a pop and immediately sat her down. V3 said that R2 complained of pain right after the pop. V3 said they went and got the nurse immediately. V3 said she did receive in-service after the incident and was aware of the gait belt policy. A document titled Results from the local hospital notes that on 1/19/23, R2 had an x-ray shoulder right 2 plus views. The impression documents 1. Proximal right humerus fracture, 2. Inferior subluxation of the humeral head as it relates to the glenoid. R2's Physician's Orders dated 2/1/23 to 2/28/23 document an order (carried over from January 2023) dated 1/19/23 for immobilizer to Rt (right) arm @ (at) all times except during care. A facility document labeled Policies documents V3 received training on the Gait Belt Policy and signed the proof of completion on 7/15/22. V4 is documented as receiving the training and signing the proof of completion on 5/17/21. A facility document labeled facility Transfer Belts/Gait Belts revised 12/17/12 notes in part that all certified nursing assistants and licensed nursing personnel engaged in the lifting and transferring of residents will use gait belts .Gait belts are mandatory. Prior to the survey date, the facility implemented the following actions to correct the deficient practice: 1. A Quality Improvement Meeting was held on 1/20/23, documenting discussion of R2's fall resulting in unspecified fracture of the humerus. New interventions listed on the form note gait belt training with staff. The following staff were noted to be in attendance to this meeting: V1 (Administrator), V2 (Director of Nursing/DON/MDS Coordinator), V8 (Business Office Manager), V9 (Maintenance), V10 (Housekeeping/Laundry/Medical Records), V11 (Social Service/Activities Director), and V12 (Food Service Supervisor). 2. A facility Inservice/Class Attendance form dated 1/25/23 with the title of the in-service noted as Proper Gait Belt Usage and Positioning documents V1 (Administrator) provided instruction on the following areas of instruction: Gait belt should be used for all transfers, repositioning in chair, and assistance with mobility. Prior to moving resident make sure leg pegs are out of the way to avoid skin tears or injuries. Belt position is low and tight. One person on each side of resident; if resident is sliding down have a third person in front of resident for safety and assistance. Additional documentation provided by V1 documents that V13 (Therapy Department) assisted in providing Gait Belt Training.