Every finding on record at Bella Terra Lagrange

Based on observation, interview, and record review, the facility failed to follow their infection control policies and practices when staff failed to wear personal protective equipment and perform hand washing when entering and exiting a resident room and failed to ensure the posting of correct isolation procedure instruction. This affected one of three residents reviewed (R4) for infection control. This has potential to affect all 27 residents residing on the first-floor unit.Findings includesBased on observation, interview, and record review, the facility failed to follow their infection control policies and practices when staff failed to wear personal protective equipment and perform hand washing when exiting a resident room and failed to ensure the posting of correct isolation procedure instruction. This has potential to affect all 27 residents residing on the first-floor unit.R4 face sheet shows diagnosis of clostridium difficile enterocolitis.On 6/24/2026 2:00pm observed contact isolation sign posted on the room door for R4. The contact isolation sign posted instructs that everyone must clean their hands, including before entering and when leaving the room with alcohol based hand rub, put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. V3 (CNA) observed standing in R4 room at her bedside wearing no personal protective equipment.On 6/24/2026 2:02pm V3 (CNA) said R4 was on contact isolation and she did not know to put personal protective equipment on every time she went in the room of R4. On 6/24/2026 2:30pm V6 (infection prevention nurse) said R4 laboratory test resulted positive for clostridium difficile, and she is on contact isolation. V6 said staff must wear gowns and gloves every time they enter the room, and they cannot use alcohol hand sanitizer to clean their hands. V6 said staff received education on the procedure for contact isolation and precautions for residents with clostridium difficile infection. On 6/25/2026 10:25am V2 (director of nursing) said staff received education on contact isolation procedure and precautions for providing care for a resident with clostridium difficile infection. V2 said everyone must put on personal protective equipment (PPE) before entering the room, remove PPE prior to leaving the room, and must perform hand hygiene by washing their hands because alcohol hand sanitizer is not sufficient. V2 confirmed the contact isolation sign posted on the door of R4 instructed everyone entering the room to clean their hands when entering the room and leaving the room to use alcohol-based hand rub. Reviewed the education provided to staff on contact precautions and clostridium difficile showed for preventing clostridium difficile (c-Diff), staff must wash hands before and after care, don PPE prior to entering resident's room and dispose of PPE prior to leaving the room, alcohol based hand sanitizer does not kill C-Diff, washing your hands with soap and water is the best way to prevent the spread of C-Diff from person to person, perform hand hygiene before and after care of resident. Reviewed facility Infection Prevention and Control policy dated 7/5/2016 with revision date of 6/30/2025 showed contact precautions are required for clostridium difficile infections and use of gown and gloves is necessary prior to room entry.Reviewed R4 laboratory clostridium difficile positive test result, physician order for contact isolation, diagnosis list indicating clostridium difficile infection, plan of care, progress notes dated June 5, 2026 to June 26, 2026. On 6/26/2026 at 10:31 am V1 (Administrator) said she was aware that V3 CNA (Certified Nursing Assistant) went into R4 isolation room to ask if the resident wanted her door to be left open. V1 said V3 mistakenly did not put on PPE (Personal Protective Equipment) and did not perform isolation precautions on accident. V1 said V3 was inserviced on donning PPE when entering isolation rooms and on the importance of utilizing proper protocol of utilizing isolation precautions for residents who are on isolation precautions. V1 said the facility's QAPI committee is tracking the trends of the facilities infection rate and utilized root cause analysis in regards to infection prevention within facility.

Based on interview and record review, the facility failed to offer staff the Covid-19 immunization vaccine and have written documentation of it. This applies to all 97 residents in the facility reviewed for immunizations in the sample of 24. The findings include: The CMS (The Centers for Medicare and Medicaid Services) form 671 titled Long-Term Care Facility Application for Medicare and Medicaid dated 3/25/25 shows the facility has a census of 97 residents. On 3/26/25 at 2:02 PM, V3 (LPN-Licensed Practical Nurse/Infection Preventionist) stated, I don't have the documentation that shows where I offered the vaccine to staff. Now, our corporate changed their policy. The Covid vaccines are not free anymore. The staff must use their own insurance, so we tell them that they can get the Covid-19 vaccines from clinics or pharmacies that accept their insurance. We don't offer it to them, but they can ask us to give it to them if they have insurance. V3's infection control binders did not have any documentation that staff were educated regarding the benefits and potential side effects of the Covid-19 vaccine. Neither did she have any documentation that staff accepted and received the vaccine. She had nothing to show the vaccination status of staff. Facility's policy titled Covid 19 Vaccination Policy (7/16/24) shows: The facility will comply with the applicable CMS, CDC (Centers for Disease Control and Prevention), and/or IDPH (Illinois Department of Public Health guidance on Covid-19 vaccination. As CMS had rescinded the mandatory Covid 19 vaccine requirement for staff and resident, the facility will continue to promote and provide Covid-19 vaccination whenever the vaccine is available, and individuals consent to Covid vaccination. Staff may obtain Covid 19 vaccine from clinics and pharmacies that offer the vaccines, as billing is now through staff insurance. If the facility pharmacy is able to bill staff's insurance, the staff may get Covid 19 vaccination in house, as long as the staff consent to it.

Based on observations, interviews, and record reviews, the facility failed to implement infection control measures while providing resident care and with the handling of soiled linen. This applies to 6 out of 7 residents (R3, R6, R47, R77, R15, R72) reviewed for infection control in a sample of 24. The findings include: 1. On 03/25/25 at 01:08 PM during lunch service, V13 (Nurse) wiped food off R3's mouth with her right hand and then uses the same right hand and puts a spoonful of food into R47's mouth. V13 did not clean her hands after wiping R3's mouth. From 01:08 PM - 01:23 PM V13 was observed using both her right and left hand to assist R3 and R47 with eating their lunch. Both R3 and R47 were sitting at the same table and V13 never cleaned her hands between each resident for the entire meal. V13 used her left hand to give R3 a drink and then V13 used her right hand to touch R47's hand to stop her from putting a bite of food into her mouth, then went back to feeding R3 with her right hand. On 03/27/25 at 01:00 PM V2 ADON (Assistant Director of Nursing) said that V13 should have cleaned her hands while feeding the residents for infection control. 2. On 03/26/25 at 12:11 PM V26 CNA (Certified Nurse's Assistant) was providing incontinence care for R6. V25 (Wound Nurse) was present. V26 wiped R6 buttocks that had stool on it, then V26 did not clean her hands and continued with putting on a new brief on R6, repositioned R6, adjusted R6's bed linen and touched the bedrails with her dirty gloved hands. On 03/26/25 at 12:15 PM V26 said that she should have washed her hands after cleaning R6 buttocks for infection control. At 12:18 PM, V25 said that she saw that V26 did not clean her hands after wiping R6 buttocks and she should have for infection control. On 03/27/25 at 12:41 PM, V2 ADON (Assistant Director of Nursing) said that the staff should have cleaned her hands after touching the resident's buttocks before doing anything else for infection control. 3. On 03/25/25 at 11:50 AM V12 CNA (Certified Nurse's Assistant) was providing incontinence care for R77 without wearing a gown. Outside of R77's door showed a sign EBP (Enhanced Barrier Precaution). V12 with a wet washcloth wiped V12 perineal area several times and then wiped R77's buttocks with the same washcloth and she did not fold the cloth before moving to a different area. Then V12 removed R77's soiled brief and touched the curtain with her dirty gloved hands as she put the soiled brief in the garbage. V12 then applied new gloves, did not clean her hands first and then applied barrier cream to R77's buttocks and attached a new brief with the same dirty gloves. V12 with the same dirty gloves then moved R77's over the bedside table before removing her gloves and cleaning her hands. At 11:56 AM V12 said that she should have cleaned her hands, and she should have worn a gown. R77's electronic health records showed that R77 has diagnoses including a stage 4 pressure ulcer of the sacral region. On 03/27/25 at 12:45 PM V2 (ADON) said that the staff should use a clean side of the washcloth with new area for infection control. V2 said that the staff should have worn a gown and staff should have changed her gloves and performed hand hygiene before touching any objects to prevent the spread of infections. The facility's infection Prevention Control policy dated 2/10/25 showed that when a resident is on EBP the staff is to use gloves and gowns during high contact resident care activities for residents infected or colonized with MDRO's as well as residents with wounds and or indwelling medical devices. The policy showed that the staff and contracted workers will perform hand hygiene before and after direct patient contact and after each situation that necessitates hand hygiene. The facility's Enhanced Barrier Precaution policy dated 7/26/24 showed the facility uses enhanced barrier precautions to reduce transmission of multi drug resistant organisms in the nursing home. The policy shows that EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and or indwelling medical devices. The facility's Hand Hygiene policy dated 7/30/24 showed that hand hygiene is important in controlling infections. The policy showed that the facility will comply with the CDC guidelines regarding hand hygiene. Hand hygiene will be done during the following situations before and after direct contact with residents, before and after performing aseptic task, before and after assisting a resident with meals, before and after assisting a resident with toileting, before moving from one soiled body site to a clean body site on the same resident, after contact with blood, body fluids. or surfaces contaminated with blood and body fluids and after removing gloves, including during wound dressing change. 46003 4. R15 admitted to the facility o 10/10/18. R15's current care plan includes impairment to skin integrity to bilateral buttocks (Kennedy terminal ulcers). On 03/25/25 10:58 AM, R15 in enhanced barrier precautions received assistance from V15 LPN (Licensed Practical Nurse), V16 LPN and V17 RN (Registered Nurse) to be repositioned in the bed. V15, V16 and V17 did not put on isolation gown before providing care to R15 39182 6. On 3/26/25 at 8:30 AM, soiled linen and a used resident gown were seen on the floor in R72's room. On 3/26/25 at 8:35 AM, V10 (LPN-Licensed Practical Nurse) stated R72 was discharged the previous day and the room was not cleaned yet. V10 (LPN) stated, for infection control reasons, soiled linen should not be left on the floor. On 3/27/25 at 10:29 AM, V2 (ADON-Assistant Director of Nursing) stated, for infection control reasons, soiled linen should not be left on the floor and that it should be bagged and sent to the laundry.

Based on observation, interview, and record review, the facility failed to ensure medications are labeled and stored securely. This applies to 8 of 8 residents (R5, R8, R19, R35, R81, R101, R102 and R247) reviewed for medication storage in a sample of 24. 1. On 03/27/25 at 12:51 PM, a first-floor medication cart was reviewed with V10 LPN (Licensed Practical Nurse). The hydrocodone- acetaminophen 5/325 mg (Milligram) medication card for R101 had one tablet blister that had been taped closed. The medication card had a count of 30 tablets. R101's current physician orders include hydrocodone- acetaminophen 5/325 mg one tablet every four hours as needed for pain. V10 LPN stated once the blister is opened it should be wasted not taped back, but she was not sure why it should not be taped. V10 stated she was one of the nurses that did the narcotic count for that cart, but she did not look at the back of the medication cards when she did the count. 2. On 03/27/25 at 12:51 PM, the pregabalin 25 mg medication card for R102 one tablet blister that had been taped closed. The medication card had a count of 7 capsules. R102's current physician orders include pregabalin 25mg give one capsule by mouth every 24 hours for neuropathy at bedtime. 3.On 03/27/25 at 12:51 PM, the lorazepam 1mg medication card for R247 had one tablet blister that had been taped closed. The mediation card had a count of 22 capsules. R247's current physician orders include lorazepam 1mg give one tablet two times per day for anxiety. 4.On 03/27/25 at 01:08 PM, a second-floor medication cart was reviewed with V22 LPN. An insulin aspart flex pen did not have a label with resident's name, open on or use by dates. V22 stated the insulin pen belonged to R247. V22 stated she was not sure how long the pen is good for after it is opened. R247's MAR (Medication Administration Record) shows she receives 7 units of insulin aspart three times per day at 9am, 12pm and 5 pm. On 03/27/25 at 02:00 PM, V2 ADON (Assistant Director of Nursing) stated narcotics should not be taped to assure accuracy and safety assuring the mediation isn't contaminated or misappropriated. If medications are opened and not administered, they should be wasted, and the waste witnessed by two nurses. Insulins should be labeled with the resident's name, an opened on and use by date. Each pen should be stored in an individual bag. The facility policy Controlled Substances dated 8/16/24 states when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The facility policy Medication Storage, Labeling and Disposal dated 8/16/24 states mediations from pharmacy will be labelled by the pharmacy to include the name of resident, route of administration, instruction, medication name, strength and expiration date when applicable. The facility did not provide a policy specific to insulins. 39182 5. On 03/25/25 at 12:17 PM, observed Nystatin cream and Lubricant Eye Drops on R8's bedside drawer. R8 stated, she used the nystatin cream for the redness under her breast and the eye drops when she felt that her eyes are dry. On 03/27/25 at 11:53 AM, R8 still had the Lubricant Eye Drops on her drawer. On 3/27/25 at 1:02 PM, R8's Physician Orders were reviewed for March 2025. It showed Nystatin External Cream, apply to groin, abdominal fold and breast topically as needed for redness. R8's Physician orders did not include any orders for the Lubricant eye drops. 6. On 3/25/25 at 10:52 AM, observed a few tabs of large colorful pills in a cup on R247's bedside table. R247 stated, they are tums and she takes them for nausea because her IV (intravenous) antibiotic makes her nauseous. R247 stated, she had a whole bottle and she pulled out a bottle of tums from her drawer, almost full. On 03/26/25 at 09:53 AM, R247 still had the bottle of tums in her drawer, and on 03/27/25 at 10:55 AM, R247 had the bottle of tums in her drawer. On 3/27/25 at 1:07 PM, R247's Physician Orders were reviewed for March 2025. R247's Physician orders did not include any orders for Tums. On 03/27/25 at 12:05 PM, V6 (LPN-Licensed Practical Nurse) stated, residents should not have any medications at the bedside. 41384 7. On 03/25/25 at 10:57 AM in R5's bathroom there was one 1oz open tube of hydrocortisone cream 1%, one 2.11oz opened tube of hydrocortisone cream 1%, and one 2.11oz opened tube of Zinc Oxide ointment 20 %. R5 said that she uses the creams under her breast. R5's electronic health records showed a physician's order for 11/07/22 for Zinc oxide 20% apply to under let breast topically every 12 hours as needed. On 03/27/25 at 12:28 PM V2 ADON (Assistant Director of Nursing) said that no medications should be in residents' bathrooms for safety and hygiene reasons. 8. On 03/25/25 at 10:39 AM on R35's overbed side table there was 1 Albuterol Sulfate HFA inhaler and 1 fluticasone propionate (Nasal spray). R35's electronic health record showed a physician's order dated 1/13/25 for Albuterol Sulfate HFA every 4 hours as needed and an order for Fluticasone Propionate nasal spray with a start date of 3/24/25. On 03/27/25 at 12:32 PM V2 ADON said that medications need to be locked and secured. The facility's Medication Storage, Labeling and Disposal policy dated 8/16/24 showed that medications will be secured in locked storage area. 31327 9. On 03/25/25 10:22 AM, during initial tour, surveyor went to R81's room. R81 was lying in bed. There was a mediation cup with 5 chewable tablets of Tums on her bedside table. R81 stated, This is my Tums. The nurse always leaves it here for me to take it whenever I want it. R81's POS (Physician Order Sheet) for March 2025 shows an order for Calcium-Carb-Cholecalciferol Oral Tablet Chewable 500-10 MG-MCG (Milligrams-Micrograms) with instructions to Give 2 tablets by mouth one time a day for supplement.

Based on observation, interview, and record review, the facility failed to ensure a resident's IV (intravenous) antibiotic therapy bag was labeled. This applies to 1 of 1 resident (R81) reviewed for IV's in sample of 24. The findings include: On 3/25/25 at 10:18 AM, during initial tour, R81 was lying in bed. There was an IV pump toward the right side of R81's bed. There was an empty IV bag of Ceftriaxone without any label that included the date and time by the nurse. R81 stated that she is taking this antibiotic because she has an abscess in her liver. On 3/25/25 at 2:43 PM, R81's morning nurse was V4 (RN-Registered Nurse). She stated that the IV antibiotic was infused over the night shift at 6:00 AM by V5 (RN). V4 stated, The IV bag should have been labeled with the date, time, flow rate, and room number. On 3/27/25 at 10:24 AM, V2 (ADON-Assistant Director of Nursing) stated, The nurses need to make sure all information related to the antibiotic is on the IV bag. This includes the patient's name, what medication it is, when they started the medication, the rate, and start time. They should check the vitals before administration. They then should initial, add the time, and date it. R81's face sheet shows diagnoses of Escherichia Coli (E. Coli) as the cause of diseases, hepatomegaly, and secondary malignant neoplasm of bone. Review of R81's POS (Physician Order Sheet) for March 2025 shows an order dated 3/04/25 for Ceftriaxone 2 GM (Grams) IV with directions to use 1 dose intravenously in the morning for abdominal infection. R81's EMAR (Electronic Medication Administration Record) shows that the medication was last administered around 6 AM by V5. The facility was unable to provide an IV therapy policy that included the labeling of IV bags.

Based on interview and record review, the facility failed to conduct required care plan meetings and invite residents to participate in their care plan meetings. This applies to 4 of 4 residents (R20, R32, R69 and R79) reviewed for care planning in a sample of 24. Findings include: 1. R32's MDS (Minimum Data Set) dated 2/12/23 shows he is cognitively intact. On 03/25/25 at 11:45 AM, R32 stated he did not know what a care plan meeting was and had never been invited to one and feels the doctors make changes to his medications without discussing it with him. No documentation for care plan meetings were noted in R32's EMR. The facility was unable to provide any care plan meeting documentation for R32 for the past year. 2. R69's MDS dated [DATE] shows he is cognitively intact. On 03/25/25 at 10:40 AM, R69 stated he had been in the facility over two years and has never been invited to a care plan meeting. The only care plan documentation in the EMR able to be provided by the facility for R69 is dated 11/13/24. The only attendees documented were social services and R69's POA (Power of Attorney). 3. R79's MDS dated [DATE] shows he is cognitively intact. On 03/25/25 at 10:40 AM, R79 stated he had not been invited to a care plan meeting and most all of his family lived out of state. Documentation in the EMR and provided by the facility for R79 was dated 12/5/24. The attendees documented were social services, therapy, nursing administration, and a sister and brother-in-law. 4. R20's MDS dated [DATE] shows he has moderate cognitive impairment. No documentation for care plan meetings were noted in R20's EMR (Electronic Medical Record). No documentation of care plan meetings for R20 was received from the facility for the last year. On 03/27/25 at 11:59 AM, V20 Social Services Director stated care plan meetings are to be held quarterly. Residents are supposed to be invited to their care plan meetings. V20 stated she did not have any documentation of R20, R32, R69 or R79 being invited to their care plan meetings. V20 stated there is no sign in sheet listing care plan meeting attendees. V20 stated social services is responsible for setting up care plan meetings. V20 stated she is responsible for over seeing the social services department to assure assignments have been completed. V20 stated residents should be invited to their care plan meetings so they are aware of their care and the facility can address any concerns they may have. The facility wants to assure residents needs are being met while they are in the facility. V20 stated, R20, R32, R69, and R79 are able to be active participants in their care planning. The facility policy Care Plan dated 7/26/24 states it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations.

4. R46's 10/30/24 SBAR showed that on 10/30/24 R46's was transferred to the hospital and the form showed under Bed hold policy, b. prior to hospital transfer, the facility's Bedhold policy was not given to the resident and/or representative. On 03/26/25 at 03:53 PM V1 (Administrator) said that the facility does not notify the Ombudsman if they send a resident out for medical reasons. V1 said that the facility is not giving written notice of the reason for transfer to the residents and the family representatives. On 03/27/25 at 12:55 PM V2 ADON (Assistant Director of Nursing) said that the facility did not know that they were to notify the ombudsman of hospital transfers. Based on interview and record review, the facility failed to provide to a resident and/or their representative in writing for the reason of transfers to the hospital, and failed to notify the ombudsman of the transfers. This applies to 4 of 4 residents (R4, R46, R70, and R75) reviewed for discharge in a sample of 24. The findings include: 1. R4's Face Sheet showed R4 was admitted to the facility on [DATE]. R4 had multiple diagnoses which included moderate protein-calorie malnutrition, osteomyelitis of vertebra, Alzheimer's Disease, chronic kidney disease, and adult failure to thrive. R4's MDS (Minimum Data Set) dated 03/10/25 showed R4 was cognitively impaired. R4's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form dated 02/22/25 showed R4 had a change in condition with delayed response and an elevated heart rate. The same form showed R4 was transferred to the hospital via emergency medical transport on 02/22/25. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and notification of the ombudsman. 2. R70's Face Sheet showed R70 was admitted to the facility on [DATE]. R70 had multiple diagnoses which included heart failure, dysphagia, asthma, anemia, depression, hypertension, and atrial fibrillation. R70's MDS dated [DATE] showed R70 had moderate cognitive impairment. R70's Change in Condition with SBAR Form dated 08/13/24 showed R70 had a change in condition with dizziness. The same form showed R70 was transferred to the hospital. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and notification of the ombudsman. 3. R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included acute on chronic diastolic (congestive) heart failure, restlessness and agitation, hypertension, and asthma. R75's MDS dated [DATE] showed R75 had moderate cognitive impairment. R75's progress notes dated 11/02/24 at 2:08 AM, At 1:20 AM, the nurse heard resident asking for help. The nurse entered the room and observed R75 sitting at the edge of the bed. He stated, I'm having a hard time breathing. The nurse started immediately obtaining his vitals. Spo2 (oxygen) was 77. 911 was called. Will call the hospital to obtain an admitting diagnosis. 11/02/24 at 2:25 AM, admitted to (Hospital) per nurse. Admitting dx (diagnosis) of hypertension. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and notification of the ombudsman.

Based on interview and record review, the facility failed to follow physician's orders and subsequently a colonoscopy had to be rescheduled. This applies to 1 of 3 residents (R23) reviewed for following physician's orders for outpatient procedures. The findings include: R23 was scheduled for a colonoscopy and an EGD (Esophagogastroduodenoscopy) on 03/19/25 per the procedure reminder form sent from the gastroenterology office on 03/14/25. The form showed to hold Eliquis [blood thinner] two days prior to the procedure. R23's MAR (Medication Administration Record) for 03/2025 showed R23 was administered a blood thinner on 03/17/25 at 9:00 AM and 5:00 PM. R23's progress notes dated 03/19/25 at 2:17 PM, showed Resident unable to complete colonoscopy d/t (due to) inability to get IV (intravenous) placed. OBC to MD (Medical Doctor), awaiting return call back . On 03/21/25 at 8:44 AM, V23's (Medical Doctor), Physician Progress note showed diarrhea d/t colon prep. HX (History) of colon cancer. Colon scope not performed, no IV access, and per GI (Gastrointestinal) anticoagulant not held, which I had clarified with nurse on 03/18 AM of holding dose. On 03/27/25 at 11:29 AM, V1 (Administrator) stated R23 was scheduled for a colonoscopy on 03/19/25. The procedure was not done due to the hospital not being able to access an intravenous site and R23 being given a blood thinner on 03/17/25. V1 stated the blood thinner was supposed to be held on 03/17/25 but it was administered on that day. The nurse should not have administered the blood thinner on 03/17/25. The nurse who put the order in did not follow the doctor's orders. R23 was admitted to the facility on [DATE] with multiple diagnoses which included pulmonary embolism without acute cor pulmonale, diastolic (congestive) heart failure, acute embolism and thrombosis of left femoral vein, unsteadiness on feet, hypertension, and osteoarthritis.

Based on observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents who require assistance to maintain their cleanliness and comfort. This applies to 3 of 5 residents (R14, R46 and R395) reviewed for ADLs in a sample of 24. Findings include: 1. On 03/25/25 at 11:45 AM, R395 stated he has not been washed up since he entered the facility on 3/21/25. R395 stated he gets sweaty, and his gown sticks to his skin. R395 had a full-face beard. R395 stated he is not a beard guy. R395 stated he is itchy and uncomfortable with the facial hair. R395 stated he has asked staff for assistance, but they have not shared their names and when staff comes in his room, he feels like he is bothering them. On 03/27/25 at 09:13 AM, R395 still had a full beard and smelled of body odor. On 03/27/25 at 10:06 AM, V19 CNA (Certified Nursing Assistant) stated he did not know he was assigned to R395. V19 stated he was working a double shift, but the current shift started at 7am. V19 stated he needed to check the assignment board at the desk. V19 stated he needed to look to see when R395's shower day was scheduled. V19 stated he did not know how R395 transfers and he only gets residents out of the bed and offer care assistance if they ask. V19 CNA stated R395 would be bathed if he had time after assisting the other residents scheduled to shower. On 03/27/25 at 02:00 PM, V2 ADON (Assistant Director of Nursing) stated, the CNAs are responsible for bathing and shaving residents. The CNAs should know which residents are on their assignment list. V2 stated residents should be made aware of who their caregivers are. V2 stated residents are showered or bathed twice per week unless they request it more frequently. V2 stated CNAs should offer care assistance and to get residents up every day. 41384 2. On 03/25/25 at 11:12 AM R14's nails were long, jagged, and with a brown substance under the nails. R14 said that her nails bothered her, and she wanted the staff to provide nail care for her. R14's 3/1/25 electronic health record shows that R14 needs substantial/maximal assistance from the staff for personal hygiene. 3. On 03/25/25 at 12:27 PM R46 nails were long, jagged and with a brown substance under the nails, and the right thumb nail was curling on top of the thumb. R46's 2/13/25 electronic health record showed that his cognition is severely impaired, and he is dependent on staff for personal hygiene. On 03/27/25 at 12:52 PM V2 ADON (Assistant Director of Nursing) said that it is her expectation that staff provide ADL care for the residents including hand hygiene and trimming nails for safety and hygiene. The facility's General Care policy with a revised date of 7/30/24 showed that the facility's policy is to provide care for every resident to meet their needs including ADL needs.

Based on interview and record review, the facility failed to provide the resident and/or their representative of the facility bed hold policy in writing. This applies to 1 of 1 resident (R75) reviewed for discharge in a sample of 24. The findings include: R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included acute chronic diastolic (congestive) heart failure, restlessness and agitation, hypertension, and asthma. R75's MDS (Minimum Data Set) dated 03/16/25 showed R75 had moderate cognitive impairment. R75's progress notes dated 11/02/24 at 2:08 AM, showed At 1:20 AM, the nurse heard resident asking for help. The nurse entered the room and observed R75 sitting at the edge of the bed. He stated, I'm having a hard time breathing. The nurse started immediately obtaining his vitals. Spo2 (oxygen) was 77. 911 was called. Will call the hospital to obtain an admitting diagnosis. 11/02/24 at 2:25 AM, admitted to (Hospital) per nurse. Admitting dx (diagnosis) of hypertension. No documentation for bed hold policy given to resident and/or their representative uploaded into the medical record. The facility was unable to provide documentation of bed hold policy given to the resident and/or the representative. On 03/27/25 at 11:39 AM, V1 (Administrator) stated a bed hold policy should have been given to R75 and or his representative. The facility's Bed Hold and readmission Policy (revised 07/26/24) showed: Procedures 1. The facility must inform the resident or family members being transferred of the duration of bed hold in writing.

Based on observations, interviews and record reviews, the facility failed to ensure residents were treated with dignity while providing care. This applies to 2 of 2 residents (R3 and R47) reviewed for dignity in a sample of 24. The findings include: On 03/25/25 at 12:49 PM, V13 (Nurse) was standing over R3 while feeding R3 her lunch. At 01:17 PM, V13 was standing over R47 while feeding R47 her lunch. At 01:23 PM, V13 comes back to R3 and again V13 is standing over R3 while feeding R3 her lunch. On 03/27/25 at 01:00 PM, V2 ADON (Assistant Director of Nursing) said that V13 should not be standing over a resident while feeding them. V2 said that V13 should be at the same eye level as the resident for dignity, and safety, and it makes the residents feel more comfortable and respected. R3's 3/2/25 electronic health records showed that R3 needs partial/moderate assistance from staff for eating and her cognition is severely impaired. R47's 1/10/25 electronic health records showed that R47's cognition is severely impaired, and the record showed that R47 is totally dependent on staff for eating. The facility did not have a Residents' Rights policy but provided their Residents Rights book from the State of Illinois. The Book showed that the facility must treat the residents with dignity and respect.

Based on interview and record review, the facility failed to send a resident to the hospital emergency department via 911 after a change in condition. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 6. The findings include: R1 was originally admitted to the facility on [DATE] with multiple diagnoses including traumatic subdural hemorrhage with loss of consciousness of unspecified duration, unspecified fracture of the fifth lumbar vertebrae with delayed healing, type 2 diabetes mellitus without complications, cognitive communication deficit and need for assistance with personal care, based on the face sheet. R1's blood specimen obtained on December 30, 2024 for CBC (complete blood count) showed that the resident's WBC (white blood cell) was 17.92 (normal range 4.80-10.80), hemoglobin was 10.4 (normal range 12.0-16.0), hematocrit was 32.3 (normal range of 37.0-47.0). R1's progress notes dated December 30, 2024 at 3:16 PM, created by V3 (Primary Care Physician) showed documentation that the resident's vital signs were stable. The same progress notes under assessment and plan showed in-part, #Leukocytosis - WBC 17.9 - no complaints - no s/s (signs/symptoms) of infection - could be reactive to pain - recheck in a few days - if elevated in 1-2 days, need to do infectious workup. R1's blood culture result for blood specimen obtained on the right and left arm on December 31, 2024 showed gram positive cocci, staphylococcus aureus. R1's progress notes dated January 1, 2025 at 4:51 PM, created by V7 (Registered Nurse) showed, Writer relayed positive blood culture for staphylococcus aureus to NP (Nurse Practitioner) (V6) per NP send to hospital. R1's progress notes dated January 1, 2025 at 5:00 PM, created by V6 (Nurse Practitioner) as a late entry showed, chief complaint of positive blood culture, positive staphylococcus aureus. The progress notes documented R1's vital signs as follows: blood pressure 88/42, heart rate 141, temperature 98.2, respiration 16 and oxygen saturation 94%. Under impression it showed, 85 [years old] female [patient with] Staphylococcus [with] acute confusion, possible septic [with] unknown source. The same progress notes showed under plans, Send to ER (emergency room ) via 911 for further evaluation and management, case discussed with NOD (nurse on duty) and Nurse Supervisor in length. R1's change of condition progress notes dated January 1, 2025 at 8:53 PM, created by V7 (Registered Nurse) showed in-part that the resident had, Positive blood culture gram positive cocci in both left and right arm cultures and elevated WBC 17.92. The progress notes documented that R1's vital signs included blood pressure of 88/42, pulse of 141, respiration of 16, temperature of 100.2 and oxygen saturation of 95%. The same progress notes showed under observations and evaluations, At [4:00 PM] writer assessed patient's vitals, BP 88/42, heart rate 141, [temperature] 100.4, [oxygen saturation] 98%. Patient was alert, stated she was not in any pain, did not display any signs or symptoms of pain. Writer received a call from [laboratory] reporting gram positive cocci in both left and right arm cultures and elevated WBC 17.92. Writer attempted to contact on call physician to relay laboratory results, left voicemail. Writer contacted infectious disease NP (V6). Per infectious disease NP send patient to [hospital] via [ambulance]. 911 not necessary resident stable, no signs of distress noted. On January 15, 2025 at 11:37 AM, V7 (Registered Nurse) stated that she was the assigned nurse to R1 on January 1, 2025 during the morning (7:00 AM-3:30 PM) and afternoon (3:00 PM -11:30 PM) shifts. V7 stated that on January 1, 2025 during the entire morning shift, R1 was doing well, took her medications and received therapy services. However, at around 4:00 PM, R1's condition changed, manifesting low blood pressure (88/42), increased heart rate (141) and high temperature (100.2), and then she received a call from the laboratory reporting gram positive cocci in both of R1's left and right arm blood cultures, as well as elevated WBC. According to V7, she attempted to call the physician to relay the laboratory results but was not successful, so she (V7) contacted V6 (Infectious Disease Nurse Practitioner). V7 stated that she informed V6 of R1's gram positive cocci blood culture, elevated WBC, and the abnormal vital signs, including low blood pressure, increased heart rate and high temperature. V7 stated that she received the order from V6 to send R1 to the emergency department for further evaluation and treatment. V7 stated that R1 waited between 45 minutes to an hour at the facility for the regular ambulance to transport her to the emergency department. V7 was asked, why 911 was not called to transport R1 to the hospital since the resident's blood pressure was low, her heart rate was high and with fever. V7 responded that she had consulted V17 (Registered Nurse/Afternoon Nursing Supervisor) whether to send R1 via 911 or regular ambulance and it was decided to use the regular ambulance since the resident was eating dinner with her daughter at the bedside. On January 15, 2025 at 11:59 AM, V6 (Infectious Disease Nurse Practitioner) stated that on January 1, 2025 she was informed by the Nurse (V7) that she was attempting to contact R1's physician but had not received any response, so she (V6) was contacted. V6 stated that she was informed of R1's trending high WBC of 17.92, hypotension (low blood pressure), increased confusion and gram positive cocci blood cultures. According to V6, that was the first time she was called/consulted regarding R1 and with the information provided to her by the nurse, she ordered to send R1 right away to the emergency department for further evaluation and treatment of the abnormal vital signs, severe leukocytosis, and possible sepsis due to bacteremia. V6 further stated that because of the presenting change in R1's condition, the appropriate and best method to transfer the resident to the hospital was via 911, especially with the abnormal vitals to immediately evaluate and treat the resident. On January 15, 2025, 2025 at 3:47 PM, V3 (Primary Care Physician) stated that when he evaluated R1 on December 28 and December 30, 2024, the resident was doing fine with stable vital signs. According to V3, he and the Nurse Practitioner were aware of R1's condition and the trending elevation of the resident's WBC, which was why blood cultures, urine culture and chest x-rays were also performed to help determine the resident's condition. V3 stated that he believed that R1's condition gradually changed on December 31, 2024, as reflected on the blood culture that was obtained that same day which showed positive staphylococcus aureus, however R1's change in condition did not manifest until January 1, 2025 when her vital signs became abnormal. According to V3, the facility should have sent R1 to the hospital via 911 on January 1, 2025 due to hypotension and increased heart rate. V3 further stated that sending R1 via 911 was the appropriate method to transport the resident to the hospital to ensure that the resident could be immediately evaluated and treated.

Based on interview and record review the facility failed to follow their abuse policy by completing background checks on 1 of 3 new hires, (V3), reviewed for background checks. This applies to all residents residing in the facility. The findings include: The facility data sheet dated December 17, 2024 shows, there are 99 residents residing in the facility. On December 17, 2024 at 4:00 PM, V1 (Administrator) stated, V3 (Kitchen Aide) was hired at the facility on February 20, 2022. The Illinois State Police background check for V3 (Kitchen Aide) was done on December 9, 2024 (almost 3 years later). The result is no record on file. The Illinois Department of Public Health (IDPH), Health Care Worker Registry (no date) with V3's (Kitchen Aide) social security number shows, no workers found. Another IDPH Health Care Worker Registry (no date) shows, V3 (Kitchen Aide) is eligible to work and had a fee_app (fingerprint) on December 11, 2024. On December 17, 2024 at 2:04 PM, V1 (Administrator) stated, when the allegation of V3 (Kitchen Aide) came about they checked his file. They could not find his original back ground check so she ran another one. They found out he had never been fingerprinted so they also had him fingerprinted. They should be done on date of hire. The facility's abuse policy dated July 12, 2024 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. 7 steps in abuse prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: screening, training, prevention, identification, investigation, protection, reporting/response. I. Screening: Have procedures to: Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working in behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions, including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency, or academic institution. 3. Check the Illinois Nurse Aide Registry how known as Healthcare Worker Registry upon hire, to determine reports of abuse, neglect, and theft, if staff is not a licensed staff. 4. Initiate Illinois State Police fingerprint check for non-licensed applicants or new hires within 10 days of hiring, unless the applicant had been previously finger-printed in accordance to the Illinois background Check Act

Based on observation, interview and record review the facility failed to ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year old Spanish, American Indian woman. Her diagnoses are listed to include: paraplegia, need for assistance with personal care, depression, third degree burn to right toe & cellulitis to right lower limb. The facility's abuse report final form dated December 11, 2024 shows, sexual abuse to R1 by V3 (Kitchen Aide). (V4-Receptionist) reported to (V1-Administrator) that resident was upset about possible discharge. (R1) then stated that maybe it is because one of the kitchen staff (V3) kissed her and touched her chest sometime on 11/15/2024. On December 17, 2024 at 10:13 AM, R1 was lying in bed watching television. She stated, she exchanged her phone number with V3 (Kitchen Aide) who worked at the facility. They originally shared phone numbers until V3 (Kitchen Aide) asked R1 to download an app called Whatsapp (an application for your phone that allows people to message, text or call without using your phone number). They would text/message back and forth on the app. She stated, she was looking for a friend but then it became uncomfortable. He started asking her about her catheter and if she had ever had sex with it. He would text her that he couldn't stop thinking about her and she was real pretty. V3 (Kitchen Aide) came to her room on two different occasions. He touched her leg the first time and the second time he tried to kiss her and touched her breast. They both sent photos of themselves to each other. He would say he was masturbating to her photos. She did not report any of this until December 5, 2024 when she thought the facility was discharging her because of what happened with V3 (Kitchen Aide). On December 18, 2024 at 11:22 AM, V3 (Kitchen Aide) stated, he did exchange phone numbers with R1. She asked for his help and then asked for his phone number. They were texting back and forth. He did send her photos of himself. They did this for a few days when he told her that he was married and he shouldn't be sending or talking with her. He told her it was inappropriate and apologized. They stopped talking after that. He denied ever having any physical contact with R1 only messaging inappropriately back and forth. He also stated, he never received any training regarding abuse and/or relationships with residents however, his personal knowledge is that he shouldn't ever have a personal relationship with a resident. R1's messages with V3 (Kitchen Aide) as translated from Spanish to English shows, the messages start on November 14, 2024 and continue until November 21, 2024. On November 14, 2024 starting at 9:25 PM, the messages between V3 (Kitchen Aide) and R1 shows: V3- The one with the legs and beautiful smile V3- Well I love your legs V3- Well, would you let me see them again? R1- Well, I don't know that came out as a surprise V3- A very nice surprise that I want to repeat V3- Ok sweetheart V3- Brighten my night let me see your beautiful legs V3- sends a heart emoji and another attached file (not visible in the message feed provided) R1- Are you going to let me see yours? V3- Okay R1- Give me a minute R1- The [NAME] is here V3- Surprise me with a very beautiful and sexy photo V3- Ok sweetheart R1- I am not able to do it ha ha R1- I look like a ball nothing sexy @ V3- ok sweetheart V3- ok sweetheart, you are I can see it V3- No ball, sexy yes and beautiful legs and beautiful smile V3- If you can R1- shows an image was sent. Not visible in the message feed provided. R1- HA HA HA how awful V3- How beautiful V3- Are you in the bathroom? R1- No in my bed V3- Sometimes we do things that we may never think about but feels good with the person you like V3- Imagine that the diaper is a short, I repeat do not feel embarrassed with me I am calm and normal person V3- wowww@ wowww@ V3- How beautiful V3- See, they are beautiful, I make no mistake R1- Why are your pictures deleting? R1- app shows, you updated the message timer. New messages will disappear from this chat 24 hours after they're sent, except with kept. Tap to change. V3- the app shows, V3 turned off disappearing messages. Tap to change. R1- HAHAHA V3- The phone is configured to sent pictures I do not know if I change the settings V3- I am going to look into the settings to avoid this from happening again V3- I had never done anything with pictures before V3- I had never sent photos with anyone before, it feels strange, but with you it feels great and I loved it R1- Well me neither, that is the reason I felt embarrassed V3- Sweetheart do not feel embarrassed with me, feel free and relax They continue to talk, when R1 says she's going to sleep. V3 replies with, are you wearing pajamas. R1 says she doesn't have any and they continue to talk until V3 asks her again, Sweetheart sent me another picture, surprise me R1- I can make you imagine things I did not know. V3- A crazy picture R1- I cannot do it anymore, sorry V3- Why my love R1- Cannot do it anymore R1- We have to leave some to mystery R1- I hope you do not get upset V3- OK V3- I understand my sweetheart, I am not upset! I would love a crazy picture R1- Crazy like you? R1- Naked V3-Sweetheart, I wait for you to surprise me R1- Yes, yes, you know V3- do you want a picture of me? How do you want it? V3- I feel very comfortable with you R1-Ok bye V3- Sweetheart, you look so beautiful, thank you for that beautiful surprise V3- 3 kissy face emojis R1- Thank you V3- message says null R1- omg (oh my god) of course I'm going to dream of you thank you V3- I hoped you liked it, sweetheart V3- the one you sent me was beautiful V3- See you are beautiful V3- Please do not be embarrassed V3- sends to files. Not visible in the message feed provided. R1- I loved it but I should not have done it R1- Good night my love V3- I felt strange but I loved it V3- God blessed you, good night R1- Thank you the same to you The messages end at 10:56 PM on November 14, 2024. They start messaging again the next day, November 15, 2024 at 6:34 AM with causal conversation. At 10:20 AM, R1 tells V3 (Kitchen Aide), I want to let you know I can only offer you my friendship. V3 replies, I understand, both liked each other and it was a beautiful experience I want to repeat. At 2:09 PM, V3 (Kitchen Aide) starts asking R1 about her catheter. V3- sweetheart do you wear the urinary catheter at night and during the day? R1- yes the entire day V3- I thought it was only at night V3- Is that uncomfortable? R1- very uncomfortable, it irritates my skin R1- Since I am paralyzed I do not have any control R1- I do not have sensation V3- I understand it must be very uncomfortable, do you apply anything in your vagina to help you? V3- you do not have any vaginal sensation?! Thought you did have some V3- Do you have any sensation when you urinate? R1- I am starting to have some sensation V3- Sweetheart that is wonderful V3- do you know your clitoris is the most sensitive part of your body because it has a lot of nerves, you can stimulate it and get sensation back R1- I know all that but I do not want to stimulate me V3- My love you can do it very softly and think of something you like, you can do it very slowly V3- you can activate your nerves V3- sweetheart you can do it V3- tell me how I can help you? V3- doing it is natural, you probably did it before, I understand it is uncomfortable in your condition R1- no is not for me R1- I am another kind of women hahaha V3- you are beautiful R1- I am not interested in masturbating, I have other things to focus on They continue to talk about R1 going to Walgreens. At 7:24 PM, V3 (Kitchen Aide) starts talking about nude pictures. V3- when you sent me the last nude picture you made me feel excited, nervous and ticklish V3- I even felt like touching myself, I had years without feeling like that R1- I also felt something, in regards to the pictures is very private, I do not send to anyone V3- I had never done with anyone else, it's private, I felt comfortable and confident with you V3- I felt excited something new for me, were you able to reach it? The conversation continues. R1- what are you looking for or want from me? V3- I do not want you to feel uncomfortable, enjoy your time, enjoy the moment like your last day, the future is uncertain V3- you are very special for me V3- I can give you massage in your beautiful legs V3- I thing is very exciting to bite your neck softly V3- also to bite and suck your breast while I penetrate you it will be delicious R1- I have more than 3 years without having sex, I think is something spiritual not only to feel like do it The conversations continue until November 21, 2024. R1's minimum data set shows, she is cognitively intact. R1's care plan dated December 6, 2024 shows, POTENTIAL ABUSE NEGLECT, I have been in declining health & require support of the LTC setting. My personal trauma related factors include my illness, need for on-going care/attention & entering the SNF (skilled nursing facility) setting. Although I have been involved in an allegation/incident, there is no reason to suspect any unusual consideration, risk or concern for mistreatment. I am observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. The facility's abuse and neglect policy dated July 12, 2024 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment Types of abuse and examples: 5. Sexual: Any sexual behavior or relationship instigated by a staff member with a resident will be viewed as an allegation of sexual abuse, unless there is a pre-existing relationship between the caregiver and the resident prior to admission to the facility

Based on observation, interview and record review, the facility failed to maintain resident room air temperatures at a comfortable temperature. This applies to 9 of 9 residents (R1-R8 and R11) reviewed for homelike environment in a sample of 11. The findings include: 1. The electronic medical record showed R1 was admitted to the facility on [DATE]. On 6/20/24 at 11:22 AM, V5 (R1's Family) stated This room is too hot! V5 stated she complained that the room was hot since R1 moved into the facility but the room remained hot. R1 and R2 stated the room had been too hot for days. There was cool air slowly blowing from the air conditioning unit in the room, but the room was very warm and felt very humid and felt much warmer than the hallway air temperature. V3 (Maintenance) stated he replaced and flushed the air conditioner unit water lines the prior week. Facility Concern/Response Form, dated 6/20/24, shows V5 expressed concern that R1's room was too warm and there was not enough circulation in the room. The form shows V5 stated someone previously checked the air conditioner but the room had not cooled off enough. The form shows R1 was moved from her warm room to a room on the first floor. 2. On 6/20/24 at 11:24 AM, R3 stated, Today is better - yesterday was really hot. We close our shades but it's still too hot! R3's room was very warm and there was a small amount of cool air blowing from her air conditioner unit. On 6/20/24 at 1:49 PM with V3 (Maintenance) and V4 (Journeyman- Contract Company), R3's room air temperature measured 78 egress F (Fahrenheit) and the humidity measured 60% when measured with a psychrometer. 3. On 6/20/24 at 11:25 AM, R4 stated, It gets too hot sometimes! We close our shades but it's still too hot! R4's room was very warm and there was a small amount of cool air blowing from her air conditioner unit. On 6/20/24 at 1:49 PM with V3 and V4, R4's room temperature measured 78 degrees F and the humidity measured 58% when measured with a psychrometer. 4. On 6/20/24 at 11:27 AM R5 stated, It's been very warm in here! R11 stated, This is an old system - it's been hot in this room since the heat wave outside. R5 and R11 both stated they felt uncomfortable in their rooms due to the warm temperatures in their room. The room temperature felt very warm and humid. On 6/20/24 at 1:49 PM with V3 and V4, R5 and R11's room temperature measured 78 degrees F and the humidity measured 59% when measured with a psychrometer. 5. On 6/20/24 at 11:38 AM, R6 and R7 both stated the room was too hot and both residents stated they were uncomfortable. The room temperature felt hot and humid. R6 and R7's air conditioner had no air blowing from the unit when the unit was set on high and the temperature was set to 50 degrees F. Changing the settings on the air conditioning unit did not result in any air blowing from the unit. On 6/20/24 at 1:49 PM with V3 and V4, R6 and R7's room temperature measured 79 degrees F and the humidity measured 57% when measured with a psychrometer. On 6/20/24 at 1:15 PM, V3 and V4 stated R6 and R7's air conditioning unit was repaired after replacing and flushing the water lines. V4 stated with the age of the building and air conditioners, as well as the poor insulation of the older building, the resident air conditioners had difficulty keeping up with the hot temperatures. 6. On 6/20/24 at 11:43 AM, R8 stated, At night it's too hot in here and you can't sleep! It's always hot! R8 stated the small amount of cool air that blew through the air conditioner only stays in front of the air conditioner unit and did not circulate in the room. R8 stated, The only way you get air is if you sit on the unit! The air conditioner unit had a small amount of cool air lightly blowing from the unit and the room was very warm. 7. Concern/Response Form, dated 6/3/24, shows V6 (Family) shared a concern regarding R9 that the air conditioning was not as cool as it should be. The form shows, Maintenance checked the air conditioning and was blowing 66 degrees F. Maintenance showed V6 on thermometer. 8. Review of facility outdoor temperature history showed the outdoor daily high temperature measurements were as follows: 6/16/24 96 degrees F 6/17/24 97 degrees F 6/18/24 95 degrees F 6/19/24 95 degrees F 6/20/24 86 degrees F Facility Concern/Response Form, dated 6/19/24, shows an unidentified caller phoned the facility and stated her loved one was complaining the resident was hot. The form shows the caller would not provide the resident's name and stated the facility needed to check all of the resident room temperatures. The form shows V3 was asked to take temperatures on all of the rooms in the second floor and document. Review of second floor room temperature logs measured with a surface laser thermometer, dated 6/19/24, show second floor room surface temperatures fluctuated between 72-77 degrees F. No room air temperatures were taken utilizing a psychrometer. On 6/20/24 at 10:57 AM, V3 (Maintenance) stated on 6/19/24 he was using a laser thermometer to check surface temperatures in resident rooms and did not have a psychrometer at the facility to measure air temperatures in the resident rooms. V3 stated the humidity in the building was fluctuating between 55-60% and the resident room surface temperatures measured between 75 and 77 degrees F. Facility electronic hall thermometer measurement document shows on 6/17/24 at 7:00 PM the temperature in the second floor hallway measured 79.9 degrees F. The document shows on 6/18/24 at 7:00 PM the temperature in the second floor hallway measured 79.9 degrees F and on 6/19/24 at 7:00 PM, the temperature of the second floor hallway measured 80.2 degrees F. On 6/20/24 at 11:43 AM during initial tour of the facility, the second floor South hallway air temperature measured 77.9 degrees F (Fahrenheit) and the second floor nursing station room air measured 77.4 degrees F. On 6/20/24 with V3 and V4 at 1:44 PM, the second floor dining room had several residents sitting in the room and V3 measured the room temperature at 79 degrees F and humidity at 61% using a psychrometer. V3 also measured the temperature/humidity in the South resident hallway which measured 78 degrees F and 61% humidity. V3 and V4 stated the second floor main air conditioner chilled water pump was not working and had just been repaired. Temperature/humidity measurements taken from random resident rooms on the second floor ranged from 76.6-79 degrees F and 55-62% humidity. On 6/24/24 at 1:32 PM, V3 stated he did not begin taking any resident room temperatures when the outdoor temperatures rose above 80 degrees. V3 stated the only day he took resident room temperatures was on 6/19/24 which were taken using the laser surface temperature thermometer. Facility Policy Extreme High Temperature & Hot Weather, reviewed 7/27/23, shows, The following hot weather and extreme high temperatures precautions have been established for all personnel to follow during the hot weather of summer (outdoor temperatures climb into the 80's and above ) 4. Check air conditioning of residents and encourage fluid intake 7. Maintenance department to conduct random temperature checks of resident rooms and resident common areas. z. Administrative Code: Zones of Physiological Perception Comfort Level (68-75 degrees F) Facility Policy Ambient Temperature, reviewed 7/27/23, shows It is the facility's policy to ensure that facility ambient temperature remains at comfortable level. Procedure: 1. Keep temperature level all throughout the facility between 71 F to 81 F. 2. Ensure residents are comfortable 3. In extreme hot temperature, facility's hot temperature procedure should be activated.

Based on observation, interview, and record review, the facility failed to ensure residents' call lights were within their reach for 2 of 4 residents (R3 and R4) reviewed for call lights in the sample of 4. The findings include: On 4/23/24 at 10:58 AM, R3 was sitting in her wheelchair in her room. R3's wheelchair was positioned next to the left side of her bed toward the middle of the bed. R3's call light was wrapped around the upper left side rail which was to the right and behind her. R3 was unable to reach her call light. On 4/23/24 at 11:08 AM, R4 was sitting in her wheelchair in her room watching TV. R4's call light was behind her lying on the night stand. R4 said she uses her call light when she needs to call for help. R4 was unable to reach her call light. On 4/23/24 at 10:41 AM, V3, Licensed Practical Nurse (LPN), said staff keep the residents' call light in reach and residents should always have their call light. On 4/23/24 at 11:18 AM, V4, Certified Nursing Assistant (CNA), said the residents are asked to put on their call light if they need anything. V4 said the residents should have a call light within reach at all times. On 4/23/24 at 2:10 PM, V1, Administrator, said every patient needs a call light and it needs to be in reach so the resident can use it. R3's Admission Record dated 4/23/24 shows R3 was admitted to the facility on [DATE]. R3's care plan initiated on 4/1/24 shows her call light is to be kept within reach. R4's Admission Record dated 4/23/24 shows R4 was admitted to the facility on [DATE]. R4's care plan initiated 4/16/24 shows her call light is to be kept within reach. The facility's Call Light Policy (revised 7/27/23) shows call lights are to be placed within reach of residents who are able to use it at all times. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (Revised 11/18) shows residents should receive the services and/or items included in the plan of care and the facility must make arrangements to meet residents' needs and choices.

Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and oral care. This applies to 4 of 10 residents (R7, R14, R16, R17) reviewed for ADL (Activities of Daily Living) care in the sample of 20. The findings include: 1. R14's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, unspecified, altered mental status, hyperosmolality and hypernatremia, and history of falling. R14's quarterly MDS (Minimum Data Set), dated November 23, 2023, showed R14 is severely impaired in cognition, and required substantial/maximal assistance in oral care and personal hygiene. R14's care plan, initiated July 21, 2023, included R14 requires assistance with ADLs which included personal hygiene. Goal for the same included resident will be assisted with ADLs as needed through the review date of February 11, 2024. On January 29, 2024, at 12:59 PM, R14 was lying in bed, and noted to have both nostrils with visible long hair sticking out, which was crusted in a brownish substance. R14's lips were dry and peeling, and R14's teeth had coating of whitish substance. R14 stated, I feel like I have a dirty mouth. They don't do (clean) it. This was relayed to V4, CNA (Certified Nursing Assistant), who had come into the room. V4 stated \she just started the shift. V4 remarked, She (R14) has long nose hairs and looks like boogers in her nose. Her lips are real dry. 2. R16's face sheet included diagnoses of unspecified lack of coordination, nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement, and spondylosis without myelopathy or radiculopathy, lumbosacral region. R16's quarterly MDS, dated [DATE], showed \R16 was moderately impaired in cognition and required partial moderate assistance in personal hygiene. R16's care plan, initiated October 18, 2023, showed \R16 had a actual ADL self care deficit related to impaired mobility and impaired vision .as evidenced by needing the substantial/maximum assistance to dependent assistance of one to two staff members to meet her ADL needs. Goal included to be assisted with the proper level of assistance to meet her ADL needs as needed through the review date of March 26, 2024. On January 29, 2024, at 12:59 PM, R16 was seated in the dining room and noted to have long jagged nails. R16's hands were trembling and stated, they are all jagged. Would it be alright if you ask them to cut it? This information was relayed to V9 (Restorative CNA). On January 31, at 01:06 PM, V2 (Director of Nursing) stated staff should assist with mouth care first thing in the morning and nails should be cut as they grow. 29562 3. R17's Minimum Data Sheet (MDS), dated [DATE], shows R17 requires substantial to maximum assistance for toileting and personal hygiene care. On January 30, 2024, at 11:25 AM, V6 (Certified Nursing Assistant/CNA) rendered morning care to R17. V6 mixed liquid Dove soap to the water in the basin. V6 cleaned/wiped R17 with soap and water using a washcloth, then she immediately patted the skin with towel. She repeatedly did this process all over R17's body without rinsing the skin with water. 4. R7's MDS, dated [DATE], shows R7 is dependent on staff for toileting and personal hygiene care. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7. V6 used a wet washcloth with soap and water, then she patted it dry, without rinsing R7's skin. The soap used for R7 has an instruction which shows, Apply to wash cloth or directly to skin. Massage into lather, rinse, and towel dry. On January 31, 2024, at 1:07 PM, V2 (Director of Nursing/DON) stated that when soap is applied to the resident's skin, the staff must rinse the resident's skin to get the soap residue off and prevent skin irritation. Facility policy titled ADL Care included as follows: ADL care is provided to each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in ADLs. 4. ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders as well as ADL documentation on various shifts. such care may include as appropriate, but is not limited to: h. Daily assistance in eating: grooming/hygiene .

Based on observation, interview, and record review, the facility failed to follow their policy for Enhanced Barrier Precautions. The facility also failed to follow their policy for hand hygiene and glove use during provisions of care. This applies to 6 of 20 residents (R7, R17, R22, R44, R58, and R80) in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, stroke, dysphagia, and gastrostomy status. R80's MDS (Minimum Data Set), dated November 23, 2023, showed R80 had a feeding tube. R80's Order Summary Report, dated January 31, 2024, showed the following order dated September 30, 2023, Isolation Reason: Enhanced Barrier Precautions related to g-tube (gastrostomy tube) and trach (tracheostomy). On January 31, 2024, at 11:27 AM, V13 (RN/Registered Nurse) entered R80's room. R80's door had a sign posted titled Enhanced Barrier Precautions. V13 did not perform hand hygiene upon entering R80's room. V13 donned gloves and administered R80's enteral feeding. V13 did not wear an isolation gown. On January 31, 2024, at 2:26 PM, V2 (DON/Director of Nursing) said R80 was on Enhanced Barrier Precautions because R80 has a gastrostomy tube. V2 continued to say V13 should have performed hand hygiene upon entering R80's room and also worn a gown when administering R80's enteral feeding. 29562 2. On January 30, 2024, at 11:25 AM, V6 (Certified Nursing Assistant/CNA) rendered morning care, which include incontinence care to R17, who was wet with urine and had a bowel movement. V6 used wet wash cloth with soap and water to clean R17. As V6 was cleaning R17's peri-area, V6's gloved hands touched the fecal matter. V6 went back and forth to the basin to wet the washcloth with soap and water, opened the bedside vanity door to get the wet wipes to use for R17's perineum, placed a clean incontinence brief and clean incontinence pad under R17, and applied barrier cream to R17's back perineum, while wearing the same soiled gloves. 3. On January 30, 2024, at 12:45 PM, V4 (CNA) rendered morning which include incontinence care to R22. V4 cleaned R22's perineum from front to back and applied barrier cream with the same soiled gloves. After V4 applied the barrier cream, she changed her gloves, without hand hygiene, and completed the care by placing new incontinence brief, assisted R22 to reposition. 4. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7. V6 cleaned peri-area, removed soiled incontinence brief, straightened clean linen/bedding, placed pillow under R7's head, and helped reposition R7, while wearing the same soiled gloves. On January 31,2024, at 1:12 PM, V2 (Director of Nursing/DON) stated staff should perform hand hygiene prior to care and change gloves and perform hand hygiene from dirty to clean task to prevent spread of infection. 43389 5. On January 29, 2024, at 10:52 AM, V3 (LPN/Licensed Practical Nurse) entered R44 and R58's room. R44 and R58 were roommates. There was an Enhanced Barrier Precautions (EBP) sign posted on the door outside of R44 and R58's room that showed gown and gloves should be worn when using tube feeding device, and when providing care to the tube feeding devise. There were isolation gowns outside of R44's room. V3 put on gloves and went into R44's room with two bottles of tube feeding and put it on the end table. V3 did not don a gown. V3 listened to R44 bowel sounds and went out of the room looking into the drawers of the medication cart and said she can't find acetaminophen liquid, and she will come back with that. V3 did not remove her gloves before going out of the room, and did not sanitize her hands before coming back into the room. V3 took R44's 60 cc (cubic centimeter) syringe that was hanging on the IV (Intravenous) Pole. V3 then went into the bathroom and filled a 60 cc syringe with water. V3 flushed the full 60 cc syringe. Water started spilling out of the tube and onto V3's gloves and on R44's stomach and bed. V3 went into the bathroom removed her gloves and got some paper towels. V3 put on new gloves, and did not sanitize her hand or wash her hands before coming out of the bathroom. V3 took and filled the feeding bag with 1.5 bottles of enteral feeding up to 400 milliliters (mL). V3 primed R44's tubing with the tube feeding and attached it while clear liquid was still coming out of the tubing. V3 took off her gloves after examining the g-tube (gastrostomy tube). and looked like she was getting ready to leave the bedside. Then V3 continued to examine the g-tube and didn't sanitize her hands. V3 was touching the tubing without any gloves on. V3 looked like she was trying to check patency while turning the knobs on the g-tube and touching enteral feeding bag. V3 grabbed the half bottle of enteral feeding and took it to her medication cart outside the room. V3 did not sanitize her hands after removing her gloves. V3 began touching the computer mouse and looking up R58's (roommate's) medical record. Then V3 took out R58 enteral feeding from the medication cart, locked cart, got gloves, and went into the room and did not sanitize her hands on the way in. V3 put gloves on and listened to bowel sounds around navel/insertion site. V3 later left the room and on the way back into the room V3 did not perform hand hygiene was not wearing any gloves or gown. V3 went into the bathroom and put water in the 60 cc syringe and got some paper towels and went out of the room to check the computer and did not sanitize her hands on the way back into the room. V3 put the paper towels down and put on gloves and pushed 60 cc of water into R58's tubing. Clear liquid flowed out of the R58's tubing. V3 primed tubing and connected the tubing. Clear liquid started coming out of the tubing and she cleaned with paper towels. V3 moved the garbage can with her gloved hands. V3 then removed her gloves and did not perform hand hygiene. V3 went to the restroom with the syringe poured some fluid into the sink and brought the syringe back to the bedside and hung it on the IV pole. V3 then went to her medication cart without performing hand hygiene. V3 started opening drawers and touching the cart. V3 did not put on a gown during any part of the encounters with R44 or R58. On January 31, 2024 at 2:33 PM, V2 (Director of Nursing) stated staff in the EBP rooms should wear gloves and a gown and possibly goggles or shield. V2 stated staff should perform hand hygiene in and out of the room. V2 stated nurses should wash hands after handling a residents G-tube especially if hands are soiled and after removing gloves. The facility's Enhanced Barrier Precautions signs that are posted outside of residents' rooms read as follows: Enhanced Barrier Precautions (EBP): EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, and Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The facility's Enhanced Barrier Precautions policy, dated October 23, 2023, shows the following: 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs (Novel or targeted multiple drug resistant organism) to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur. Examples of high-contact resident care activities require gown and glove use among residents that trigger EBP use include: a) Dressing, b) Bathing/Showering, c) Transferring, d) Providing hygiene, e) Changing Linens, f) Changing briefs or assisting with toileting, g) Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and h) Wound Care: any skin opening requiring a dressing. The facility's Hand Hygiene policy, dated July 28, 2023, shows the following: Policy Statement: Hand hygiene is important in controlling infections. Hand hygiene consist of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines in regards to hand hygiene. Procedures: Hand Hygiene using alcohol-based hand rub is recommended during the following situations: a. Before and after direct resident contact. g. Before moving from work on soiled body site to a clean body site on the same resident. h. After contact with blood, body fluids or surfaces contaminated with blood and body fluids. i. After removing gloves including during wound dressing change.

Based on observation, interview, and record review, the facility failed to provide personal privacy during provisions of Activities of Daily (ADL) care. This applies to 4 of 6 residents (R40, R11, R22, and R7) reviewed for privacy in the sample of 20. The findings include: 1. On January 30, 2024, at 9:58 AM, V4 (Certified Nursing Assistant/CNA) assisted R40 with ADL care. V4 removed R40's clothes to render incontinence care. R40 was wet with urine and had a bowel movement. During the process of care, V4 went back and forth to the bathroom multiple times to change her gloves and perform hand hygiene, leaving R40 totally naked in bed. In addition, V4 did not close the window curtain and draw privacy curtain all throughout the care. Though R40's roommate was not in the bedroom, he could have come in anytime. 2. On January 30, 2024, at 10:42 AM, V4 (CNA) assisted R11 to the bathroom for toileting care. The bathroom was located by the entrance of the bedroom. V4 did not close the bedroom door or the bathroom door while R11 was using the toilet. R11's roommate (R40) was inside the bedroom, sitting in his wheelchair and propelling it. 3. On January 30, 2024, at 12:45 PM, V4 (CNA) rendered morning care and incontinence care to R22. V4 cleaned R22's peri-area, changed clothes, and emptied the catheter bag. However, V4 did not draw the window curtain and privacy curtain during provisions of care. R22's bed was by the window. There were houses across the parking lot, which was facing R22's window. 4. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7 and changed R7's incontinence brief. R7's bed was positioned near the window about 2.5 feet away, and was on the same level as the window. V6 did not close the window curtain during care. There was a building with a window across the facility, which was facing R7's bedroom window. On January 31, 2024, at 1:19 PM, V2 (Director of Nursing/DON) stated, Staff should provide privacy when providing care like closing the door, drawing privacy curtain and window curtain; it doesn't matter which floor the bedroom was located at, the staff should close the window curtain. The staff should expose only body parts they're providing care to. Facility's Policy and Procedure for Privacy and Dignity with revised date of July 28, 2023, shows: Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is always respected by staff. Procedures: 1. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and privacy screen will be used.

Based on interview and record review, the facility failed to ensure residents were offered pneumococcal vaccination in accordance with their policy and CDC (Center for Disease Control) guidelines. This applies to 5 of 9 residents (R7, R26, R29, R32, and R46) reviewed for immunizations in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R7 was [AGE] years old. R7 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, diabetes type 2, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non dominant side. R7's immunization record showed R7 had not been offered nor received any pneumococcal vaccine since admission, prior to January 13, 2024. R7 had consented to receive the vaccine on January 13, 2024, but as of January 31, 2024, had not received the vaccine. On January 31, 2024, at 1:40 PM, V12 (Infection Preventionist) stated there is no documentation to show R7 had previously been offered the pneumococcal vaccine prior to January 13, 2024. V12 also stated the facility can obtain the pneumococcal vaccine from the pharmacy and administer the vaccine within the facility. V12 further stated R7 was eligible to receive the pneumococcal vaccine according to the CDC policy and facility policy at the time of admission. 2. The EMR showed R26 was [AGE] years old. The EMR showed R26 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, atherosclerotic heart disease, essential hypertension, and unspecified dementia without behavioral disturbance. R26's immunization record showed R26 had not been offered the pneumococcal vaccine since admission until January 11, 2024, when R26 consented to receive the vaccine. The facility does not have documentation to show R26 has been administered the pneumococcal vaccine. On January 31, 2024, at 1:41 PM, V12 stated there is no documentation to show R26 had been offered the vaccination previously, and stated R26 would have been eligible to receive the pneumococcal vaccine at the time of admission. 3. The EMR showed R29's was age [AGE] years old. The EMR showed R29 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, combined systolic and diastolic congestive heart disease, atherosclerosis artery disease of both the right and left legs with ulceration, osteoarthritis unspecified and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R29's state immunization record showed R29 had received the Prevnar 13 pneumococcal vaccine on September 9, 2015, prior to admission. R29's EMR did not contain the Prevnar 13 administration data. R29 consented to pneumococcal vaccine on January 10, 2024, and the vaccine had not been administered as of January 31, 2024. On January 31, 2024, at 1:38 PM, V12 stated R29 should have been offered the pneumococcal vaccine, either the PCV20 or PPSV23 in accordance with the facility policy at the time of admission. V12 stated there is no record that showed R29 had been offered the pneumococcal vaccine prior to January 10, 2024. 4. The EMR showed R32 was [AGE] years old. The EMR showed R32 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, peripheral vascular disease, chronic kidney disease stage 4, morbid obesity severe due to excess calories, paroxysmal atrial fibrillation and neuromuscular dysfunction of the bladder. R32's immunization record showed R32 has not been offered the pneumococcal vaccine since admission and has not received the vaccine, prior to January 31, 2024. R32 signed a consent to receive the pneumococcal vaccine on January 31, 2024. On January 31, 2024, at 1:36 PM, V12 stated R32 would have been eligible to receive the pneumococcal vaccine at the time of admission. V12 stated there is no documentation to show that R32 had been offered the pneumococcal vaccine since admission. 5. The EMR showed R46 was [AGE] years old. The EMR showed R46 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, unspecified, venous insufficiency with peripheral vascular disease, muscle wasting, and atrophy not elsewhere classified, multiple sites, and pressure ulcers of the right and left heels. R46's state immunization record showed R46 received Prevnar13 vaccine on March 15, 2018, prior to admission. This vaccine was not documented as administered in R46's immunization tab in the medical record. R46 signed a consent to receive the pneumococcal vaccine on January 11, 2024, and as of January 31, 2024, the vaccine has not been administered. On January 31, 2024, at 1:30 PM, V12 stated R46 was eligible to be offered the pneumococcal vaccine, either PCV20 or PPSV23 in accordance with the facility's policy at the time of admission. There was no documentation that showed R46 was previously offered the pneumococcal vaccine from the time of admission until January 11, 2024. On January 31, 2024, at 1:30 PM, V12 stated at the time of admission, all residents' immunizations should be reviewed to determine the need for pneumococcal vaccine. V12 further stated there is a website from the state to view any previous vaccine administration, and that website lists data that can be added to the resident's immunization tab in their medical record as historical data, in order to have a complete immunization record. V12 stated the facility uses an outside vendor to hold vaccine clinics, but there is currently no date for a pneumococcal vaccine clinic. V12 also stated the facility can obtain the vaccine from the pharmacy and administer the vaccine in the facility. The facility policy titled Pneumococcal Vaccination, dated October 5, 2016, and revised December 12, 2023, showed, It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident as recommended by the CDC's ACIP (Advisory Committee on Immunization Practices) unless otherwise contraindicated or the resident or responsible party has refused the vaccine.

Based on interview and record review, the facility failed to protect a resident's right to be from sexual abuse by another resident. This failure resulted in R1 experiencing sexual abuse at the facility when R2 put his hand underneath R1's clothing and touched her breast area. R1's medical diagnosis makes assessing the effects of sexual abuse difficult. A reasonable person would not want to be touched in the breast area without consent. This applies to 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: On December 28, 2022 at 1:30 PM, R1 was sitting in a high-back wheelchair near the doors of the dining room, and close to the nurse's station. R1 was fully dressed and seated next to another resident. R1 was not able to answer questions due to her cognitive status. The EMR (Electronic Medical Record) shows R1 is a [AGE] year-old female resident, who was admitted to the facility on [DATE]. R1 has multiple diagnoses including metabolic encephalopathy, protein-calorie malnutrition, dementia, and hypertension. R1's MDS (Minimum Data Set), dated October 12, 2022, shows R1 has severe cognitive impairment, is totally dependent on facility staff for locomotion, and requires extensive assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of urine and frequently incontinent of stool. R1's MDS continues to show R1 has unclear speech, is rarely/never understood, and rarely/never understands verbal content of others. On December 23, 2022 at 6:28 PM, V6 (RN-Registered Nurse) documented, Two staff members reported [R1] being touched inappropriately by another resident. Completed head to toe assessment with nothing noted. MD (Medical Doctor), POA (Power of Attorney) and Administrator made aware. Full investigation to follow. The facility's Abuse Report Initial Form, dated December 23, 2022 at 7:30 PM shows: Type of Abuse: Sexual Date and time when staff became aware of the incident: 12/23/2022 6:30 PM Alleged Victim: [R1] Alleged Perpetrator: [R2] Who made the allegation: [V3] (CNA-Certified Nursing Assistant) What was the reported allegation of abuse: On December 23, 2022 around 6:37 PM, [V1] (Administrator) was alerted by CNA [V3] that the resident, [R2] appeared to have his hand underneath the blouse of [R1], another resident. [V3] separated the residents immediately. Head-to-toe assessment completed on [R1], with no concerns. MDs and POAs made aware. MD for [R2] does not want resident sent out for psychiatric evaluation. [R2] is being moved to [another room]. [Local police department] came and interviewed both residents and the family of [R1]. There are no concerns at this time. Full investigation to follow. The EMR shows R2 is an [AGE] year-old gentleman, who was admitted to the facility on [DATE] and discharged to home on December 24, 2022. R2 had multiple diagnoses including, low back pain, abnormal gait and mobility, heart disease, anxiety disorder, hypertension, atrial fibrillation, chronic kidney disease, unsteadiness on feet, history of falling, Alzheimer's disease, diabetes, and depression. On December 19, 2022 at 5:00 PM, V 14 (Physician) documented: Initial H&P (History and Physical) .Physical Exam: Neuro: AAO (Awake, Alert and Oriented) times 3 (Person, Place, Time). R2's MDS, dated [DATE], shows R2 had moderate cognitive impairment, required supervision with eating, and extensive assistance with all other ADLs. R2 was always continent of stool and occasionally incontinent of urine. R2's MDS continues to show R2 had clear speech, was able to make himself understood and was able to understand verbal content of others. On December 27, 2022 at 3:40 PM, V13 (Police Officer) said, We did make contact with the staff and residents (R1 and R2). After our interviews, we believe [R2] acted with intent and knew what he was doing. He stuck his arm under [R1's] shirt and was squeezing her breast area. On December 28, 2022 at 12:12 PM, V3 (CNA) said, I had noticed when I came out of a room after doing patient care that [R2] was sitting over by [R1]. She (R1) was sitting by the nurse's station. She usually sits by the nurse's station. She is a fall risk and tries to get up a lot so we can keep an eye on her when she is there. One of the nurses was out of the facility on a dinner break, and the other nurse was in the restroom. No other staff were around. I tiptoed over to [R1] and [R2] because [R2] was so close to [R1]. When I got close, I saw [R2] was holding [R1's] right hand with his right hand, and he had his left hand under her shirt in the front. When I asked him why his hand was under her shirt, his eyes got big. When he saw that I was there, he brought his hand out from under her shirt. I told him to go to his room and he followed my instructions. I worked a lot that week and know both residents well. [R1] would not be able to tell anyone what happened to her because she is so confused. I was surprised by the situation. I have worked here since 2015 and never seen anything like it. On December 29, 2022 at 10:27 AM, V5 (RN-Registered Nurse) said, I am an agency nurse. I was assigned to care for [R2] on December 23. I left the facility for about ten minutes to get food. I agreed to stay over into the next shift to pass medications. I did not bring food with me, so I ran to the store to get some food. When I returned, the other nurse and CNA told me there was an incident with [R1] and [R2]. I did not actually witness the incident. I always ask the residents their name, birthday, where they are and why they are there. [R2] was able to answer three of the four questions correctly, though I cannot recall which three he answered correctly. He said he understood me. On December 29, 2022 at 10:40 AM, V6 (RN-Registered Nurse) said, [R1] was assigned to me that day. I started at 3:00 PM. [R1] was sitting in the chair outside of the dining room so we could keep an eye on her, which is pretty standard. I had to use the restroom and the other nurse was on a break off the floor. All of a sudden [V3] (CNA) was banging on the restroom door calling me to come out because [R2] had his hand under [R1's] shirt in the front. I did not actually witness the resident's hand under her shirt because [V3] had stopped the situation before I got there. I don't think [R2] realized [V3] (CNA) saw what he was doing to [R1] when she said something to him. No other staff were around. [R2] was able to follow instructions to go back to his room, and he looked like he was shameful when he got sent back to his room. The fact that he waited until no one was around to touch the other resident, made it seem like he knew what he was doing. On December 29, 2022 at 2:45 PM, V12 (Physician) said, I am familiar with the patient (R1). She is alert, there is a language barrier and a history of dementia. She has cognition issues. She would not be able to give consent to hold hands with a male resident or allow him to touch her underneath her clothing. It is not appropriate for anyone who is not related to touch someone in that way. The facility's Abuse and Neglect policy, effective 10/24/22, shows: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Types of Abuse: .5. Sexual: Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Even if there is capacity to give consent, consent obtained through intimidation, coercion or fear is considered sexual abuse. Must be reported examples in the SOM (State Operations Manual) includes: Unwanted touching of the breast or perineal area. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal or non-verbal cues.Sexual activity or fondling where one of the resident's capacity to consent is unknown.

Based on interview and record review, the facility failed to ensure that residents were free from mental abuse and failed to protect vulnerable residents from abuse. These failures affect 1 out of 1 resident (R277) reviewed for abuse in a sample size of 19. This failure resulted in R1 feeling embarrassed and violated about being seen on live video during personal care and felt threatened when the agency aide returned to the facility days later. Findings include: On November 2, 2021 at 12:05 PM, R277 was observed lying in bed in her room. She had a cast on her right arm and dressing on her right leg. R277 said she was in a car accident and both her legs and her right wrist were broken. R277 said on October 25, 2021 around 3:45 PM, (V11) an agency CNA (Certified Nurse Aide) came into her room to assist her with toileting. R277 noticed that V11 had an earpiece on and was talking on the phone. While V11 was assisting R277 on the bedpan, V11 placed her phone down beside R277, and R277 saw a man on the phone. R277 realized that V11 was on Face Time (video call). R277 said she felt embarrassed because if she was able to see the man on the V11's phone, then he would also have seen her while V11 was assisting her with toileting. R277 said she reported the incident to V3 (Restorative Director) immediately. R277 was informed by V1 (Administrator) that V11 would no longer work at the facility. R277 said that on October 27, 2021, the same agency CNA (V11) came to her room around 7:30 AM. V11 did not speak to R277; all V11 did was look at R277 and then left her room. R277 said she felt threatened because there was no way for her to protect herself due to her injuries from the car accident. R277 said once V11 left her room, she informed V1 (Administrator). V11 was sent home immediately. R277 said the whole incident was embarrassing and she felt violated. R277's Face Sheet shows multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R277's MDS (Minimum Data Set) dated October 27, 2021 shows R277's BIMS (Brief Interview for Mental Status) score of 15, which indicates her cognition is intact, and R277 requires extensive 2 person assist with transfers and 1 person assist with personal hygiene. On November 2, 2021 at 1:30 PM, V1 (Administrator) said R277 informed her on October 25, 2021 that while an agency CNA (V11) was toileting her, V11 was talking on the phone and when V11 placed her phone down, R277 realized V11 was on Face Time because she saw a man's face on V11's phone. V1 said R277 was not sure of what the man saw. V1 contacted V11's agency after the incident occurred and told the agency that V11 could not return to the facility. V11 was placed on the Do Not Return list. V1 said R277 informed her that V11 came into her room on October 27, 2021. V11 was sent home immediately after that. V1 said she was not sure why V11 returned to the facility after the first incident. V1 said she felt the incident was a privacy concern and not an abuse concern, and she did not report the incident to the state agency. V1 said she did not ask R277 how she felt about the incident that occurred. V1 said she completed a grievance form in regard to the incident. V1 said she is the abuse coordinator. On November 2, 2021 at 3:00 PM, V3 (Restorative Director) said at the beginning of last week, R277 reported to her that while she was being toileted by an agency CNA (V11), V11 was on the phone, and when V11 placed her phone down, R277 saw that V11 was on Face Time, because she saw a man on V11's phone and he may have seen her while she was being toileted. V3 said R277 said she was in disbelief about the incident. V3 said she reported the incident to V1 (Administrator); V1 is the abuse coordinator. V1 told her that she would take care of it. The Grievance and Satisfaction Form completed on October 26, 2021 at 8:00 AM showed that R277 reported to V1 that on October 25, 2021 during the 3-11 shift, an agency CNA (V11) was on the phone while providing care, it looked like Face Time, but R277 was not sure. The facility's 2021 policy titled Abuse and Neglect shows, Mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear of shame. Mental abuse includes nursing home staff or using photographs or video recordings in any manner that would demean or humiliate a resident(s). This would include using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media.

Based on observation, interview and record review the facility failed to ensure R1 received insulin as ordered by the physician and failed to ensure R4's cardiac medication was administered as ordered by the physician. These failures resulted in R1 sustaining elevated blood sugars and R4 requiring intravenous fluids and experiencing low blood pressure on multiple days. This affects 2 of 4 residents (R1, R4) reviewed for improper nursing and medication administration in the sample of 9. Findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was transferred from the facility to the local hospital on September 5, 2021 and admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated September 5, 2021 shows R1 was cognitively intact, required supervision with locomotion and eating, extensive assistance with bathing, and limited assistance with all other ADLs (Activities of Daily Living). R1's hospital transfer/discharge medication list, dated September 2, 2021 at 6:00 PM, shows multiple medication orders for R1 including [MEDICATION(S)] (diabetes medication) 10 mg orally every morning, insulin [MEDICATION(S)] (fast-acting insulin) subcutaneously, three times a day before meals, with the next dose of insulin [MEDICATION(S)] due on September 3, 2021. The discharge medication list continues to show insulin [MEDICATION(S)] (long-acting insulin) subcutaneously, two times a day, with the next dose due on September 2, 2021 PM. The hospital discharge paperwork shows R1's blood sugar was 231 at dinner on September 2, 2021 prior to discharge from the hospital to the facility. The EMR shows the [MEDICATION(S)] 10 mg orally every morning was ordered for R1, and [MEDICATION(S)] (fast-acting insulin) was ordered on a sliding scale three times a day, with blood glucose monitoring. The facility did not have documentation to show R1's insulin [MEDICATION(S)] (long-acting insulin) was ordered or administered to R1 while residing at the facility. The facility does not have documentation to show R1's physician was notified of the order for the long-acting insulin or the reason the resident was not receiving the medication as ordered. R1's blood sugars while residing at the facility were documented and treated as follows: 9/3/21 9:00 AM: 283 - gave 6 units of [MEDICATION(S)] insulin 9/3/21 1:00 PM: 344 - gave 8 units of [MEDICATION(S)] insulin 9/3/21 5:00 PM: 216 - gave 4 units of [MEDICATION(S)] insulin 9/4/21 9:00 AM: 362 - gave 10 units of [MEDICATION(S)] insulin 9/4/21 1:00 PM: 307 - gave 8 units of [MEDICATION(S)] insulin 9/4/2021 5:00 PM: 113 - no coverage required 9/5/2021 5:00 PM: 350 - gave 8 units of [MEDICATION(S)] insulin Facility documentation shows R1 experienced multiple bouts of nausea on September 3, 4, and 5, 2021. R1 received anti-nausea medication. Nursing documented the medication was effective three of the five times the medication was administered on September 3, 4, and 5, 2021. On September 5, 2021 at 3:25 AM, V10 (Registered Nurse/RN) documented R1 was having nausea/vomiting/diarrhea. R1 was sent to the local hospital via 911 ambulance. V10 documented at 6:53 AM, R1 was admitted to the local hospital's intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Hospital documentation dated September 5, 2021 shows R1 was admitted to the local hospital with a blood glucose level of 333 mg/dL (milligrams/deciliter) (High) DKA, leukocytosis, and vomiting. On October 18, 2021 at 2:56 PM, V9 (Consultant Pharmacist) said, The [long-acting insulin] medication was never ordered by the facility. Nursing staff should clarify medication orders and dosages with the physician when the orders come from the hospital. Our pharmacy sent a recommendation to the facility to request the facility staff obtain the order for the long-acting insulin and clarify the dosage after we reviewed the hospital orders and saw the medication was not ordered by the facility. The recommendation went out to the facility on [DATE], but the resident had already been transferred to the hospital. On October 18, 2021 at 3:32 PM, V1 (Administrator) said, When a new resident is admitted to the facility, the medication orders from the hospital are audited by a nursing manager. It would have been our post-acute manager who should have audited [R1's] hospital orders and clarified the insulin dosage. The post-acute manager is no longer working here. On October 18, 2021 at 3:59 PM, V8 (Physician) said, I was not aware [R1] was admitted to the hospital with DKA, or that she had sustained high blood sugars over the few days she was at the facility. I would have expected the facility to clarify the long-acting insulin dosage with me if they were unsure. I would have made sure she got the medication. Elevated blood sugars can be a result of not receiving insulin as ordered. The facility's nursing care guidelines entitled Medication Reconciliation, dated May 5, 2018 shows: The facility will accurately and completely review and reconcile all medications upon the resident's admission to the organization and with the involvement of the patient or responsible party as indicated and to communicate list of resident's medications to the next provider of services when referred or transferred to another setting, service, or level of care within or outside the organization. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Procedures or steps: 1) New Admission - the steps may include: a) Obtain, review, and verify medications orders from the hospital discharge summary/instructions and/or medication history. b) Verify orders with the attending physician. Clarify that the medications and dosages are appropriate. Reconcile and document any changes. c) Create/enter medication administration record. 2. On October 19, 2021 at 9:38 AM, V16 (Licensed Practical Nurse/LPN) administered multiple medications to R4, including [MEDICATION(S)] (Extended-Release beta-blocker/cardiac medication) 25 mg to R4. V16 documented R4's blood pressure on October 19, 2021 at the time of administration of the [MEDICATION(S)] 25 mg. as 100/60, and heart rate as 60 beats per minute. The EMR shows an order dated September 29, 2021 for [MEDICATION(S)] 25 mg tablet extended release 24-hour daily at 9:00 AM. The EMR shows the order was discontinued on October 4, 2021 in order to crush medications. The EMR shows a new order dated October 4, 2021 for [MEDICATION(S)] [MEDICATION(S)] (beta blocker/cardiac medication) 12.5 mg orally, twice a day for [CONDITION(S)]. Hold if SBP (Systolic Blood Pressure) is less than 110 and/or HR (Heart Rate) is less than 60. On October 19, 2021 at 1:00 PM, V16 was asked if the blood pressure of 100/60 was R4's blood pressure at the time of administration of the [MEDICATION(S)] 25 mg. V16 said, Yes. V16 could not give a reason why she administered the medication when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V16 confirmed she administered [MEDICATION(S)] 25 mg, not the order shown in the EMR for [MEDICATION(S)] [MEDICATION(S)] 12.5 mg. V16 said, This is what we've been giving and showed R4 had been receiving the [MEDICATION(S)] 25 mg twice a day since October 4, 2021. On October 19, 2021 at 12:26 PM, V11 (Pharmacy Technician) said, On October 4, 2021 we received an order from the facility for [R4] for [MEDICATION(S)] [MEDICATION(S)] 12.5 mg orally twice a day and an order to discontinue the [MEDICATION(S)] 25 mg daily. The [MEDICATION(S)] [MEDICATION(S)] 12.5 mg medication was never sent to the facility. During the same telephone interview, V17 (Pharmacist) said, The [MEDICATION(S)] [MEDICATION(S)] 12.5 mg was never sent to the facility. The [MEDICATION(S)] [MEDICATION(S)] medication can be taken more often than the extended-release medication. The extended-release medication cannot be crushed, so that would be a reason to switch a resident from the extended-release to the [MEDICATION(S)] [MEDICATION(S)] so the medication can be crushed. If the facility has been giving the extended-release [MEDICATION(S)] to the resident twice a day, the side effects of the medication would increase, including lower heart rate and lower blood pressures. On October 19, 2021 at 2:35 PM, V18 (Nurse Practitioner/NP) said, The facility reported to me [R4] wasn't urinating much and her blood pressure was on the low side, so I ordered intravenous fluids for the resident. The resident receiving [MEDICATION(S)] 25 mg twice a day would give her low blood pressure. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE] shows R4 has significant cognitive impairment, requires limited assistance with eating, and extensive assistance with all other ADLs (Activities of Daily Living). R4's October 2021 MAR (Medication Administration Record) shows nursing documentation for administering [MEDICATION(S)] [MEDICATION(S)] 12.5 mg by mouth twice a day starting October 4, 2021 at 5:00 PM, despite the fact the facility never received the medication from the pharmacy. Nursing documentation shows R4 received the [MEDICATION(S)] 25 mg tablets on the following days, despite the medication being discontinued by the physician: 10/4/2021 - one dose 10/5/2021 - one dose 10/6/2021 - one dose 10/7/2021 - (2 doses, 9:00 AM and 5:00 PM) 10/8/2021 - (2 doses), 10/9/2021 - (2 doses) 10/10/2021 - one dose 10/13/2021 - (2 doses) 10/14/2021 - (2 doses) 10/15/2021 - one dose 10/16/2021 - (2 doses) 10/17/2021 - one dose 10/18/2021 - one dose 10/19/2021 - one dose Nursing documentation also shows R4 received [MEDICATION(S)] 25 mg outside the physician-ordered SBP (Systolic Blood Pressure) parameters (hold for SBP less than 110) on the following days: 10/4/2021 at 5:00 PM 109/64 10/6/2021 at 5:00 PM 95/60 10/9/2021 at 5:00 PM 100/62 10/10/2021 at 9:00 AM 96/58 10/15/2021 at 5:00 PM 100/80 10/18/2021 at 5:00 PM 97/55 10/19/2021 at 9:00 AM 100/60 On October 11, 2021 at 7:29 PM, V19 (RN) documented intravenous fluids were started on R4. R4's blood pressure reading on October 11, 2021 at 9:00 AM was 96/70 and at 5:00 PM R4's blood pressure was 92/51. On October 11, 2021, at 10:30 PM, V20 (LPN) documented, This nurse went into resident's room to answer call light and noticed that resident pulled out her IV to Left arm. Blood noted on resident but denies pain at this time. BP 85/65 HR 82. Spoke with [V18] (NP) and was given orders to insert IV at 100ml/Hr. On October 19, 2021 at 3:37 PM, V21 (Pharmacist) said, The [MEDICATION(S)] [MEDICATION(S)] 12.5 mg was never sent to the facility by the pharmacy. It was an error on the pharmacy's part that it did not get sent. If the resident was receiving the [MEDICATION(S)] 25 mg twice a day, that would be double the dose of her prescribed medication, plus it was extended-release medication. If the facility was crushing the extended-release medication for the resident, the resident could potentially get too much medication too quickly. The resident should have been closely monitored for low blood pressure and low heart rate because those are the major side effects of getting too much [MEDICATION(S)]. Also, the resident should not be given the medication if her blood pressure or heart rate is low or outside the parameters set up by the physician. On October 20, 2021 at 3:23 PM, V1 (Administrator) provided the policy entitled, Physician Orders, revised July 28, 2021. The policy shows: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician orders. The facility shall ensure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .7. Medication orders entered in the POS shall be reflected accurately in the MAR (Medication Administration Record). In addition, wound treatment orders entered in the POS shall be reflected in the TAR (Treatment Administration Record).

Based on interview and record review, the facility failed to develop a plan to reduce and prevent the risk of constipation for 1 of 3 residents (R1) reviewed for constipation. This failure resulted in R1 being transported to the local hospital and assessed with [REDACTED]. Findings include: R1 was admitted [DATE] from the hospital for rehabilitation therapy, following left hip surgery due to fracture. R1 had [DIAGNOSES REDACTED]. V3's (NP -Nurse Practitioner) assessment [DATE] indicates R1 was alert and oriented to person only, with periods of confusion. R1's [DATE] MDS (Minimum Data Set) notes a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive deficits. R1's Continence record dated [DATE] through [DATE] indicates only one bowel movement, which was on [DATE]. R1's November MAR (Medication Administration Record) indicates the order for [MEDICATION NAME] Sodium (stool softener laxative) 100 mg (mg) daily by mouth, as needed; however, no doses were ever given. Per Nursing notes and MAR, R1 did not complain or get medicated for abdominal pain or constipation during the course of her stay at the facility, [DATE] through [DATE]. V5's (Nurse) Nursing Admission assessment dated [DATE] indicates R1's abdomen as soft with bowel sounds present. V4's (Nurse) Nursing note dated [DATE] at 4:44pm indicates R1's abdomen as soft and non distended. V3 stated [DATE] she saw R1 [DATE] and again on [DATE], and R1's abdomen was soft, non-distended, with present bowel sounds, and R1 had no complaints of abdominal pain. V3's notes from these visits indicate these findings. V6 (NP) stated [DATE] at 2:14pm that when she saw R1 on [DATE] and [DATE], R1's abdomen was soft. V6 noted the presence of normal bowel sounds on [DATE], but did not listen to R1's bowel sounds on [DATE]. R1 did not complain of abdominal pain on either of these visits. V6's notes from these visits indicate these assessments. V9 (Rehab Physician) stated [DATE] she saw R1 on [DATE] and [DATE]. Upon both of these visits, R1's abdomen was soft, non-distended, and bowel sounds were present. V9's notes from these visits indicate these findings. V9 did not receive any reports from Nursing that R1 was not moving her bowels. V8 (R1's Attending Physician) stated [DATE] at 2:26pm he saw R1 [DATE] and again [DATE]. Upon both of these visits, R1's abdomen was soft, non-distended, non-tender, with bowel sounds present. V8 did not receive any reports from Nursing that R1 was constipated or not having bowel movements. V11 (CNA - Certified Nursing Assistant) stated [DATE] at 2:22pm she helped care for R1 on [DATE] the 7:00 am - 3:00 pm shift. In the early afternoon, R1 was not as alert as she normally was, and she moaned a little when repositioned. R1's abdomen was distended, and tender to touch. R1 hadn't urinated that day yet. V11 took R1's vital signs and reported these findings immediately to V4. V11 could not remember what these vital signs were, but thinks R1's BP was approximately 90's/50's. V12 (Occupational Therapist) stated [DATE] at 3:40pm when she went to see R1 for her therapy session [DATE] about 1:30pm R1 was in bed, moaning. R1 seemed to have both a physical and cognitive decline, was lethargic, and could not follow commands or participate in therapy. R1's abdomen was distended. V12 told V4, who was attending to another resident, but came immediately. V12's note from that day indicates these occurrences. V4 stated [DATE] at 3:15pm R1's vital signs and condition were stable when she came on duty in the morning of [DATE]. R1 was up in her wheelchair at the Nurses' station that morning. At approximately 1:00pm - 1:30pm, V11 told V4 R1 had not urinated that day, and had not wanted to eat/drink. When told about R1's change in condition from V11 and V12, V4 immediately went to assess R1, then called V6 to come and see R1 for lethargy/changes in condition. R1's blood pressure was ,[DATE], pulse 100, and respiratory rate 18. V6 stated [DATE] she arrived to assess R1 on [DATE], she found R1 drowsy, but arousable, opening her eyes quickly to command, but then closing them. V7 was present, and insisted R1 be sent to the hospital. V6 called V13 (R1's Attending Physician's NP), who agreed to send R1 to the hospital for evaluation. V6 stated ordered V4 to send R1 to the hospital via regular ambulance, as she didn't feel this was a 911 situation, as 911 calls are for chest pain, stroke, severe traumatic injury, or unresponsiveness. R1 had no respiratory distress, and stable blood pressure. R1's heart rate was somewhat elevated, but not dangerously so. Neither V4 nor V6 stated they made a choice of ambulance transportation for insurance/money criteria. V4's Nursing note [DATE] at 2:37pm indicates the ambulance was called at 1:45pm, and arrived at 2:10pm to transport R1 to the hospital for evaluation. R1 was re-routed by the ambulance to a closer hospital by the ambulance due to a drop in her blood pressure to ,[DATE]. Hospital records indicate R1 arrived in the hospital ER (emergency room ) at 2:49pm on [DATE] with a heart rate of 107, and a blood pressure of ,[DATE]. R1's mouth appeared dry, and her abdomen was soft, with normal bowel sounds and diffuse abdominal tenderness with guarding. R1 was sleepy, but arousable to voice. R1 began vomiting after arrival in the ER. R1 was sent for a CT (Computerized Tomography) exam of the abdomen and pelvis ,[DATE] which showed [MEDICATION NAME] artifact in the right mid colon and rectum, significant distention of the rectum up to 9 cm (centimeters) with wall thickening and surrounding fat stranding as well as mildly prominent bowel loops with wall thickening more prominent in the [MEDICATION NAME] colon, a fluid filled left colon and an air-fluid level involving the sigmoid colon. These findings could represent a component of large bowel obstruction in the setting of fecal impaction of the rectum/associated [MEDICAL CONDITION]. Small amount of reactive free fluid identified in the right paracolic gutter and anterior pelvis. Superimposed infection not excluded. R1's WBC (White Blood Cell Count) was high at 26.1 (normal value 4XXX,[DATE].8), and serum lactic acid level was critical at 6.8 (normal value 0.5 - 1.0). R1 was admitted to the Intensive Care Unit for of [MEDICAL CONDITION], Abdominal Distention, and Probable Large Bowel Obstruction. V14 (Surgeon) was consulted, and saw R1 on [DATE] at 6:00pm. V14 assessed R1 as being in mild distress, opening her eyes to painful stimuli. R1's abdomen was soft, distended and somewhat full feeling, with non-focal tenderness, not peritonitic. R1 appeared dehydrated. R1 did not have any blood in her rectum, but had soft, pasty stool mixed with [MEDICATION NAME], which V14 disimpacted. V14 reviewed R1's abdominal CT results, and was told by V7 R1 drank [MEDICATION NAME] on [DATE] for a swallow study. V14 presumed the [MEDICATION NAME] remained in R1 since that time, since no [MEDICATION NAME] had been given that day. V14 believed dehydration could be driving her colonic wall thickening. R1 did not have a small bowel obstruction or any definite signs of perforation. R1 tolerated the disimpaction fairly well. V14 determined R1 was not in need of surgery at that time. V15's hospital Discharge Summary dated [DATE] indicates Patient with severe illness. Made DNR (Do Not Resuscitate) by family. Patient expired peacefully. Hospital records obtained by Surveyor do not indicate the details surrounding R1's death. R1's death certificate signed by V16 (Medical Examiner) indicates R1 died [DATE] at 10:16pm at the hospital. The causes of death listed on this death certificate [MEDICAL CONDITION] and Probable Large Bowel Obstruction. An autopsy was not performed. V2 (Director of Nursing) stated [DATE] at 1:00pm Nurses and CNA's (Certified Nursing Assistants) are responsible to document each resident's bowel movements. It is the Nurse's responsibility to monitor these records to ensure residents are moving their bowels regularly, by information shared in verbal report, as well as review of the resident's Continence record. If the Nurse finds a resident hasn't moved his/her bowels, the Nurse should interview the resident (if cognitively intact and able to speak) regarding his/her normal bowel pattern, or interview the resident's family, when appropriate. Then, the Nurse should assess the resident's abdomen for distention, firmness, and the presence or absence of bowel sounds. The Nurse should then check the resident's MAR for any laxative/stool softer orders, and administer this medication. If no laxatives/stool softeners are listed on the resident's MAR, the Nurse should call the Physician or NP for orders. V8 (R1's Attending Physician) stated [DATE] at 2:36pm he was not aware R1 had not been having bowel movements. V8 stated, Constipation is a common problem with residents who are not regularly ambulating. If notified, V8 or any of the NP's would have given orders for laxatives or enemas, as needed. R1's care plan includes the problem Potential for constipation related to: Decreased mobility, use of the following - diuretic and [MEDICAL CONDITION] Medication, with interventions including Monitor for signs of possible constipation, such as poor appetite, nausea, abdominal distention, decrease bowel movement frequency/output or change in bowel pattern, and Monitor BM (bowel movement) output every shift and record, and Refer to MD if no bowel movement for 3 days.

Based on interview and record review the facility failed to use the required number of staff during a resident transfer, failed to use the appropriate safety device during a resident transfer, and failed to perform a complete investigation following a resident injury during a transfer (a leg wound with uncontrollable bleeding), which required hospitalization . These failures affected one of three residents (R2) reviewed for accidents/incidents in a sample of 22. Findings include: A policy on Transfer, Ambulation, and Re-Positioning dated 2/2010 says, "Injuries will be reduced and safety awareness increased through: Identification of the residents' physical limitations by assessments." The policy also says, "Gait belts are provided by the facility and are to be used during ambulation, and/or transfer of a resident...Investigation of resident injuries which occur during transfers...should include information regarding the use of all safety devices and safe transfer techniques prior to the incident." A Minimum Data Set Assessment, dated 5-15-14, documents R2 is cognitively intact and requires extensive assistance of two people for transfers. A Physical Therapy assessment dated ,[DATE] documents that at the time of the assessment R2 was totally dependant on staff for transfers. A physician's orders [REDACTED]. On 6-25-14 at 10:50 a.m., R2 stated that on 4-11-14, E14 (Certified Nurse Aide) was assisting R2 to transfer from the bed to the wheelchair. R2 stated that during the transfer, E14 transferred R2 to the wheelchair without using a gait belt and also without the assistance of another staff person. R2 stated E14 had difficulty with the transfer which caused R2's leg to hit the wheelchair, cutting R2's leg. R2 stated that when E15 (Registered Nurse) was providing care to R2 later that day, E15 noted that R2's leg was bleeding and applied a dressing. R2 stated that when E15 was unable to stop the bleeding, R2 was sent to the hospital. R2 stated that R2 was not interviewed about the incident and not informed whether an investigation of the incident was conducted by the facility. An incident report dated 4-11-14 documents that on 4-11-14 R2, "...bumped R2's right lower leg against the side of the wheelchair," during a transfer from the bed to the chair. The incident report documents that R2 had bleeding from the right lower leg wound which was, "not controlled with application of pressure." An incident investigation, dated 4-15-14, documents that, "R2 continued to have moderate to heavy bleeding hours after skin tear...Was sent to ER (emergency room )..." The incident investigation follow-up states, "Investigation included chart review, and staff interview." An interview with R2 was also not included in the investigation. On 6-26-14 at 7:40 a.m. E9 (Physical Therapist) verified that during R2's 4/2014 assessment, R2 was totally dependant on, "either two staff or a mechanical lift for transfers." On 6-25-14 at 12:25 p.m. E7 (Post Acute Manager) stated that E7 investigated the right lower leg injury which occurred to R2 while being transferred from the bed to the wheelchair by E14. E7 verified that E14 (Certified Nurse Aide) transferred R2 from the bed to the wheelchair without another staff person assisting. E7 was unable to verify if R14 used a gait belt during the transfer. E7 also verified the incident investigation did not include an interview with R2, stating, "R2 was in the hospital during the investigation."

Based on interview and record review, the facility failed to conduct comprehensive assessments and revise care plans as necessary to provide appropriate interventions for safe wheelchair transport for one of three sampled residents (R1). This failure resulted in R1 falling from a wheelchair during transport and going to the hospital with a laceration of the forehead requiring stitches. Findings include: According to the closed medical record, R1 was a [AGE] year old with [DIAGNOSES REDACTED]. R1 was admitted to the facility in 2007. On the Minimum Data Set Falls Rap Key for 5/26/10, R1 was assessed as high risk for falls with poor safety awareness and limited mobility and balance. According to the medical record and E3 on 2/4/11, 2:45 PM, R1 had to be transported by wheelchair and was pushed by staff. According to E2 on 2/4/11 at 4:30 PM in the conference room, R1 had a habit of dropping her feet down while being pushed in the wheelchair. E2 said that R1's foot got caught as she was being pushed in the wheelchair on 11/24/10, resulting in R1 falling from the wheelchair before staff could catch her and lacerating the left side of her forehead. Z1 (family member) stated that he was informed by the nurse on duty at the time of the fall that the wheelchair did not have leg guards on it that day. Per the facility Fall Management Guidelines and Best Practices Policy, the facility evaluates residents for potential risk of falling so that reasonable and appropriate measures will be taken upon admission / readmission, after a fall incident, quarterly or as significant change occurs. As stated, R1 displayed the unsafe practice of dragging her feet while being pushed in the wheelchair. However, R1's fall prevention care plan did not include leg rests on her wheelchair until 12/3/10, after her fall with injury on 11/24/10. R1 was sent to the emergency room for stitches for the laceration of the left forehead.

Based on interview and record review, the facility failed to ensure that the care plans were appropriate for one resident (R1) who required leg supports while being transported per wheel chair, in the sample of 3 residents. This failure resulted in R1 falling from a wheelchair during an unsafe transport and going to the hospital with a laceration of the forehead requiring stitches. Findings include: According to the closed medical record, R1 was a [AGE] year old with [DIAGNOSES REDACTED]. R1 was admitted to the facility in 2007. On the Minimum Data Set Falls Rap Key for 5/26/10, R1 was assessed as high risk for falls with poor safety awareness and limited mobility and balance. According to the medical record and E3 on 2/4/11, 2:45 PM, R1 had to be transported by wheelchair and was pushed by staff. According to E2 on 2/4/11 at 4:30 PM in the conference room, R1 had a habit of dropping her feet down while being pushed in the wheelchair. E2 said that R1's foot got caught as she was being pushed in the wheelchair on 11/24/10, resulting in R1 falling from the wheelchair before staff could catch her and lacerating the left side of her forehead. Z1 (family member) stated that he was informed by the nurse on duty at the time of the fall that the wheelchair did not have leg guards on it that day. Per the facility Fall Management Guidelines and Best Practices Policy, the facility evaluates residents for potential risk of falling so that reasonable and appropriate measures will be taken upon admission / readmission, after a fall incident, quarterly or as significant change occurs. As stated, R1 displayed the unsafe practice of dragging her feet while being pushed in the wheelchair. However, R1's fall prevention care plan did not include leg rests on her wheelchair until 12/3/10, after her fall with injury on 11/24/10. R1 was sent to the emergency room for stitches for the laceration of the left forehead.