Every finding on record at Burgess Square Healthcare CTR

Based on observation, interview, and record review, the facility failed to monitor for and report changes in existing pressure ulcers, prevent the development of new pressure areas, and failed to ensure pressure ulcer treatments were in place.This failure resulted in delayed identification of a resident's stage two coccyx pressure ulcer deteriorating to a necrotic and unstageable pressure ulcer, with a subsequent delay in treatment changes.This applies to 2 out of 4 (R1and R4) reviewed for pressure ulcers. The findings include:1. The EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, dementia, muscle weakness, squamous cell carcinoma of skin, abnormalities of gait and mobility, and needs assistance with personal care. The MDS (Minimum Data Set), dated March 24, 2026, showed R4 was cognitively intact and dependent on staff for ADLs (activity of daily living). The MDS continued to show R4 was at risk for developing pressure ulcers because she had existing stage two and stage three pressure ulcers. On May 19, 2026, at 10:25 AM, R4 was in bed. V4 (Wound care Nurses/WCNs) said R4 has a facility-acquired stage two pressure ulcer on her coccyx. V4 and V5 (WCNs) removed R4's foam dressing to assess the wound. R4's coccyx wound bed had approximately 50% slough and necrotic soft tissue. V5 said her wound was last assessed and measured on May 12, 2026, (seven days earlier) and the wound had no necrotic tissue. V5 said the floor nurses performed daily dressing changes, and no one had informed the wound care team the wound had deteriorated. V4 cleaned R4's wound with normal saline and gauze. V4 said the wound measured 2.1 cm (length) (centimeter) x 1.5 cm (width) x 0.2 (depth). V4 confirmed the wound bed had yellowish-black necrotic tissue and believed it was now a stage 3 pressure ulcer. V4 said R4 was last seen by the wound physician in March 2026, and she did not believe R4's wound needed to be re-evaluated or treated by the physician. V4 also said she did not believe R4's wound required any change in treatment and proceeded to apply a xeroform and boarded gauze dressing. R4's Skin Issues note, dated May 12, 2026 (seven days earlier), showed her pressure ulcer was a stage two and was stable with 100% granulation tissue and measured 2.47 cm x 4.57 cm x 0.1 cm. R4's care plan showed she had a wound to her coccyx that was acquired at the facility on March 10, 2026, and R4 was at risk for additional skin impairment. The care plan said she would be free of wound complications and interventions included to follow the facility's protocol for pressure injury, monitor and report abnormalities, assess for progression and declination, and consult the wound care physician. On May 20, 2026, at 12 PM, V4 (WCN) said R4's wound had deteriorated and to her it appeared to now be a stage three. V4 said she had not notified R4's physician or the Wound Physician about the wound changes. V4 said it was her understanding that the Wound Physician did not see all the residents unless their wounds required debridement or a change in treatment orders. V4 continued to say the wound did not require any mechanical or enzymatic (chemical) debridement for the removal of the necrotic tissue. V4 said wound care nurses were dependent on the nursing staff to inform them of any changes in the wounds. V4 said the nurses were responsible for completing daily wound care dressing changes and reporting wound changes or deterioration to ensure the wound care team reassess and determine proper wound management. R4's Skin Issue note, dated May 19, 2026, said her coccyx pressure ulcer had deteriorated and was now a stage three. The wound measured 1.8 cm x 3.5 cm x 0.2 cm with 10% eschar/maroon tissue. The assessment said R4's wound did not require change in treatment. On May 20, 2026, at 2:00 PM, V19 (NP/Nurse Practitioner) said she was R4's primary NP and she reassessed her coccyx wound on May 20, 2026. V19 said R4's wound was unstageable because the wound bed had 100% slough tissue. V19 said she was going to change the treatment order to Santyl (chemical debriding agent) and she was going to ensure that R4 was re-evaluated by the Wound Physician. V19 said she expected the facility staff to follow their wound care policy and procedure to ensure residents with pressure ulcer were being assessed, monitored, and treated appropriately. V19's progress note, dated May 20, 2026, said R4 was seen due to worsening of her coccyx wound. The note said it was now an unstageable coccyx ulcer. V19 said R4 requires a change in her treatment to remove the necrotic tissue, and it needed to be evaluated by the wound physician. 2. R1's EMR showed she was admitted to the facility on [DATE], with multiple diagnoses including right hip pain, lymphedema, obesity, difficulty in walking, and multiple wounds, including pressure ulcers and MASD (Moisture Associated Skin Damage). The EMR also said she had an indwelling catheter and was incontinent of bowel. R1's MDS, dated [DATE], showed R1 was cognitively intact and dependent on staff for dressing, bathing, and toileting assistance. The MDS continued to show that R1 had multiple ulcers present on admission that still required daily treatments. On May 19, 2026, R1 was lying in bed. V4 and V5(WCN) said R1 had multiple pressure ulcers, including in her buttock area, which required daily dressing changes. R1 said she had discomfort in her buttocks and inner thigh areas because of her catheter. V4 and V5 assessed R1's buttock, and there was no dressing present. R1's catheter tubing was also pressing against her left inner thigh, and she requested the tubing be readjusted because it was uncomfortable. R1's left inner thigh had two distinct open linear areas. V4 said she was not aware of the areas, and the wound was a new facility-acquired pressure ulcer related to the catheter's tubing. V4 said the facility provided leg straps to secure catheter tubes. R1 then said that due to her weight, she preferred not to have the strap because of the potential discomfort to her skin. V4 said R1's tubing should have been properly positioned on the anterior of her body to prevent pressure when on her back. V4 said the new wound would be clustered, and the left outer thigh area measured 5 cm x 0.5 cm x 0.1 cm, and the inner was 3.5 cm x 0.3 cm x 0.1 cm. V4 said both had 100% granulation, and the wound was a facility acquired stage two pressure ulcer. V4 said she expects staff to monitor and assess skin during care to ensure changes were reported and treated appropriately. V4 further said that R1's right buttock pressure ulcer should have been covered as ordered to prevent further breakdown. R1's Skin note, dated May 19,2026, said R1 had a new facility acquired medically-device related stage two pressure ulcer (MDRPU) to her rear left thigh. The note said R1's Left posterior thigh noticed with a new MDRPU from Foley tubing. Two linear skins break downs stage 2. One approx. 5 x 0.5 x 0.1 cm and second one approx. 3 x 0.4 x 0.1. Wounds cleansed and covered with xeroform and foam dressing. NP/MD notified of new findings. The note also said R1's right buttock stage two pressure ulcer present on admission now measured 5 x 0.5 x 0.1 cm and had 100% granulation tissue. The ulcer still required daily and as needed xeroform and foam dressings. On May 20, 2026, at 9:45 AM, V8 (Certified Nurse Assistant/CNA) said she was expected to assess the residents' skin for new alterations when rendering care. V8 said she was assigned to R1 on May 18, 2026, and May 19, 2026, and was unable to recall if she assessed her posterior thigh areas for new skin breakdown or if she reported that her buttock wounds required the application of new dressings. On May 20, 2026, at 12 PM, V4 said she reviewed R1's weekly wound assessments, but she was confused because she had MASD to her rear left thigh that was last assessed on May 2, 2026 (at admission), but still determined that the newly identified skin breakdown to her left rear inner thigh was a new facility-acquired MDRPU. V4 said R1's required weekly wound assessments were not completed for the past two weeks. V4 said residents with wounds required weekly wound assessments to ensure they were monitored for potential complications. R1's last Skin note, dated May 1, 2026, said R1 had multiple wounds present on admission, including a stage two pressure ulcer to her right buttock. The wound measured 1.86 x 2 x 0 cm with pink or red tissue. R1 also had MASD on her bilateral rear thighs. The note said both wounds to the right buttock and bilateral thighs required daily xeroform and foam dressings. R1's care plan said she had multiple wounds, including pressure ulcers, and was at risk for additional skin impairment. The care plan said she would be free of wound complications, and the interventions included following the facility's protocol for pressure injury, monitoring and assessing wounds, reporting skin abnormalities, and ensuring her catheter's tubing was stabilized to prevent catheter-related trauma. On May 20, 2026, V2 (Director of Nursing) said she expected staff to monitor the skin of residents during routine care and report abnormalities, especially for those with known skin breakdown. V2 said all nurses were expected to follow treatment orders as ordered. V2 also said all wounds had to be fully assessed weekly to ensure they were being tracked for complications and that they were being treated appropriately. The facility's policy titled Wound Management, dated 2019, stated the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers. Any resident with a wound would receive treatment and services consistent with the resident's goal of treatment and promoting healing. The wound management program incorporated accepted standards of practice and guidelines, the framework including accountability in prevention by staff observing the skin integrity daily, ongoing comprehensive wound assessments, wound management principles, wound care and the application of dressings as ordered, wound documentation, individualized care planning, proper notifications, and staff education.

Based on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions and the kitchen was maintained in a clean and sanitary condition. The facility failed to ensure dietary staff utilized hair restrains while preparing food. This failure applies to all 136 residents in the facility. The findings include:On September 29, 2025, at 9:15 AM, V10 (Dietary Aide) walked through the kitchen while assisting with dishwashing, with her hair not completely covered and a large amount of hair exposed from the front and sides of her hairnet. V9 (Dietary Manager) tested the sanitizer levels in the three-compartment sink being used to clean dishes with a result of 150 ppm. On September 30, 2025 at 10:08 AM, V11 (Cook) tested the sanitizer levels in the three compartment currently being used to clean dishes to be between 0 - 150 PPM. V9 said dietary uses Quaternary sanitizer and the levels should be between 200 and 300 parts per million for proper sanitation. On September 30, 2025, at 9:41 AM, V11 (Cook) prepared food, with her hair not completely covered, and exposed from the front and sides of her hairnet. On December 01, 2025, at 10:33 AM, V13 (Cook) prepared burgers in the kitchen with hair not completely covered and hair exposed from front, sides, and back of her hairnet. V19 (Dietary Aide) prepared fruit cups, with hair not completely covered by and hair exposed from back of hairnet. On September 30, 2025, at 10:04 AM, V10 (Dietary Aide) walked through the kitchen while assisting with dishwashing, with her hair not completely covered and a large amount of hair exposed from the front and sides of her hairnet. On September 30, 2025 at 9:53 AM, paint was noted to be peeling and bubbling around the vent located above the main kitchen food prep table being used consistently to prepare food, and had several uncovered cups V11 (Cook) said was being used to prepare fruit cocktail; alarm system ceiling panel directly above the main food prep table with heavy presence of dust around the lining and on the surface of the panel and dust hanging from it with air from the adjacent vents blowing the dust; large gray vent located directly above the main food prep table and blowing air with heavy presence of dust surrounding surface; large white vent located adjacently above the main food prep table and blowing air with heavy presence of dust throughout surface; and cracked and peeling paint on the ceiling near the steam table. On September 30, 2025 at 10:00 AM, a large blender was being used by V11 (Cook) to make mechanical breakfast sausages, with heavy presence of food particle buildup on base. On December 1, 2025 at 10:33AM, the main kitchen food prep table where mechanical soft, pureed burgers, melons, and other food items were being prepared had two large vents blowing air with heavy presence of dust and particles throughout the surface of the vents, and a large ceiling panel with presence of dust and particles throughout the surface. V14 (Dietary Aide) prepared juices with hair not completely covered and hair exposed from sides and back of hat. V12 (Dietary Aide) rolled silverware for meal service with hair not completely covered and hair exposed from the sides and back of hairnet. V11 (Cook) tested the sanitizer levels of the three-compartment sink being used to clean dishes at 150 PPM; V11 said she would change the sanitizer solution. On December 01, 2025 at 10:42 AM, an uncovered personal mug holding a hot beverage was sitting on top of the kitchen meat slicer base that was partially covered with plastic. On December 02, 2025 at 12:37 PM, V9 (Dietary Manager) said ideally hair should be completely covered by a hair covering, V9 believes hair coverings in the kitchen are not required in Dupage County, but V9 will have to check the facility's policies regarding hair coverings. V9 stated there is a weekly cleaning schedule and there is also daily cleaning schedule. Ideally, there shouldn't be any visible signs of dust and particles on the vents over the food prep table; the vents are active and the dust and particles could get into the food. V9 could see the heavy dust and particles on the vents and ceiling panel above the food prep table and said he wasn't sure if the kitchen or maintenance staff are responsible for cleaning those areas. V9 confirmed the small blender is used for food prep and said the base should not have food substance or particle buildup. V9 confirmed the presence of food substance and particles on the base of the small blender and said this could indicate it was not cleaned properly. On December 03, 2025, at 9:19 AM, V9 (Dietary Manager) said he tries to encourage staff not to keep personal beverages in the kitchen; it's obviously a sanitation issue, and should be covered. V9 also added that the peeling and bubbling paint in the kitchen should be repaired, as this could potentially contaminate food. The facility's Kitchen Cleaning Policy and Procedures; received 12/02/2025 from the facility; documents:The Purpose of the policy is To ensure all food preparation and service areas in the facility kitchen are maintained in a sanitary condition, preventing foodborne illness, and ensuring compliance with state health regulations, and infection control standards. The facility will maintain a clean, sanitary kitchen environment at all times. During Food Preparation: Wipe spills immediately. Wash/rinse/sanitize utensils and equipment. The facility's Hair Covering Policy and Procedures received 12/02/2025 from the facility states:The purpose of the policy is To prevent contamination of food, food-contact surfaces, and equipment by ensuring that all individuals working in or entering dietary service areas wear appropriate hair restraints in accordance with federal, state, and local food safety regulations. All staff, contractors, volunteers, visitors, and inspectors who enter the kitchen, food preparation, dishwashing, or food storage areas must wear an appropriate hair covering (A device such as a hairnet, bouffant cap, chef hat, beard net, or head wrap) designed to secure hair that restrains hair and prevents shedding. Hats may be worn only if hair is fully restrained underneath. The facility's Sanitizer (QUAT) Policy and Procedures received 12/02/2025 from the facility states:The purpose of the policy is To ensure all food-contact and non-food-contact surfaces within the dietary department are properly sanitized using Quaternary Ammonium (QUAT) in accordance with manufacturer specifications, to prevent foodborne illness and environmental contamination. The facility will use an approved QUAT-based sanitizer in all food preparation, service, and ware washing areas at the proper concentration range specified by the manufacturer (typically 200-300 ppm, or as labeled). Sanitizer concentrations must be monitored and documented regularly to ensure effectiveness. The facility's Food Preparation Policy and Procedures received 12/02/2025 from the facility states:The purpose of the policy is To ensure that all food prepared and served in the facility is safe, sanitary, and compliant with federal, state, and local health regulations. All food preparation activities within the facility must be performed using safe food-handling practices to prevent contamination, foodborne illness, and compromised resident safety. No personal belongings, drinks, or food may be kept in prep areas.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices regarding hand hygiene and gloving during provisions of perineum and wound care. The facility also failed to ensure the use of complete PPE (Personal Protective Equipment) for caring of residents who are on EBP (Enhance Barrier Precaution). This applies to 4 of 27 residents (R13, R20, R105, R152) reviewed for infection control in the sample of 27. The findings include: 1. R20's care plan, with a target date of December 1, 2025, shows R20 currently has an abscess to his right buttock. R20 has decreased mobility and requires assistance with ADL (activities of daily living) care. An EBP signage on R20's bedroom door was observed during this survey. On December 1, 2025, at 1:11 PM, V22 (Certified Nursing assistant/CNA) assisted R20 to the toilet. V22 placed a gait belt around R20's trunk, assisted R20 to transfer from wheelchair to the toilet, and pulled R20's pants down prior to sitting on the toilet. At 1:21 PM, when R20 finished using the toilet, V22 came back to help R20 wearing full PPE. V22 rendered peri-care to R20; she changed her gloves in between tasks multiple times without hand hygiene. On December 2, 2025, at 1:20 PM, V23 (Nurse) rendered wound care to R20. V23 stated R20's wound started as a cyst which later opened with a fistula. They inserted a tube in the fistula to drain the wound. V23 removed the soiled dressing, and it was wet with the discharged from the tube. V23 cleansed the wound with NSS (Normal Saline Solution), she applied Zinc cream and covered the wound with bordered foam dressing, while wearing the same soiled gloves. 2. On December 1, 2025, at 1:49 PM, V22 assisted R13 to the bathroom. After R13 used the toilet, V22 provided peri-care. V22 changed her gloves in between multiple tasks with no hand hygiene. On December 2, 2025, at 11:55 AM, V4 (Assistant director of Nursing/ADON/Infection Preventionist Nurse) stated when staff provides incontinence care they are to perform hand hygiene and change their gloves from dirty to clean tasks to prevent spread of infection. The staff are to wear complete PPE for resident who are on EBP. They should wear the PPE when they are giving direct care such as incontinence/toileting, transfers, and wound care to prevent spread of potential infection. 3. The EMR (Electronic Medical Record) showed R105 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, scoliosis, chronic kidney disease, and other abnormalities of gait and mobility. R105's EBP (Enhanced Barrier Precautions) care plan, dated August 30, 2025, showed, [R105] requires enhanced barrier precautions identified by: wounds including but not limited to: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers. The care plan continued to show multiple interventions dated August 30, 2025, including, EBP is employed when performing the following high-contact resident care activities but not limited to: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. On September 30, 2025, at 10:45 AM, V20 (Therapy Technician/Certified Nursing Assistant) was assisting R105 in the bathroom and transferring R105 back to her wheelchair. V20 was not wearing a gown or gloves. V20 said she was assisting R105 with toileting hygiene and transferring. R105's doorway had a sign displayed for Enhanced Barrier Precautions. 4. R152's EMR (Electronic Medical Record) showed R152 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and retention of urine. R152's MDS (Minimum Data Set), dated September 29, 2025, showed R152 was cognitively intact. R152 was dependent on staff for toileting and required staff substantial/maximal assistance for showering/bathing. R152's care plan showed R152 had an indwelling urinary catheter related to recent surgery and acute urinary retention. Interventions included provide routine hygiene using clean technique of the urinary meatus during daily bathing/hygiene and cleanse the perineal area after each bowel movement using soap and water or a similarly gentle cleaning agent. To avoid contaminating the urinary tract, always clean by wiping away from the urinary meatus.Enhanced Barrier Precautions staff will utilize proper designated PPE such as: gown and glove use, and face protection as needed and adhere to other recommended infection prevention practices including but not limited to: performing hand hygiene, cleaning and disinfection of environmental surfaces and resident care equipment, proper handling of indwelling medical devices, and care of wounds for prevention of MDRO transmission per facility policy. On September 30, 2025, at 9:29 AM, R152 had a sign on her door that showed R152 was in EBP (Enhanced Barrier Precautions). V7 put on gloves without washing her hands or using hand sanitizer and V7 did not put on an isolation gown. V7 opened the incontinence brief and used a wipe to clean the right groin, left groin, and under R152's stomach fold with the same wipe. V7 pushed the incontinence brief through and had R152 turn onto her right side. R152 was not able to turn fully onto her right side and expose her buttocks V7 grabbed a new wipe with the same gloves she had cleaned the front area with and blindly reached her hand in and wiped the buttock area including in between the buttocks, using circular motions. V7 did not change gloves or use hand sanitizer. V7 had R152 turn onto her left side. R152 was unable to turn fully to expose her buttocks. V7 pulled out the old incontinence brief, and with the same gloves, used a wipe and reached her hand in and wiped in circles where she could reach on the buttock area and in between buttocks. V7 while wearing the same gloves, placed a new incontinence brief under R152, had her turn to her left side and pulled the incontinence brief through and fastened it. On December 2, 2025, at 10:08 AM, V2 (DON/Director of Nursing) said, If resident is on EBP (Enhanced barrier Precautions) and the staff will be providing direct care, they need to wear the appropriate PPE. They need to put on a gown, hand sanitize, and put on gloves, before starting care. When providing care, the staff should use a few washcloths, then dry the area, and inspect skin. Staff should change gloves multiple times during cleaning, use hand sanitizer, and put on new gloves or wash hands. Facility provided their September 1, 2022 policy titled, Policy and Procedure for Preventing the Spread of Multi-drug Resistant Organisms (MDROs) The policy showed, Tis policy and procedure is intended to provide guidance for PPE use and room restriction in nursing facilities for preventing transmission of MDROs.Enhanced Barrier Precautions: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunistic for transmission of MDROs to staff hands and clothing. MDROs maybe indirectly transferred from patient to patient during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are especially high risk of both acquisition and colonization with MDROs. Examples of high-contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing of briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Facility provided their EBP sign that is placed on any room door where EBP are required. The sign identified what everyone entering the room must do: clean hands including before entering the room and when leaving the room. The sign identified what providers and staff must also do: wear gown and glove for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing of briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Facility provided their policy January 2025, and titled, Policy and Procedure: Handwashing and Hand Hygiene. The policy showed, Purpose: to prevent the spread of infection and ensure compliance with the CDC (Centers for Disease Control and Prevention), CMS (Centers for Medicare and Medicaid), and OSHA (Occupational Safety and Health Administration) guidelines by establishing proper practices for hand hygiene, including handwashing, use of alcohol-based hand rubs (ABHR), and correct glove removal in the nursing facility. Policy: 1. All staff and providers are required to perform hand hygiene according to CDC guidelines before and after resident contact, after contact with potentially contaminated surfaces, and after removal of gloves or PPE.5. Gloves are not a substitute for hand hygiene. Hands must be cleaned before putting on gloves and immediately after removing gloves. Glove Use and Removal: 1. Perform hand hygiene before donning gloves. 2. [NAME] clean gloves immediately before contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated surfaces. Indications for a hand hygiene: Before and after resident contact, before performing aseptic tasks (e.g., catheter care, dressing changes), after contact with blood, bodily fluids, or contaminated surfaces.after removing gloves or other PPE, and before entering and leaving the resident room.

Based on interview and record review, the facility failed to offer residents the updated 2025-2026 COVID-19 vaccine. This applies to 5 of 5 residents (R13, R39, R78, R97, and R112) reviewed for immunizations in the sample of 27. The findings include:1. R13's EMR (Electronic Medical Record) showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic diastolic heart failure, hypotension, and paroxysmal atrial fibrillation. R13's Immunization Report, dated December 2, 2025, did not show R13 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R13 was offered the updated 2025-2026 COVID-19 vaccine. 2. R39's EMR showed R39 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, and chronic diastolic heart failure. R39's Immunization Report, dated December 2, 2025, did not show R39 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R39 was offered the updated 2025-2026 COVID-19 vaccine. 3. R78's EMR showed R78 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's Disease, type 2 diabetes mellitus, and chronic kidney disease. R78's Immunization Report, dated December 3, 2025, did not show R78 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R78 was offered the updated 2025-2026 COVID-19 vaccine. 4. R97's EMR showed R97 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, seizures, hypertension, and acute upper respiratory infection. R97's Immunization Report, dated December 2, 2025, did not show R97 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R97 was offered the updated 2025-2026 COVID-19 vaccine. 5. R112's EMR showed R112 was an [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including chronic diastolic heart failure, chronic kidney disease, and atrial fibrillation. R112's Immunization Report, dated December 2, 2025, did not show R112 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R112 was offered the updated 2025-2026 COVID-19 vaccine. On December 2, 2025, at 1:43 PM, V2 (DON/Director of Nursing) said the facility follows the CDC (Centers for Disease Control and Prevention) guidelines for vaccinations. V2 said newly admitted residents to the facility are being offered the updated 2025-2026 COVID-19 vaccine. V2 said R12, R39, R78, R97, and R112 have not been offered the updated 2025-2026 COVID-19 vaccine because they all received or were offered the 2024-2025 vaccine in February 2025, and the COVID-19 vaccine is given yearly, so the residents are not due for another vaccine. The facility's policy titled Policy and Procedure for Monitoring Community Transmission of COVID-19, dated June 12, 2023, showed, Policy: It is the policy of [the facility] to closely monitor the community transmission of COVID-19 with the intention of mitigating the risk of an outbreak in the facility. b. Vaccinations: i. The facility will encourage residents, families and staff to remain up to date with COVID-19 vaccinations, including all eligible boosters. ii. The facility will offer vaccinations and boosters to residents and staff on a routine basis. The CDC's Recommended Adult Immunization Schedule for Ages 19 Years or Older, dated October 7, 2025, showed adults 65 years or older are recommended to receive two or more doses of 2025-2026 COVID-19 vaccine. The guidelines do not show to wait one year after 2024-2025 COVID-19 vaccine was received.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity by maintaining adequate draping and privacy during personal care and assisting a resident in a dignified manner during feeding.This applies to three residents (R31, R107, and R152) reviewed for dignity in a sample of 27.The Findings include: 1.Review of the Electronic Medical Record (EMR) showed R31 is a [AGE] year-old female, with diagnoses including malignant neoplasm of the breast, major depressive disorder, muscle weakness, and basal cell carcinoma. R31's Minimum Data Set (MDS) assessment, dated August 5, 2025, indicated R31 is alert and cognitively intact. The MDS also showed R31 is totally dependent on staff for showering and personal hygiene. R31's care plan, dated November 3, 2025, documented R31 has a self-care deficit related to impaired mobility and requires staff assistance. On September 9, 2025, at 10:43 A.M., R31 was assisted into a wheelchair for a shower. R35 was propelled by V15 (Certified Nurse Assistant) through the residents' hallway to the shower room. Multiple staff and residents were present in the hallway. R31 was covered only with a small, folded blanket that did not fully cover the resident's chest and the side of the back area. At 10:45 A.M., R31 was again observed being transported by V15 via wheelchair back to the resident's room through the same hallway. R31 remained partially draped, with the chest area still exposed. When asked how R31 felt about being partially draped with portions of her chest and back exposed, R31 stated, I don't want my body to be exposed for everyone to see. R31 reported she was not aware that she was not fully covered and stated the CNA should have ensured she was properly draped. Review of the facility's policy titled Promoting Dignity, dated February 2020, showed:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. 1. Residents are always treated with dignity and respect. 10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. R107's Face sheet shows R107 is 91 years-old, with multiple medical diagnoses including dementia, generalized weakness, and needs for assistance with personal care. On September 30, 2025, at 12:29 PM, during lunch time in the dining room, V21 (Certified Nursing assistant/CNA) was feeding R107 while she was standing. When V21 was asked if it's better for her to sit down while feeding R107, she (V21) stated it's better for her to stand because people tend to get lazy when sitting down. On December 2, 2025, at 12:04 PM, V4 (Assistant director of Nursing/ ADON/ Infection Preventionist Nurse) stated when staff are feeding residents in the dining room the staff must sit beside them to ensure resident is being fed in a dignified manner. Facility's Dining Policy and Procedure, dated April 2014, showed: The facility will provide dining service to all resident in an environment that promotes a homelike atmosphere. This policy also shows a procedure that if a resident requires assistance with eating, the staff member will sit next to the resident. 3. R152's EMR (Electronic Medical Record) showed R152 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and retention of urine. R152's MDS (Minimum Data Set) dated September 29, 2025, showed R152 was cognitively intact. R152 was dependent on staff for toileting and required staff substantial/maximal assistance for showering/bathing. R152's care plan showed R152 was admitted to the facility after a hospitalization with self-care deficit, requiring assistance from staff for ADL (Activities of Daily Living) care. On September 30, 2025, at 9:29 AM, V7 (CNA/Certified Nurse Assistant) was in the room getting R152 ready for physical therapy. R152 was in the first bed closest to the door. There was a roommate who had a personal caregiver on the other side of the room. The center privacy curtain, located between the two beds, was pulled to provide privacy between the residents. The other privacy curtain was by the room door and had not been extended around R152's bed, allowing anyone who opened the room door or who walked past R152's bed, to see the care being provided to R152. V7 had R152 lying in the bed with her hospital gown pulled up to her waist exposing her incontinence brief, which V7 opened to provide indwelling urinary catheter care. During this care, someone knocked on the door and opened it right away. They did not enter but saw V7 providing care and left. At 9:44 AM, caregiver for resident in the second bed left the room and came back; she opened the door and R152 was sitting on the side of the bed with nothing covering her breast. R152 put on her own bra. V7 helped R152 with her shirt. R152 said, I wish they would give me my dignity and not expose my nakedness to everyone who opens the door or walks into the room. On December 2, 2025, at 10:08 AM, V2 (DON/Director of Nursing) said before starting care, staff should pull the privacy curtain, close door, explain to resident what going to do, and provide dignity by covering the resident's areas not being washed.

Based on observation, interview, and record review, the facility failed to safely transfer residents. This applies to 2 of 2 residents (R5 and R105) reviewed for transfers in the sample of 27. The findings include:1. The EMR (Electronic Medical Record) showed R105 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, scoliosis, chronic kidney disease, and other abnormalities of gait and mobility. R105's MDS (Minimum Data Set), dated September 4, 2025, showed R105 was cognitively intact and required moderate assistance from facility staff to come from sitting to standing. R105's fall care plan, dated August 30, 2025, showed,Fall risk related to recent spinal fusion, required ADL (Activity of Daily Living) care assist, decrease in mobility, recent hospitalization, diuretic use, episodes of incontinence. The care plan continued to show multiple interventions, dated August 30, 2025, including, Monitor for safety with transfers and mobility while in room and other common areas. On September 29, 2025, at 11:06 AM, R105 was kneeling on the floor facing her chair. V18 (CNA/Certified Nursing Assistant) was holding R105 by the waistband of her pants. R105 did not have a gait belt in place. On September 30, 2025, at 10:52 AM, R105 said V18 was attempting to weigh R105 yesterday. R105 said V18 had R105 go back and forth between her chair and the scale, and R105's legs gave out, resulting in R105 kneeling on the floor. R105 said V18 did not place a gait belt on R105 when V18 was transferring R105 to the scale. R105 said she her foot hurt after the fall. On September 30, 2025, at 11:27 AM, V18 said she was weighing R105 yesterday. V18 said it was a chair scale with a platform and R015's feet were on the platform. V18 said V18 was bending down to move the scale platform to transfer R105 back to her chair and all of a sudden, R105 fell and was kneeling on the floor. V18 said she had taken the gait belt off of R105 to weigh he and had not placed the gait belt back on. On September 30, 2025, at 11:37 AM, V2 (DON/Director of Nursing) said V18 should have put a gait belt back onto R105 since she was done weighing R105 and ready to transfer R105 back to the chair. 2. R5's Electronic Medical Record (EMR) showed R5 is a [AGE] year-old individual, with medical diagnoses including congestive heart failure, coronary artery disease, peripheral vascular disease, and a history of coronary artery bypass grafting. R5 was admitted to the facility on [DATE], and was discharged home under hospice care on November 9, 2025. R5's MDS (Minimum Data Set) assessment, dated October 26, 2025, documented R5 had severe cognitive impairment and required total assistance from staff for transfers. The assessment indicated a mechanical lift device was to be used for all transfers. The care plan, initiated May 19, 2025, identified a self-care deficit related to impaired mobility post-hospitalization, and specified R5 required staff assistance for mobility-related tasks including transfers. On September 30, 2025, at 10:55 A.M., R5 was transferred from the bed to a reclining wheelchair using a mechanical lift device. The transfer was performed by V17 (Certified Nurse Assistant/CNA) with assistance from V16 (R5's private caregiver). Both individuals reported this was not the first time they had transferred R5 using the mechanical lift device. However, V16 stated she had not received training on the operation of the mechanical lift. On September 30, 2025, at 3:55 P.M., V2 (Director of Nursing) confirmed V16 was not authorized to participate in any transfer involving the mechanical lift device. V2 stated untrained individuals are not permitted to assist with mechanical lift transfers due to the risk of injury or accident. The facility's policy. dated February 2017, titled Policy and Procedure on Safe Lifting and Movement of Residents, states the following: -The facility will use appropriate techniques and devices to ensure resident safety during lifting and movement. -Manual lifting of residents is to be eliminated when feasible, and mechanical lift devices are required for heavy lifting or when necessary for resident care. -Only staff with documented training in the safe use and care of mechanical lift equipment are permitted to lift or move residents. -Staff must be regularly observed for competency in using mechanical lifts and for adherence to established safety procedures. -Safe lifting and movement of residents is part of the facility's employee health and safety program, which engages staff in identifying problem areas and implementing safety and injury-prevention strategies.

Based on observation, interview, and record review, the facility failed provide catheter and peri-care in a manner that would prevent urinary tract infection (UTI).This applies to 2 of 4 residents (R20, R152) reviewed for perineum and catheter care in the sample of 27. The Findings include: 1.R20's Face sheet shows R20 is 79 years-old who has multiple medical diagnoses including hemiplegia affecting left non-dominant side, reduced mobility, and personal history of urinary tract infection (UTI). R20's Minimum Data Sheet (MDS), dated [DATE], shows R20 requires assistance with toileting and hygiene and is incontinent of bowel and bladder. On September 30, 2025, at 1:41 PM, V22 (Certified Nursing Assistant/CNA) assisted R20 to the toilet R20 and removed R20's soiled incontinence brief. After R20 completed using the toilet, V22 assisted R20 to get up and proceeded to wipe/clean R20's back perineum only. V22 placed a new incontinence brief to R20 without cleaning R20's groins and frontal perineum. On December 2, 2025, at 12:02 PM, V4 (Assistant director of Nursing/ADON/ Infection Preventionist Nurse) stated when providing peri-care the staff must clean from front to back of the perineum and thoroughly clean every area that could be contaminated or soiled to prevent infection, skin breakdown and promote hygiene. Facility's Perineal Care policy and procedure, dated September 27, 2023, showed, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observed resident's skin condition. Procedure for male resident: 17. Wash the perineal area including the penis, scrotum, and inner thighs. 2. R152's EMR (Electronic Medical Record) showed R152 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and retention of urine. R152's MDS (Minimum Data Set), dated September 29, 2025, showed R152 was cognitively intact. R152 was dependent on staff for toileting and required staff substantial/maximal assistance for showering/bathing. R152's care plan showed R152 was admitted to the facility after a hospitalization with self-care deficit, requiring assistance from staff for ADL (Activities of Daily Living) care. R152 had an indwelling urinary catheter related to recent surgery and acute urinary retention. Interventions included provide routine hygiene using clean technique of the urinary meatus during daily bathing/hygiene and cleanse the perineal area after each bowel movement using soap and water or a similarly gentle cleaning agent. To avoid contaminating the urinary tract, always clean by wiping away from the urinary meatus. On September 30, 2025, at 9:29 AM, V7 (CNA/Certified Nurse Assistant) V7 was putting on R152's pants. The pants were around both ankles and V7 was starting to pull her pants up. V7 said she was about to do catheter care. R152 stated she can't remember anyone cleaning around her catheter tube. V7 did not remove R152's pants and put on gloves without washing her hands or using hand sanitizer. V7 used a wipe to clean the right groin, left groin, and under R152's stomach fold with the same wipe. V7 was not able to spread R152's legs because of R152's pants being around her lower legs. V7 never spread the labia and did not touch the indwelling foley catheter tube or clean around the catheter insertion. On December 2, 2025, at 10:08 AM, V2 (DON/Director of Nursing) said, Before starting care, staff should wash hands or use hand sanitizer and put on gloves. When getting ready to do catheter care, staff need to remove any clothing they have on the lower half of their body. The staff should clean from the inner area to outer area using a few washcloths, then dry the area, and inspect skin. When cleaning, they should wipe from front to back and if female, they must spread the labia and hold catheter tube while cleaning away from resident. Staff should change gloves multiple times during cleaning, use hand sanitizer, and put on new gloves or wash hands before moving to another area. Facility provided their policy, dated June 4, 2023, and titled, Urinary Catheter Care Policy and Procedure. which showed, Infection control: 2. Maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag. a.Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.

Based on observation, interview, and record review, the facility failed to administer medications as ordered and following standards of care and facility policy. There were 25 medications and 3 errors resulting in a 12% medication error rate. This applies to 1 of 4 residents (R65) reviewed for medication administration in the sample of 27.The findings include:On September 30, 2025, at 9:45 AM, V5 (Nurse) administered multiple medications to R65 including Fluticasone Vilanterol inhaler, Tiotropium Bromide Inhaler, and Mucinex ER (Extended-Release) tablet. V5 administered the two inhalers one after another in less than a minute. V5 also crushed the Mucinex ER when she gave it to R65. On December 2, 2025, at 2:09 PM, V2 (Director of Nursing/DON) stated, <edications that are ER (Extended-Release), or DR (Delayed-Release) should not be crushed because it affects the effect of the medication. Crushing these medications causes immediate release effect in what supposed to be an extended release. V2 also stated when administering inhaler medications, there should be more than a minute in between inhalations, whether it is the same medication or different medications, to give enough time for each dose to be absorbed in the lungs. Facility's policy and procedure for administering Medications, dated December 2020, shows: Medications are administered in a safe and timely manner, and as prescribed. This policy also shows.Implementation and interpretation: 25. Medication can only be crushed if indicated in the medication order. If the manufacturer states that the medication should not be crushed (for example, long acting or enteric coated medications), the nursing staff and/or pharmacist must notify the attending physician to identify an alternative medication and/or dosage form. Facility's policy and procedure for Administering Medications through a Metered Dose Inhaler, dated October 2010, shows: The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. This policy also shows.Procedure: 11. Allow at least one (1) minute in between inhalations of the same medication and at least (2) minutes between inhalations of different medications.

Based on interview and record review, the facility failed to ensure residents were offered the pneumococcal vaccine. This applies to 2 of 5 residents (R13 and R78) reviewed for immunizations in the sample of 27. The findings include:1. R13's EMR (Electronic Medical Record) showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic diastolic heart failure, hypotension, and paroxysmal atrial fibrillation. R13's Immunization Report, dated December 2, 2025, showed R13 received the PCV13 (Pneumococcal Conjugate Vaccine 13-Valent) on November 16, 2022. The facility does not have documentation to show R13 was offered additional pneumococcal vaccines. 2. The EMR showed R78 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's Disease, type 2 diabetes mellitus, and chronic kidney disease. R78's Immunization Report, dated December 3, 2025, showed R78 received the PCV13 on December 1, 2015. The facility does not have documentation to show R78 was offered additional pneumococcal vaccines. On December 2, 2025, at 1:43 PM, V2 (DON/Director of Nursing) said the facility follows CDC (Centers for Disease Control and Prevention) vaccination timing recommendations. V2 said R13 and R78 should have already been offered an additional pneumococcal vaccine. The facility's policy titled PNEUMONIA VACCINE POLICY, dated 7-2023, showed, Purpose: To provide for the administration of the Pneumococcal Vaccinations. Policy: It is the policy of [the facility] that each resident or resident's legal representative be provided with information published by the CDC and written consent obtained prior to administration of the Pneumococcal Vaccinations. The vaccinations will be offered and administered to all qualifying residents. The Pneumococcal Vaccines will be re-offered at later dates for those who refuse. Adults 65 years or older complete pneumococcal vaccine schedules, prior vaccine PCV13 only at any age, Option A after one year or more PCV20 (20-valent Pneumococcal Conjugate Vaccine). Option B after one year or more PPSV23 (Pneumococcal Polysaccharide Vaccine).

Based on interview and record review, the facility failed to administer blood thinner medication as ordered by the physician. This failure resulted in R1 experiencing an elevated INR (International Normalized Ratio) blood test and requiring the administration of Vitamin K and hospitalization. This applies to 2 of 3 residents (R1, R4) reviewed for medication administration in the sample of 5.The findings include: 1. On November 17, 2025, R1 was sitting quietly. She was unable to answer questions due to her cognitive status.The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on November 4, 2025 and returned to the facility on November 5, 2025. R1 has multiple diagnoses including, kidney stones, bacteremia, sepsis aftercare, asthma, ureteral stent, tachycardia, anemia, difficulty walking, and long-term use of anticoagulants. R1's MDS (Minimum Data Set), dated November 2, 2025, shows R1 has severe cognitive impairment, is able to eat independently, requires partial/moderate assistance with oral and personal hygiene, substantial/maximal assistance with showering, lower body dressing, and bed mobility, and is dependent on facility staff for toilet hygiene and transfers between surfaces. R1 is always incontinent of urine, and frequently incontinent of stool.The facility's final report to the State agency, dated November 7, 2025 shows R1 received additional doses of Warfarin (blood thinner medication) due to a previous Warfarin order not being discontinued, resulting in R1 requiring the administration of Vitamin K, and being transferred to the local hospital on November 4, 2025.The facility's Order Audit Report, dated November 19, 2025, shows R1 had an order dated October 27, 2025 for Warfarin 1 mg. (milligram) tablet by mouth one time a day every Monday, Wednesday, Friday, Saturday, and Sunday. This order was discontinued in the EMR on October 28, 2025, at 1:43 PM.On October 28, 2025, at 1:46 PM, V11 (LPN-Licensed Practical Nurse) entered the following order into the EMR for R1's Warfarin as ordered by V9 (NP-Nurse Practitioner): Warfarin Sodium oral tablet 2 mg. Give 1 tablet by mouth one time a day for Warfarin therapy. The Warfarin 2 mg. order was not discontinued until November 3, 2025 at 2:58 PM.On October 28, 2025, at 7:23 PM, V12 (LPN) entered the following order into the EMR for R1's Warfarin as ordered by V10 (Physician): Warfarin Sodium oral tablet 4 mg. Give 1 tablet by mouth one time a day for anticoagulant. Take 1 tablet for three days. V12 did not discontinue the previous Warfarin 2 mg. order.On October 30, 2025, at 4:46 PM, V7 (LPN) entered the following order into the EMR for R1's Warfarin as ordered by V10 (Physician): Warfarin Sodium oral tablet 2 mg. Give 1 tablet by mouth one time a day for anticoagulation. This order was discontinued by V9 (NP) on November 3, 2025. The EMR shows R1 received the following doses of Warfarin:October 27, 2025: 1 mg. at 6:00 PMOctober 28, 2025: 4 mg. at 8:00 PMOctober 29, 2025: 2 mg. at 8:00 PM and 4 mg. at 8:00 PM (Total 6 mg.)October 30, 2025: 2 mg. at 6:00 PM and 2 mg. at 8:00 PM (Total 4 mg.)October 31, 2025: 2 mg. at 6:00 PM and 2 mg. at 8:00 PM (Total 4 mg.)November 1, 2025: 2 mg. at 6:00 PM and 2 mg. at 8:00 PM (Total 4 mg.)November 2, 2025: 2 mg. at 6:00 PM and 2 mg. at 8:00 PM (Total 4 mg.) The EMR shows the following INR results for R1:October 28, 2025, reported to facility at 11:35 AM: INR 1.42 ratio (Normal range 2.00-3.00) The following INRs are commonly followed: Prevention of venous thrombosis 2.00 to 3.00 ratio. Treatment of mechanical heart valve 2.50 to 3.50 ratio.October 30, 2025, reported to facility at 11:28 AM: INR 2.26 ratioOctober 31, 2025, reported to facility at 12:59 PM: INR 3.73 ratioNovember 3, 2025, a critical lab value was reported to the facility at 1:26 PM: INR 10.64 ratio. The EMR shows Phytonadione (Vitamin K) 2.5 mg. was administered to R1 on November 3, 2025 at 3:13 PM.November 4, 2025, a critical lab value was reported to the facility at 1:10 PM: INR 13.10 ratioHospital documentation shows R1 was admitted to the local hospital on November 4, 2025 at 1:22 PM ,and diagnosed with a supratherapeutic INR. In the emergency department R1's INR ratio was 7.13 ratio, and another dose of Phytonadione 2.5 mg. was administered to R1.On November 18, 2025 at 3:23 PM, V12 (LPN) said, on October 28, 2025 she notified V10 (Physician) of R1's INR result of 1.42. V12 continued to say she was not aware R1's INR result had been addressed earlier in the day by V9 (NP), or that V9 increased R1's Warfarin dose from 1 mg. to 2 mg. V12 entered the new order of Warfarin 4 mg. from V10 (Physician), without discontinuing the previous order of Warfarin 2 mg. V12 said, The doctor ordered Warfarin 4 mg. so that's what I entered into the computer.On November 17, 2025, at 12:53 PM, V2 (DON-Director of Nursing) said, R1's Warfarin 2 mg. order was never discontinued prior to each new order being obtained. This error resulted in R1 receiving an additional dose of Warfarin 2 mg. each day, on October 29, 30, 31, 2025, and November 1, and 2, 2025, with the scheduled doses of Warfarin. V2 continued to say, [R1's] INR results were becoming more and more elevated each day, until the point where we had to give Vitamin K to help clot her blood and eventually send her to the hospital. There were multiple mistakes made, and the nurses involved (V5, V6, V7, V8) were all terminated. They were terminated for falsification of documentation. They copied someone else's documentation and didn't look at the INR lab results. 2. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, orthopedic aftercare following surgical amputation of the right fourth toe, acute osteomyelitis of the right ankle, foot, and toe, PVD (Peripheral Vascular Disease), MRSA (Methicillin Susceptible Staphylococcus Aureus) infection, dementia, atrial fibrillation, anxiety disorder, depression, history of bladder cancer, and history of cerebral infarction.R4's MDS, dated [DATE], shows R4 has severe cognitive impairment, requires partial/moderate assistance with bed mobility and transfers between surfaces, and setup assistance with all other ADLs (Activities of Daily Living). R4 is frequently incontinent of bowel and bladder.R4 was not able to answer questions during this investigation due to her cognitive status.The facility's Medication Error Incident Report, dated November 18, 2025, shows, Today, November 18, 2025, it was discovered that on October 31, 2025, [R4] received an additional dose of Coumadin (Warfarin).Nurse obtaining the order from the physician failed to discontinue the previous order. Nurse administered both doses of Coumadin. The facility's Order Audit Report, dated November 19, 2025, shows R4 had an order dated October 29, 2025 for Warfarin 5 mg. tablet by mouth one time a day. The facility's Order Audit Report continues to show an order was obtained by V13 (RN-Registered Nurse) for R4 for Warfarin 6 mg. Give one tablet one time a day. R4's October 2025 MAR (Medication Administration Record) shows V5 (RN) administered Warfarin 5 mg. to R4 at 4:00 PM on October 31, 2025, and Warfarin 6 mg. to R4 at 8:00 PM on October 31, 2025, for a total of Warfarin 11 mg. on October 31, 2025.On November 18, 2025, at 2:15 PM, V9 (NP) said, My order on October 28, 2025 was to increase [R1's] Warfarin dose from 1 mg. to 2 mg. The nursing staff called [V10] (Physician) and obtained the 4 mg. order. If that is what he wanted the resident to receive, the nursing staff should have discontinued my 2 mg. order, but they did not. All along, I thought [R1] was on Warfarin 2 mg. I never knew she received 6 mg. on October 29, 2025, or that the extra Warfarin 2 mg. order never got deleted so she continued to receive the wrong dose for five days. That would explain the elevated INR results. The inaccurate administration of the Warfarin caused [R1's] INR to rise to the level of 13.10, resulting in hospitalization and Vitamin K administration. V9 continued to say R4 should not have received a total of 11 milligrams of Warfarin on October 31, 2025, and R4's elevated INR result of 5.04 ratio on November 4, 2025 was a result of R4 receiving the incorrect dose of Warfarin.

Based on interview and record review, the facility failed to prevent misappropriation of resident proptery as per the facility abuse policy. This applies to 5 of 6 residents (R1-R4, and R6) reviewed for misappropriation of proptery in a sample of 6. The findings include: 1. Face sheet, dated 2/10/25, shows R1's diagnoses include cellulitis right lower limb, urinary tract infections, atrial fibrillation, dysphagia, lymphedema, depression, chronic kidney disease, and chronic respiratory failure with hypoxia. MDS (Minimum Data Set), dated 1/12/25, shows R1's cognition was intact. On 2/10/25 at 1:37 PM, R1 stated she was called by a convenience store and asked if she made a charge for approximately $21.00 to her credit card at the store. R1 stated she told the store she was residing in the facility for rehabilitation and she had not made any charges to her card since she was admitted at the facility. R1 stated she called her daughter to see if she made a charge, and her daughter told her to cancel the card right away. R1 stated she called the credit card company and they asked if she had her card. R1 stated she looked in her purse and discovered her credit and debit cards were missing. R1 stated the credit card company told her there were five other purchases on her card at different locations. R1 stated she called the police and filed a report. R1 stated her purse was located unlocked in the closet of the room. Resident grievance, dated 1/30/25, shows R1 's daughter reported R1's credit card was used without R1's authorization. On 2/10/25 at 2:40 PM, V1 (Administrator) stated the facility determined during the initial and addendum investigations that V4 (Agency CNA - Certified Nursing Assistant) was the individual who stole the credit cards/cash from facility residents due to the fact she was assigned to all of the rooms of the residents who had cards/cash stolen during the time the items were stolen as well as unauthorized charges were made near V4's home. Facility Addendum to Final Reportable, dated 2/3/25, shows on 2/3/25, a facility investigation showed multiple residents were missing credit cards at the facility. The report shows the facility implemented a monitoring process to ensure there were no further incidents of missing credit cards. On 2/4/25, the facility identified an additional resident who was missing a credit card and the facility re-opened the investigation. The report shows small charges from a vending machine were made to the missing credit card on 2/1/25, 2/2/25, and 2/3/25. Utilizing the credit card charge times, the facility was able to identify a temporary agency employee that worked all the shifts and units where the missing credit cards were reported. The facility also confirmed a charge was identified to have taken place at a restaurant 0.7 miles from the temporary agency employee's home address. The facility immediately notified the temporary agency and the police investigating the original theft reports. Final Reportable, dated 2/3/25, shows R1 had a recent hospital stay and on 1/30/25, R1 received a text message from her credit card company asking her to verify a purchase at a convenience store for $11.00. R1 checked her bank account and identified a fraudulent charge attempt on her account. R1 contacted her daughter V3 (Family) who contacted V1 (Administrator) to assist R1 in canceling her credit card. V1 assisted R1 in canceling her credit card and began a facility investigation. R1 searched her purse and identified her credit card as missing. V1 assisted R1 in filing a police report. During the investigation, three additional residents on the 500 unit reported missing credit cards or small amounts of cash, and one resident located on the 2500 unit. An additional police report was made to include the additional information of missing items. During the investigation, the facility reviewed staffing and identified one staff who worked both units in the time frame of the missing items. Review of the employee's work history showed the employee worked 1/21/25-1/28/25 but did not show up for her scheduled shift on 1/31/25 and 2/1/25 resulting in automatic termination. Final reportable shows the facility reviewed the hiring of the employee and a criminal background check was conducted prior to hire and was clear. The healthcare registry form was reviewed prior to hire and the staff was eligible to work as a CNA. The residents were reimbursed any missing cash and the missing credit card was deactivated. Residents were encouraged to send valuable items home with trusted family or friends. If residents wish to keep their valuable items they have the option of having it locked up in a secure closet in the administrator office. Residents do continue to have the choice of keeping valuables with them at the bedside if they choose. Review of facility staffing schedules, dated 1/19/25 to 2/2/25, show V4 worked caring for R1-R4 during her worked shifts. 2. Face sheet, dated 2/10/25, shows R2's diagnoses include fracture of greater trochanter of left femur, fracture of third lumbar vertebra, falls, hypotension, chronic obstructive pulmonary disease, respiratory failure, asthma, polyneuropathy, sick sinus syndrome, anemia, takotsubo syndrome, rheumatoid arthritis, and depression. MDS, dated [DATE], shows R2's cognition was intact. On 2/10/25 at 1:44 PM, R2 stated on 2/3/25, she checked her bank account to look for a charge she was expecting. R2 stated she noticed there were approximately nine charges on her account that she did not recognize, including some that she was told by the credit card company were vending machine charges. R2 stated she called the bank to report the fraud, and also reported it to the Administrator. R2 stated when she looked in her purse, she was missing a cash card and another credit card. R2 stated she was also missing $40. R2 stated she was as admitted to the facility on [DATE] and kept her purse in the top drawer in her room. R2 stated she provided V1 with the time and amounts of the fraudulent charges and the following day she received a text from the credit card company that another fraudulent charge of $125 was attempted at a gas station on her credit card which was blocked by the company. R2 stated there were four unauthorized charges on 2/1/25, four unauthorized charges on 2/2/24, and one more unauthorized charge on 2/3/25 for vending machine food she believed was here at the facility. R2 stated she provided the times of the charges to V1 so V1 could check the cameras by the vending machine. Progress note, dated 2/4/25, shows, Pt (patient) reported to Writer that her credit card, bank card and $40.00 was stolen from upstairs. Write reported it to AM supervisor and Administrator. Resident grievance, dated 2/4/25, shows R2 was missing a debit card, credit card, and two $20 bills from her purse. 3. Face sheet, dated 2/10/25, shows R4's diagnoses include urinary tract infection, acidosis, hypo-osmolality and hyponatremia, anemia, muscle weakness, diabetes, hypertension, and Norwalk virus. MDS, dated [DATE], shows R4's cognition was intact. On 2/10/25 at 2:10 PM, R4 stated on 2/2/25 R4 looked in her purse and discovered she was missing one credit card and $48.00 in cash. R4 stated she reported the missing items items to the facility and to the police. R4 stated she discovered the following unauthorized charges on her credit card: 1/28/25 Four snack vending charges - $1.10, $1.10, $1.10, $1.85 1/31/25 Uptown Smoke Zone $61.16 1/31/25 Windy City Gyros $28.74 2/1/25 Three $5.00 snack vending charges Grievance, dated 2/2/25, shows R4 reported she was missing her credit card and $48 dollars from her wallet. 4. Face sheet, dated 2/10/25, shows R3's diagnoses include intertrochanteric fracture of right femur, fall, diabetes, heart failure, depression, and osteoporosis. MDS, dated [DATE], shows R3's cognition was intact. On 2/10/25 at 1:30 PM, R3 stated after she heard her roommate, R4, had items stolen, she asked staff to look in an envelope in her drawer where she was keeping $43.00 and the staff found her money was missing from the envelope. R3 stated the night prior, she was resting in bed and groggy when her roommate, R4, was assisted to the bathroom by a staff member. R3 described the staff member as Caucasian, tall, slim with a slim face, and had tattoos on her arm. R3 stated after she helped R4 to the bathroom, the staff pulled the curtain between the resident beds and R3 heard the staff member rummaging in the dressers between the resident beds. R3 stated the room was dark and the curtain was drawn so she did not see the staff take anything, but R3 stated it was odd she was rummaging through the dressers while R4 was in the bathroom. R3 stated it was the next day she and R4 discovered there were items missing from their room. Grievance, dated 2/2/24, shows R3 reported missing $43 as of 2/1/25. 5. On 2/11/25 at 9:34 AM, V1, Administrator, stated she was contacted by a nursing supervisor who reported R6 was contacted via text by V4. V1 stated V4 told R6 she was experiencing personal hardships and was in need of money. V1 stated she reported the contact to the police. On 2/11/25 at 11:53 AM, screen shots of text messages between R6 and V4 show V4 told R6 she needed $300 because she was being evicted due to being fired, her spouse beat her, her son was taken by her mother in law, her family will not communicate with her, and she needed help to stay at her residence or return to her home state. Resident statement, provided 2/10/25, shows V4 provided R6 her personal cell phone number after telling R6 that V4's child was ill. The statement shows R6 later texted V4 to ask how her child was doing and V4 responded asking for $300. Employee statement, dated 2/10/25 by V5 (Nurse), shows V5 was passing medication when R6 showed her text messages from V4 and V5 reported the messages immediately after instructing R6 to block the number and not respond. Facility document, dated 2/10/25, shows R1 experienced five fraudulent transactions totaling $253.70, R2 experienced nine fraudulent transactions totaling $13.70 and $40 cash taken, R3 experienced $43 cash taken , and R4 experienced eight fraudulent transactions totaling $158.05. Facility Abuse Prevention Program Policy and Procedure, dated 2012, shows Resident are to be free from . misappropriation of resident property . and all times. Misappropriation of Property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Examples include, but are not limited to, stealing cash or property; misuse of checks, credit cards, or accounts; forgery of a signature; identity theft.

Based on observation, interview, and record review, the facility failed to safely reposition a resident and failed to secure oxygen tanks to prevent them from falling and combusting. This applies to 9 of 9 residents (R14, R2, R32, R371, R379, R26, R41, R45, and R84) reviewed for accidents and supervision in a sample of 31. The findings include: 1. R14 was readmitted to the facility on [DATE], with diagnoses including Parkinson's disease, dementia, muscle weakness, altered mental status, osteoporosis, malignant melanoma of skin, and history of falling. R14's MDS (Minimum Data Set) was not available, but the Significant Change Assessment completed on 9/20/24 showed R14 had moderate cognitive impairment. R14's GG Assessment, dated 9/23/24 showed R14 was dependent on staff for all activities of daily living. On 9/25/24 at 3:23 PM, V8 (CNA/Certified Nurse Assistant) came to R14's room to assist V13 (Wound Care Nurse) and V14 (Wound Care Nurse) with fixing R14's bed height. R14 was lying in bed and the head of the bed was elevated, and R14's upper body was leaning towards the left side. V8 fixed R14's bed, and then came around to R14's right side, and pulled the resident by the upper arm, by placing her hands under his armpit to straighten him out. V8 did not ask V13 or V14 to assist with repositioning R14. On 98/25/24 at 3:51 PM, V8 (CNA) said she should not have pulled R14's arm, and should have asked for assistance to reposition R14. V8 said she should have used the draw sheet and pillows to reposition R14. V8 said the resident could have been bruised by the way he was pulled. On 9/25/24 at 3:23 PM, V14, who had observed V8 reposition R14, said V8 should not have pulled R14 and should have asked for assistance to help reposition him. On 9/25/24 at 3:48 PM, V12 (CNA) said, To reposition a resident, you ask for help by using a draw sheet to straighten them out. Staff should not pull the resident by their arms because the residents are often fragile, and it could break their arm. On 9/25/24 at 3:55 PM, V9 (CNA) said if a resident was leaning, she would not pull the resident, but would use other staff assistance and a draw sheet. On 9/25/24 at 3:58 PM, V10 (OT/Occupational Therapist) said staff should use the draw sheet to prop the resident up and V11 (PTA/Physical Therapist Assistant) said he would use the draw shift as well, and then use pillows to prop them up. V10 and V11 said the staff should not be pulling the resident to straighten them out. On 9/25/24 at 4:06 PM, V2 (DON/Director of Nursing) said V8 should have repositioned R14 gently, with two staff assistance because R14 required maximal assistance from staff. V2 also said the staff should have used the draw sheet. The facility's Repositioning Policy, revised May 2013, showed, Use two people and a draw sheet to avoid shearing while turning or moving the resident up in bed. 48944 2. The Electronic Medical Record (EMR) showed R32 had diagnoses of acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease. R32's Order Summary Report, dated 9/26/2024, showed an order for oxygen via nasal cannula 4-8 LPM (liters per minute). On 9/24/2024 at 12:30 PM, there were two metal oxygen tanks at the entrance of R32's room. The oxygen tanks were not secured in a holder to prevent them from tipping over. On 9/25/2025 at AM 9:03 AM and 9/26/2024 at 9:00 AM, the oxygen tanks were still in the same location and not secured in a holder. On 9/26/204 at 9:05 AM, V18 (Respiratory Therapist/RT) said the oxygen tanks should not be placed directly on the floor for safety. V18 said oxygen tanks should be placed on oxygen holders to prevent them from tipping over. On 9/24/2024, 9/25/2024, and 9/26/2024, R14's room was in close proximity to R379, R2, and R371's rooms. 46380 3. On 09/25/24 at 09:27 AM, R45 was sleeping in his bed. An unsecured portable oxygen tank was on the floor on the left side of his dresser across his bed. It did not have any holder to prevent the tank from tipping over. R45's portable oxygen tank was full. R45 shared the room with R26. R45's room was near R41 and R84's room. On 9/26/24 at 11:39 AM, V2 (DON-Director of Nursing) said, Portable tanks are stored in 2200 hallway of the facility. Portable tanks are also stored and secured behind resident's wheelchair. Portable oxygen needs to be secured for safety reasons and so they will not tip over and blow up. The facility's Oxygen Management Policy and Procedure, dated 4/22/2015, documented the following: If the resident uses oxygen, a portable container may be kept in the room. The portable oxygen container should be protected from falling over when not in use.

Based on observation, interview, and record review, the facility failed to safely store medications. This applies to 5 of 5 residents (R373, R171, R425, R272, and R274) reviewed for medication storage in the sample of 31. Findings include: 1. R373's Oder Summary Report, dated [DATE], showed orders for Mirabegron ER (extended-release) 50 mg (milligrams) daily for stress incontinence, Sertraline 100 mg daily for anxiety, and Wellbutrin XL (extended-release) 300 mg daily for depression On [DATE] at 3:46 PM, V22's (Licensed Practical Nurse/LPN) medication cart was checked for medication storage. V22's cart had 3 pills that were loose in an unlabeled clear medication cup. V22 said her shift had just started, and she was not sure whose medications they were, nor what the pills were. V22 said opened and unlabeled medications should have been stored inside the medication cart. On [DATE] at 12:00 PM, V2 (Director of Nursing/DON) said R373's morning nurse on [DATE] prepared her 9 AM medications, but forgot to administer them, and stored them in the medication cart. V2 said she expects nurses to prepare medications at the time they are being administered. V2 continued to say medications removed from their original packages should not be stored in the medication cart once opened to ensure safe medication storage and administration. 44387 2. On [DATE] at 10:45 AM, there was a bottle of generic eye drops, Clear Eyes Triple Relief on R425's bedside table. There was a Ventolin HFA (Hydrofluoroalkane) Albuterol Sulfate Inhalation Aerosol inhaler, and two tablets of Children's allergy medication, expired ,d+[DATE], in a clear bag on R425's bedside dresser. At 12:12 PM, R425 said she uses the eyedrops when her eyes gets dry, and she uses the inhaler because she has asthma and COPD (Chronic Obstructive Pulmonary Disease). Review of R425's physician order shows an order for Albuterol Sulphate Inhalation Aerosol Powder Breath Activated 108 (90 base) mcg, 2 puff inhale orally every four houses as needed for wheezing and shortness of breath. There is no order for the Children's allergy medication, eye drops or to have medications stored at the resident room. 3. On [DATE] at 8:50 AM, during medication pass, there was ampule of Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5 mg/3 mg (milligram) on R171's bedside table. R171 also pointed to Spiriva Respimat Tiotropium Bromide Inhalation inhaler on the bedside dresser. R171 told V15 (Registered Nurse/RN) that his daughter brought it because the facility did not have it in stock. V15 said the nebulizer treatment and the inhaler should not be in the resident's room. Review of R171's physician orders shows order for Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5 mg/3 mg; there was no order for Spiriva Respimat Tiotropium Bromide Inhalation inhaler or to have medications stored in the resident's room. 46380 4. On [DATE] 11:52 AM, R272 had an unlabeled tube of glucose tablets on top of his bedside table, and another tube of glucose tablets on his nightstand on the left side of his bed. He said he self-administers it when he sees his blood sugar level is low. R272 had an unlabeled Ipratropium Bromide Nasal Solution 0.03% on top of his bedside table. He said he self-administers it twice a day, one to two sprays to each nostril every morning and every evening. R272 had an unlabeled tub of Hemp EMU relief cream on the windowsill on the right side of his bed; he said he administers it to himself and applies it on his thighs when it hurts as needed. All medications are unlabeled. On [DATE] at 9:54 AM, same unlabeled medications were observed on his bedside table. Review of R272's POS (Physician Order Sheet) showed no order to keep medication by bedside. There were no orders for glucose tablets, Ipratropium Bromide Nasal Solution 0.03%, and Hemp EMU relief cream. 5. On [DATE] at 11:35 AM, R274 had Cortizone-10 cream on her bedside table that was in front of her. It was not labeled. She said she applies it herself to her arms when it itches. Review of R274's POS showed no order for medication at the bedside and no order for Cortizone-10. On [DATE] at 11:39 AM, V2 (DON-Director of Nursing) said, Currently, there are no residents in the facility that have an order to have medication by the bedside and order to self-administer medication. Before an order for medication by the bedside and order to self-administer is obtained, assessment needs to be done to determine if resident is competent. If resident is competent, order is obtained, resident is given a lock box with a key to store the medication in. The resident is given a sign out sheet to document when they take medication so nurses can check it. If family brings in medication from outside, they are instructed to give it to the nurses, and nurses administer it as house stock if there is an order. All medications should be kept under lock and key with the nurse. If there is no order for medication, nurses should call family to inform them that medication will be returned to family or disposed. The facility's policy titled Storage of Medications, dated ,d+[DATE], showed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . The facility's policy titled Administering Medications, dated ,d+[DATE], showed, Medications shall be administered in a safe and timely manner, and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame .

Based on observation, interview, and record review, the facility failed to follow infection control practices for residents on transmission-based precautions. This applies to 5 of 5 residents (R325, R324, R62, R45, R374) reviewed for infection control in a sample of 31. The findings include: 1. R325 was admitted to the facility on [DATE], with diagnoses including urinary tract infection, cellulitis of right lower limb, severe dementia, and need for assistance with personal care. R325's POS (Physician Order Sheet) showed R325 had an order for contact isolation for a diagnosis of MDRO (Multi-Drug Resistant Organism) urine. R325's Admission Social History Progress Note, dated 9/25/24, showed R325 was cognitively intact. On 9/26/24 at 10:15 AM, R325's room door had a sign showing she was on contact precautions. R325 had an isolation bin outside her room with gowns, masks, face shields, red bags, and blue bags. V5 (CNA/Certified Nurse Assistant) was in R325's room with no gown on, and said she was providing R325 patient care and was finishing providing a bed bath for the resident. On 9/26/24 at 1:40 PM, V5 said R325 was on isolation for burns and so the CNAs and nurses needed to wear PPE (Personal Protective Equipment) such as a gown, gloves, and a mask to go into the room. On 9/26/24 at 1:46 PM, V16 (LPN/Licensed Practical Nurse) said for residents on contact isolation, the staff should wear a gown, gloves, and optionally could wear a mask. V16 said the PPE (personal protective equipment) is worn to protect themselves as well as the patient. V16 said any part of the staff body that could touch the resident should be covered. On 9/26/24 at 1:55 PM, V24 (LPN) said the staff should wear a gown and gloves to go into contact isolation rooms. On 9/26/24 at 12:12 PM, V2 (DON/Director of Nursing) said for residents on contact precautions, the staff should wear gowns and gloves if they are going into contact precaution rooms. The facility's Policy and Procedure for the Prevention and Control of Infection Disease Outbreaks, revised on 6/1/21, showed to Implement appropriate isolation precautions (i.e. contact, droplet, etc.). Wear personal protective equipment to include gloves, gown, and mask upon entry to the room and when in contact with the symptomatic resident. The facility's undated Contact Precautions signage showed Put on gown before room entry. 2. R324 was admitted to the facility on [DATE], with diagnoses including an unstageable pressure ulcer of the sacral region, methicillin resistant staphylococcus aureus infection, local infections of the skin and subcutaneous tissue, and extended spectrum beta lactamase resistance. R324's Social History Progress Note, dated 9/23/24, showed R324 had moderately impaired cognition. R324's POS (Physician Order Sheet) showed an order, dated 9/24/24, for a new central/midline order and an order for Ertapenem Sodium Injection Solution Reconstituted 1 gram. R324's September 2024 MAR (Medication Administration Record) showed R324 was given Ertapenem by V4 on 9/24/24 and 9/25/24. On 9/24/24 at 11:01 AM, R324's door had signage for EBP (Enhanced Barrier Precautions), and there were gowns located outside of her room. On 9/25/24 at 1:04 PM, V4 (LPN) went to R324's room to disconnect her from her IV (Intravenous) antibiotic administration, and did not apply a gown while providing IV maintenance. On 9/26/24 at 1:46 PM, V16 (LPN) said for residents under EBP, any time the staff was in direct contact with the resident, they are supposed to wear a gown and gloves, including with IV management. On 9/26/24 at 1:55 PM, V24 (LPN) said staff going into resident rooms on EBP should have gloves and a gown on and could choose to wear a mask. 3. R62 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, dementia, hypertension, and atherosclerotic heart disease. R62's MDS (Minimum Data Set), dated 8/30/24, showed R62 was cognitively intact. On 9/24/24 at 12:09 PM, R62's room door had signage for EBP. V7 (Housekeeping) was providing linen change and bed making for R62's bed, and had only a pair of gloves on, no gown. V7 placed the dirty linen directly on the ground, touched R62's bed with the same gloves, picked up the linen off the ground, placed the dirty linen onto the bed, and then grabbed the dirty linen against her clothing and walked out of the room. V7 said R62's room was not under any kind of isolation or precautions. 4. R45's Oder Summary Report, dated 9/26/2024, showed an order for Enhanced Barrier Precautions due to his urinary catheter. R45's Care Plan, dated 9/26/202,4 said R45 had an indwelling catheter and was at risk for infections. The care plan had multiple interventions including Enhanced Barrier Precautions. On 9/25/2024 at 4:15 PM, R45's room door had an Enhanced Barrier signage posted with instructions for staff to apply proper PPE when rendering direct care. V12 (CNA) entered R45's room and applied clean gloves to provide urinary catheter care to R45. V12 did not perform hand hygiene nor applied a PPE gown. V12 proceeded to render urinary catheter care to R45. On 9/26/24 at 10:29 AM, R45's room door had signage for EBP. V23 (Housekeeping) was observed making R45's bed and only had gloves on, no gown. V23 said she changed his bed sheets every day. V23 said R45 was not on any isolation or precautions, and when shown the EBP signage, said only the aide needed to wear a gown and gloves. 48944 5. R374's Order Summary Report, dated 9/26/2024, said an order for Enhanced Barrier Precautions due to her PICC (Peripheral Intravenous Central Catheter) and urinary catheter. R374's Care Plan, dated 9/26/2024, said R374 was at risk for infections and required enhanced barrier precautions due to her indwelling medical devices. The care plan had multiple interventions including PPE to be worn when caring for the resident to protect themselves and the resident. On 9/25/2024 at 3:20 PM, R374's room door had an Enhanced Barrier signage posted with instructions for staff to apply proper PPE (Personal Protective Equipment) when rendering direct care. V19 (CNA) entered R374's room and applied clean gloves to provide urinary catheter and incontinence care to R374. V19 did not perform hand hygiene nor applied a PPE gown. V19 proceeded to render urinary catheter and incontinence care to R374. On 9/26/2024 at 12:00 PM, V2 (Director of Nursing/DON) said staff are expected to wear proper PPE when entering rooms with transmission-based precautions and when providing high-contact care for residents under enhanced barrier precautions. V2 said high-contact activities where PPE was required for those under enhansed barrier precautions included intravenous catheter care, incontinence care, catheter care, linen changing. V2 said proper use of PPE and hand hygiene needs to be followed to prevent the transmission of infections. The facility's signage titled Enhanced Barrier Precautions said everyone must Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for following High-Contact Resident Care Activities. The signage said high-contact resident care activities included bathing, showering, changing linens, providing hygiene, changing briefs, or assisting with toileting, and device care or use of central lines and urinary catheters. The facility's policy titled Policy and Procedure for Preventing the Spread of Multidrug Resistant Organisms (MDROs), dated 9/1/2022, showed, Patients in nursing facilities are at increased risk of becoming colonized and developing infection with MDROs .This policy and procedure is intended to provide guidance for PPE use and room restriction in nursing facilities for preventing transmission of MDROs. For purpose of this policy, the MDROs for which the use of enhanced based precautions applies are based on organisms targeted by the CDC .Contact Precautions: .Contact Precautions require the use of gown and gloves on every entry into a patient's room .Enhanced Barrier Precautions: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

Based on observation, interview, and record review, the facility failed to ensure intravenous medications were administered by qualified staff. This applies to 3 of 4 residents (R321, R324 and R426) reviewed for intravenous therapy in a sample of 31. The findings include: 1. R426 Physician Order shows R426 has an order for Ceftriaxone Sodium injection solution reconstituted 2gm, intravenously one time a day until 10/28/24. On 9/25/24 at 11:24 AM, V16 (Licensed Practical Nurse/LPN) administered R426's Ceftriaxone 2 gm (grams) IV (intravenous) medication through right upper arm PICC (Peripherally Inserted Central Catheter) line with the use of an IV pump. On 9/25/24 at 12:11 PM, V16 said she routinely administers IV medications when assigned to residents that are on IV medications. On 9/26/24 at 11:56 AM, V2 (Director of Nursing/DON) said the LPN's are trained by the Registered Nurses to administer medications via IV, including saline flushes and IV antibiotics. 46409 2. R324 was admitted to the facility on [DATE] with diagnoses including an unstageable pressure ulcer of the sacral region, Methicillin resistant staphylococcus Aureus infection, local infections of the skin and subcutaneous tissue, and extended spectrum beta lactamase resistance. R324's Social History Progress Note dated 9/23/24 showed R324 had moderately impaired cognition. R324's POS (Physician Order Sheet) showed an order dated 9/24/24 for a new central/midline order and an order for Ertapenem Sodium Injection Solution Reconstituted 1 gram. R324's September 2024 MAR (Medication Administration Record) showed R324 was given Ertapenem by V4 on September 24, 2024 and September 25, 2024. On 9/25/24 at 10 AM, R324 was lying in bed and there was a PICC line in her right arm, with the dressing dated September 24, 2024. The dressing was clean, dry, and intact. On 9/25/24 at 12:26 PM, V4 (LPN/Licensed Practical Nurse) said R324 was receiving IV (Intravenous) antibiotics because she had a urinary tract infection and a wound. V4 said she started the IV antibiotics at 12:05 PM, and had also hung it on 9/24/24. V4 said she cleaned the hub of the PICC (Peripherally Inserted Central Catheter), flushed it with 10 ML (Milliliters) of normal saline, checked for blood return, and hung her antibiotics. At 1:04 PM, V4 disconnected the IV tubing from the hub, wiped the hub with an alcohol wipe, and flushed 10 ML of normal saline. 3. On 9/24/24 at 10:16 AM, R321 had a PICC line on the right arm and the dressing was clean, dry, and intact. On 9/25/24 at 9:54 AM, R321 had a bag of Sodium Chloride IV fluids running at 80 ML/Hour. On 9/25/24 at 12:26 PM, V4 said she hung R321's Sodium Chloride maintenance fluids around 9:45 AM, and signed it off in the MAR after she started it. R321 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the digestive system and adjustment and management of vascular access device. R321's MDS (Minimum Data Sheet). dated 9/13/24, showed R321 was cognitively intact. R321's POS (Physician Order Sheet) showed an order, dated 9/7/24, for central/midline care to the right upper extremity, and an order for one liter of Sodium Chloride started on 9/25/24. R321's September 2024 MAR (Medication Administration Record) showed R321 was given Sodium Chloride by V4 on 9/25/24 at 10 AM. On 9/26/24 at 1:55 PM, V24 (LPN) said she does not hang IV's because she is an , and they were not allowed to. V24 said if she had a resident with an IV, she would ask an RN (Registered Nurse) to hang the IV antibiotic. The facility's document titled Job title: LPN states the LPN performs various patient test and administers medications within the scope of practice and requires knowledge and skills related to medical/operational systems to successfully maintain excellent nursing care. The facility's Central Vascular Access Device (CVAD) Flushing and Locking policy (revised 6/1/21) states the nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. The National Library of Medicine article titled Nursing Advance Skills dated 2023 said a midline is a long and deep peripheral catheter inserted in the veins of the upper arms, not a short intravenous catheter inserted by a percutaneous venipuncture into a peripheral vein. The Illinois Nurses Act (section 1330.240) amended on June 14, 2019, shows the scope of practice for LPNs which does not include initiating the administration of IV medications through a midline (long peripheral catheter) or central lines, nor reconstituting IV antibiotic medication solutions

Based on observation, interview, and record review, the facility failed to provide proper catheter care, secure catheter tubing placement, and safely anchor the catheter drainage bag. This applies to 2 of 3 (R374 and R45) reviewed for urinary catheters in a sample of 31. The findings included: 1. The EMR (Electronic Medical Record) showed R374 had diagnoses of urinary retention and urinary tract infection. R374's EMR continued to show she required the use of an indwelling catheter. R374's MDS (Minimum Data Set), dated 9/2/2024, showed R374 was incontinent of bowel and dependent on facility staff for toileting hygiene care. On 9/25/2024 at 9:15 AM, V26 (Certified Nurse Assistant/CNA) was rendering toileting care to R374 after having a bowel movement. V26 did not provide catheter care to R374. V26 then assisted R374 into her wheelchair and placed her catheter drainage bag on the floor. On 9/25/24 at 3:20 PM, R374 was in bed with her catheter's drainage bag loosely hanging over the right side of her bed not secured. V19 (CNA) was asked to provide catheter care to R374. R374's catheter tubing was located underneath her right thigh, and the tubing contained urine. V19 turned R374 on her left side, which caused her catheter to pull to the right side. V19 proceeded to provide catheter care. V19 wiped R374's catheter with multiple upstrokes towards R374's urethra, and then downstrokes using the same wipe. V19 then said she would change R374's incontinence brief because it was stained with yellow fluid drainage. Then when V19 was done rendering incontinence care, she left R374's catheter tubing placed underneath her right thigh, and drainage bag unsecured hanging over the right side of the bed. 2. The EMR showed R45 had diagnoses of urinary retention, neuromuscular dysfunction of the bladder, and urinary tract infections. R45's EMR continued to show he required the use of an indwelling catheter. R45's MDS, dated [DATE], showed R45 was incontinent of bowel and dependent on facility staff for toileting hygiene care. On 9/25/2024 at 4:15 PM, R45 was in bed. V12 (CNA) was asked to provide catheter care to R45. V12 proceeded to render catheter care to R45. V12 used one wet washcloth to clean R45's catheter. V12 cleaned the catheter with multiple upward and downward strokes. Then V12 used the same washcloth to clean R45's penis area and scrotum, and then again cleaned R45's catheter with the same washcloth. On 9/26/2024 at 12:00 PM, V2 (Director of Nursing/DON) said catheter care should be provided every shift and during incontinence care. V2 said catheters for male and female residents should be cleaned by wiping them down, away from the urethra. V2 said catheter drainage bags should not be placed on the floor and should be safely secured not hanging loosely. V2 continued to say catheter tubing should also be checked to ensure they are not kinked, and residents should not be lying on top of the tubing to prevent obstruction. V2 said she expects nursing staff to provide proper catheter care for infection control and to provide proper hygiene care. The facility's policy titled Urinary Catheter Care Policy and Procedure, dated 9/18/2019, showed, The purpose of this policy to ensure the safe insertion of catheters to prevent resident injury and reduce the risk of catheter-related infections .Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .Infection Control .2. Maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag .Routine hygiene .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to verify Percutaneous Endoscopic Gastrostomy tube (PEG tube) placement prior to administering medications through PEG-tube and failed to properly administer water flushes and medications via the G-tube. This applies to 1 of 1 resident (R171) reviewed for medication administration via PEG-tube in a sample of 31. The findings include: R171's Physician Order shows the following orders: PEG tube three times a day flush 30 cc (ml) prior to med admin, 10-15 cc between each med flush, 30 cc flush post med admin. Potassium Chloride Oral Solution 20MEQ/15 ML (10%) give 15 ml via PEG tube one time a day for supplement. On 9/25/24 at 9:00 AM, V15 (Registered Nurse/RN) went to R171's room to administer his morning medications via the PEG-tube. V15 placed a stethoscope on R171's abdomen injected 30ml (milliliters) of air using the piston syringe through the port. V15 used the stethoscope to auscultate to check for PEG-tube placement. V15 failed to check the gastric content. V15 flushed R171's PEG-tube with 60 ml of water before administering medications, flushed with 20 ml of water in between each medication, and flushed with another 60 ml of water after administering medications. V15 failed to dilute liquid Potassium Chloride prior to administering it via the PEG-tube. On 9/26/24 at 10:15 AM, V2 (Director of Nursing/DON) said nurses check G-tube placement by pushing air in PEG-tube and auscultating or by measuring the tube. V2 said the nurse should follow the physician order for water flushes and liquid potassium should be diluted with 4 to 8 ounces of water to prevent gastrointestinal irritation. The facility's Manufacturer's Guideline for Potassium Chloride Oral Solution 20MEQ/15 ml states to dilute prior to administration. Warnings and Precautions: Gastrointestinal Irritation dilute before use. The facility's Administering Medications through an Enteral Tube (3/16/22) states to verify placement of feeding tube.

Based on observation, interview, and record review, the facility failed to change residents' PICC (Peripherally Inserted Central Catheter) dressings, measure arm circumferences, and external catheters as ordered for intravenous catheters. This applies to 2 of 4 residents (R374 and R424) reviewed for intravenous catheters in a sample of 31. The findings include: 1. On 9/24/24 at 10:37 AM, R424 had an intravenous (IV) PICC catheter to right upper arm. R424's PICC line catheter had transparent dressing, with no date; the bio-patch dressing, and butterfly outer catheter was covered in dry blood, dressing was soiled. On 9/25/24 at 10:55 AM, R424's PICC line dressing still soiled with dry blood. R424's Physician Order states PICC line (single lumen) care to right upper extremity one time a day every Friday and as needed, dressing change and change of caps. 48944 2. The Electronic Medical Record (EMR) showed R374 had diagnoses of discitis of the lumbar region and urinary tract infection. R374's EMR showed R374 was receiving daily IV antibiotic therapy for her infections via her right upper arm PICC. R374's Order Summary Report, dated 9/26/2024, showed an order for PICC LINE care to RUE one time a day every Fri and prn, measure arm circumference, external catheter measurement, dressing change, and changing of caps. On 9/25/2024 at 9:15 AM, R374 had an intravascular central catheter (PICC) to her right upper arm. R374's PICC line had a transparent dressing, dated 9/18/2024. On 9/26/2024 at 9:39 AM, R374 had the same transparent dressing, dated 9/18/2024. On 9/26/2024 at 11:40 AM, V2 (Director of Nursing/DON) said central venous catheter dressings should be changed every 7 days or if soiled, and dated for infection control prevention. V2 said she expects nurses to be assessing PICC line dressing routinely. V2 said R374's PICC line dressing was not changed because she went to the hospital, and when she returned it was missed. The facility's Central Vascular Access Device (CVAD) Dressing Change, dated 6/01/2021, showed, 1. Central vascular access devices (CVADs) included: 1.1 Peripherally inserted central catheter (PICC) .2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Guidance: 1. Perform sterile dressing changes using Standard-ANTT: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label 1.1.1.1 Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment 1.2 At least weekly 1.3 If the integrity of the dressing has been compromised (wet, loose, or soiled) .7. Assessment of the vascular access site is performed .7.3 Before and after administration of intermittent infusions 7.4 At least once every shift when not in use .8. Assessment of indwelling vascular access insertion site, an entire arm with PICC, for infusion related complications is to include .8.2 Drainage 8.6 Integrity of transparent dressing .

Based in observation, interview, and record review, the facility failed to get an order for oxygen for a resident receiving oxygen. This applies to 1 of 1 resident (R322) reviewed for oxygen administration in a sample of 31. The findings include: R322 was admitted to the facility on [DATE], with diagnoses including hypertensive encephalopathy, type 2 diabetes mellitus, dementia, hypertension, constipation, osteoarthritis, gait and mobility, cognitive communication deficit, need for assistance with personal care, and history of falling. R322's Admission Social History Progress Note, dated 9/20/24, showed R322 had moderate cognitive impairment. R322's POS (Physician Order Sheet), dated 9/26/24 at 2 PM, did not show an order for oxygen administration. On 9/24/24 at 11:22 AM, R322 was lying in bed and was receiving between 3.5 to 4 liters of oxygen via the nasal cannula. On 9/25/24 at 10:07 AM, R322 was wearing oxygen via the nasal cannula, and she was still receiving between 3.5 to 4 liters of oxygen. On 9/26/24 at 1:46 PM, V16 (LPN/Licensed Practical Nurse) said residents who are on oxygen need an order. V16 said R322 was receiving oxygen. V16 checked R322's POS (Physician Order Sheet) and said V16 did not have an order for oxygen. On 9/26/24 at 12:12 PM, V2 (DON/Director of Nursing) said when residents are receiving oxygen should have an order from the physician. R322's oxygen saturation vitals showed R322 required and had been receiving oxygen from 9/19/24. The facility's Oxygen Management Policy and Procedure, dated 4/22/15, showed, All residents that receive oxygen in the facility will have a physician order that designates the number of liters the resident should receive.

Based on observation, interview, and record review, the facility failed to verify the counting logs accuracy for residents with controlled medications, and failed to dispose of controlled medications per facility policy. This applies to 2 out of 2 (R377 and R378) residents reviewed for control medications in a sample of 31. Findings include: 1. R377's Order Summary Report, dated 9/26/2024, showed an order, dated 9/23/2024, for Alprazolam Oral Tablet 0.25 MG (Alprazolam) give 0.5 tablet by mouth every 12 hours as needed for anxiety. On 9/25/2024 at 3:46 PM, V22 (Licensed Practical Nurse/LPN) was asked to review the controlled box for storage in the 300-hall medication cart. R377's Controlled Substances Proof of Use sheet was stored inside the controlled box (not in the cart's narcotic control counting log binder), and had two tablets in separate individualized packages stapled to the sheet. One package was sealed with one whole tablet, and the other package that was not sealed had a cut half tablet that was loose. The packages said they contained Alprazolam 0.25 mg (milligrams) tablets. R377's Controlled Substance Proof of Use sheet, dated 9/21/2024, did not indicate the name of the medication, dosage, nor the medication order administration instructions. 2. R378's Controlled Substance Proof of Use sheet was stored inside the controlled box in the 300-hall medication cart (not in the cart's narcotic control counting log binder). R378's sheet had one tablet in an individualized package stapled to the sheet, which said it contained Tramadol 50 mg. R378's Controlled Substance Proof of Use sheet, dated 8/20/2024, did not indicate the ordered medication administration instructions. R378's Order Summary Report, dated 9/26/2024, did not show an active order for Tramadol. V22 (Licensed Practical Nurse/LPN) was present during R377 and R378's observations. V22 said they frequently pre-pull controlled medications from the facility's narcotic convenience box to have them available if needed for new admissions. V22 was not able to explain why the Controlled Substance Proof of Use sheets were not in the cart's narcotic control counting log binder. On 9/26/2024 at AM, V2 (Director of Nursing/DON) said, All individualized Controlled Substance Proof of Use sheets should be kept inside the narcotic control sign-off binder to ensure all controlled medications are accurately accounted for. The Controlled Substance Proof of Use sheets should have proper documentation to ensure the safety and correct administration of controlled medications. Controlled medications should be obtained from the facility's convenient controlled box at the time they are needed, not pre-pulled. Opened controlled medications should be disposed of accordingly and not be placed back into the package once open to prevent diversion. The facility's policy titled Controlled Substance Policy and Procedure, dated 12/2022, showed, The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of s II and other controlled substances .If the count is correct, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance .This record must contain .The name and strength of the medication; quantity received .Name of physician; Prescription number; Name of issuing pharmacy .When a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tables or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container. Nursing staff must count controlled medications at the beginning and end of each shift .They must document and report any discrepancies to the Nurse Manager .

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure sores. This failure resulted in R1 developing a Stage 3 pressure sore to her sacrum. This applies to three of four residents (R1, R3 and R4) reviewed for wounds. Findings include: 1. R1 was admitted to the facility on [DATE] for rehabilitation following a bilateral hip replacement. R1 has diagnoses that includes anemia, morbid obesity, diabetes, urine retention, constipation, anxiety, congestive heart failure, muscle weakness and a history of falling. R1 was discharged from the facility on 11/05/2023. The admission assessment, dated 9/29/2023, identified bruises on R1's left hand and right lower leg. R1's MDS (Minimum Data Set), dated 10/05/2023, indicated she is cognitively intact. The admission assessment identified R1 as being dependent on staff for toileting hygiene, showers / bathing, dressing lower body and personal hygiene. R1 was assessed as completely dependent on staff for repositioning. The care plan dated, 9/29/2023 documented R1 presented with decreased transfers and ADL (Activities of Daily Living) due to weakness post hospitalization . R1 is admitted with surgical wound to bilateral lower extremities post-surgical repair due to right and left intertrochanteric (hip) fracture. At risk for skin impairment related to required ADL care assist due to recent hospitalization , decreased mobility, history of diabetes and urinary incontinence. Intervention includes encourage / assist with turning / repositioning often. Monitor pressure areas for color, sensation and temperature. Monitor skin status with routine care and notify provider of any changes. There was no wound or skin concern documentation for R1 prior to 10/12/2023. On 10/12/2023, a stage 3 (full thickness tissue loss) pressure sore to R1's sacral area measuring 5.50 cm x 3.50 cm x 0.10 cm (centimeters) was documented per physician's order sheet, dated 1/15/2023, Tx: to sacral and right buttock wounds - cleanse with NS (Normal Saline), apply skin prep to peri wound area, apply cut to fit Xeroform to open wounds, cover with secondary dressing daily and as needed. Every day shift for stage 3. PCT (Patient Care Technician) documentation for October 2023 was reviewed. Assistance to roll left and right was documented as NA 10/6/2023- 10/12/2023 and 10/25/2023 on the night shift. Toileting hygiene was documented as NA 10/6/2023- 10/12/2023, 10/18, 10/19, 10/28 and 10/21/2023 on the night shift. Skin observation across three shifts in October 2023 was documented as NA for 17 shifts and no issues observed for 62 shifts. November 2023 skin observations across three shifts were documented as NA for 7 shift and no issues observed on 1 shift. On 3/7/2024 at 3:42 PM, charting abbreviations were clarified with V2, DON. X= the task was not due at that time. NA (Not Applicable) = it did not apply to that task, and it did not occur. Blank spaces = missed charting. On 3/6/2024 at 12:15 PM, V3, Wound Nurse, stated R1 did not have a pressure wound or MASD (Moisture Associated Skin Damage) on admission. V3 stated R1 developed a right buttock and sacral / coccyx MASD that progressed to a stage 2 (partial thickness loss of dermis) pressure wound. V3 stated on 9/29/2023, R1 was identified as being at risk for developing a pressure wound on admission. V3 stated on 10/2/2023, skin barrier and a protective dressing were ordered. On 10/3/2023, off-loading of heels, turn and repositioning was ordered. On 10/5/2023, an air mattress was ordered. V3 stated pressure wounds can develop overnight. V3 stated she did not document any episodes of R1 refusing care. On 3/6/2024 at 4:10 PM, V2, DON (Director of Nursing), stated she knew of R1's facility acquired wounds through discussion. V2 stated she had no knowledge of R1 refusing care. If (R1) had refused care, nursing would document it and report it to therapy and management. V2, DON, stated having a bilateral hip replacement as well as other risk factors put her at a higher risk of developing a pressure wound. V2 stated when a referral is submitted for a new admission, the admissions department assess patient needs and interventions prior to their arrival. Interventions are specific to each resident's needs. V2 stated she could not say what was or was not done to prevent R1's pressure wound. On 3/7/2024 at 11:52 AM, V4 (R1's Family Member) stated she stayed overnights at the facility from 9/29/2023 to 10/11/23. V4 stated on the nights she stayed at the facility, staff looked in R1's the room, but no staff repositioned R1 or changed her undergarment. V4 stated the nurse straight catheterized R1, but did not turn her. V4 stated she did not turn or reposition R1 because she did not know that was necessary. On 3/7/2024 at 12:24 PM, V6, RN (Registered Nurse), stated he worked the night shift and recalled caring for R1. V6 stated V4 (R1's Family Member) did stay overnights at the facility for a few weeks. V6 stated V4 stayed for R1's emotional support and did not provide care for R1. V6 stated R1 was not able to move independently and required staff assistance for repositioning and hygiene assistance. V4 stated on the occasions he straight catheterized R1, he did not reposition her. V6 stated the CNAs (Certified Nursing Assistants) also known as PCTs (Patient Care Technicians) would answer R1's call light. V6 stated he would not say the CNA turned R1 every two hours. CNAs would change and turn someone who wasn't alert, but a resident like (R1), we'd just peek in on so she could get rest. On 3/7/2024 at 11:56 AM, V5 (Wound Physician) stated he recalled R1's name, but not her care. V5 stated he did not know what caused R1 to develop her pressure wounds. V5 stated prolonged periods of not being repositioned would cause anyone to develop a pressure wound regardless of predisposing risk factors. 2. R3 was admitted to the facility on [DATE]. R3 has diagnoses that includes Parkinson's Disease, Alzheimer's Disease, Overactive bladder, anxiety, history Cerebral Infarction, and Major depressive disorder. The Minimum Data Set, dated dated [DATE], indicated R3 is cognitively impaired. R3's primary mode of transportation is a wheelchair and walker with staff assistance. R3 requires supervision to partial / moderate assistance staff assistance with Activities of Daily Living. The risk of pressure ulcer / injuries was identified. No pressure related issues identified at time of assessment. R3's care plan, dated 12/20/2023, states R3 has self-care deficits and requiring assistance from staff for ADL care. R3 is at risk for skin impairments required ADL care assist due to decreased mobility. R3's right heel pressure related redness was identified on 1/3/2024 as a stage 1 (non- blanchable redness). R3's left heel pressure ulcer was identified on 1/3/2024 as a stage 2 (partial thickness loss of dermis) measuring 0.50 cm x 0.50 cm x 0.00 cm. Skin observations by the PCT across three shifts for the January 2024 documents NA on 36 shifts and no issues observed on 53 shifts. Skin observations by the PCT across three shifts for the February 2024 documents NA on 38 shifts and no issues observed on 42 shifts. On 3/5/2024 at 12:42 PM, R3 stated she didn't think she had any skin wounds. On 3/6/2024 at 9:27 AM, the dressing change to the right and left heels of R3 was observed. Both heels appeared purple but blanchable On 3/6/2024 at 12:15 PM, V3, Wound Nurse, stated R3's pressure related skin issues were first observed on 1/3/2024. V3 stated R3 had physician orders in place for off loading her heels. V3 stated if R3's heels had been off loaded there should be no reason for her to develop heel redness. V3 stated with the foam dressings off loading is still being done. V3 stated the direct care responsibilities fall to the CNAs. The CNAs should be placing the heel protecting boots on the resident and alerting the nurse of any issues. 3. R4 was admitted to the facility on [DATE]. R4's medical diagnoses includes diabetes, anemia, congestive heart failure, peripheral vascular disease, muscle weakness, dementia, and anxiety. R4's Minimum Data Set, dated dated [DATE], indicates resident is cognitively intact. R4 is dependent on staff assistance for toileting hygiene, showers / baths, and dressing lower body. R4 requires substantial staff assistance with repositioning left to right. The care plan, dated 3/5/2024, stated R4 has potential for pressure ulcers related to decreased mobility, bowel and bladder incontinence as evidence by previous skin alterations. Skin observations by the PCT across three shifts for the January 2024 documents NA on 36 shifts and no issues observed on 26 shifts. Skin observations by the PCT across three shifts for the February 2024 documents NA on 36 shifts and no issues observed on 18 shifts. No documentation of refusal of care was noted in progress notes. R4's current care plan does not address refusal of care related to off loading with pillows and heel boots. R4 facility acquired stage 2 pressure wound was identified on 2/7/2024. Wound measurements 0.50 cm x 0.40 cm x 0.00 cm. R4's physician orders in place prior to wound development includes off load back / buttocks with pillow, heels with boots and reposition when in bed. Turn R4 every two hours while in bed. Place R4 back to bed if she has been sitting for more than one hour. On 3/6/2024, R4's skin was observed during her dressing change. R4's buttocks were reddened and not blanchable. R4 had a small opening to her left buttocks slightly smaller than a pea. No drainage was noted. On 3/5/2024 at 12:37 PM, R4 stated she has a wound on her buttocks, but she did not know how she got it. R4 stated the staff change her undergarment and assist her to reposition when she calls them for assistance. R4 stated she does not call for staff assistance every two hours. On 3/6/2024 at 12:15 PM, V3, Wound Nurse, stated other staff stated R4 has refused care. On 3/6/2024 at 4:10 PM, V2, DON, stated R4 often refuses care, and is particular about her caregivers. V2 stated R4's pressure ulcer is related to her refusal of care. The facility provided Policy and Procedure for Skin Checks, dated July 2018, states PCT assignment to assess patient's skin from head to toe every shift. The PCT and nurse should complete a skin check regardless of if the shower or bath is done, biweekly on shower days. All skin impairments should be documented in the task menu in POC for PCT documentation and notify the nurse immediately. The nurse should assess skin changes or concerns and document in the treatment assessment record or create an incident report. If appropriate (patient, family and physician should all be notified of any skin changes noted.

Based on observation, interview, and record review, the facility failed to ensure a resident received the prescribed amount of tube feeding. This failure caused the resident to receive too much tube feeding, resulting in an eight-day hospitalization for acute congestive heart failure. This applies to 1 of 2 residents (R1) reviewed for tube feedings. The findings include: R1's Face Sheet showed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's August 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's 8/14/21 Initial Facility Report showed, Nurse administered incorrect amount of tube feeding. Resident sent to hospital for eval (evaluation) and treat. Final report to follow. R1's 8/15/21 history and physical notes from the local hospital showed she presented with shortness of breath and increasing abdominal pressure and pain. Under the Assessment and Plan portion of R1's hospital history and physical, the note showed Hypertensive heart disease with new onset congestive heart failure .We think this is secondary to her feedings being given too quickly . On 8/25/21 at 10:00 AM, V2, RN, ADON (Registered Nurse, Assistant Director of Nursing) stated R1's tube feeding ran for about five hours continuously at 275 ml per hour. V2 stated R1's feeding was started around 5:00 PM on August 14, 2021, and not stopped until around 10:00 PM. V2 stated R1 received around 1300 ml of tube feeding during that time, which caused her shortness of breath, abdominal pain, and nausea. V2 stated R1 also became hyperglycemic with a blood glucose of 499 when the feeding was stopped. On 8/25/21 at 10:30 AM, V3 (R1's Physician) verified R1 was sent to the hospital because of a nursing error with R1's tube feeding. V3 stated R1 was put on a continuous feeding of 275 ml per hour, instead of a bolus feeding of 275 ml. V3 stated R1 experienced abdominal pain, shortness of breath, and fluid overload, which caused R1 to go into acute heart failure. V3 stated R1 received 275 ml for four to five hours, and the average amount of continuous feeding is only 80 to 100 ml per hour. V3 said, Anyone given that much fluid- it would push them into heart failure. R1's acute heart failure could have been avoided if she was given the bolus feeding and not the continuous feeding. On 8/25/21 at 12:03 PM, V4, RN (Registered Nurse), said, When giving a resident a bolus feeding first check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/28/21 at 11:50 AM, R1 was in her wheelchair at her bedside. R1 stated she remembered going to the hospital because she didn't feel well. The facility's May 2021 Enteral Tube Bolus Feeding policy showed Preparation 1. Verify the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Rate of administration

Based on interview and record review, the facility failed to ensure safe practices or follow their policy when turning a resident in bed for a confused resident with a high fall risk. This failure resulted in the resident falling out of bed sustaining a subacute subdural hemorrhage and was admitted to the Intensive Care Unit. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: According to the Electronic Health Record (EHR), R1 had diagnoses including nontraumatic chronic subdural hemorrhage, urinary tract infection, [CONDITION(S)], [CONDITION(S)], skin cancer, asthma, anxiety disorder, colon cancer, prostate cancer, and [CONDITION(S)]. The Minimum Data Set (MDS), dated [DATE], showed R1 needed extensive assistance of one person for bed mobility, transfers, walking, dressing, hygiene, and toilet use. R1 was frequently incontinent of bowel and bladder. The MDS showed R1's cognition was severely impaired. A care plan showed R1 had decreased functional mobilities, transfers, and Activities of Daily Living (ADLs) due to weakness post hospitalization ; R1 had an acute confusional state characterized by changes in consciousness, disorientation, environmental awareness, and behavior related to traumatic subdural hemorrhage and depressive disorders; and neurological deficits related to a recent craniotomy on 05/17/2021 and a craniotomy six years prior. An Admission Assessment, dated 06/07/2021 at 4:15 PM, showed (R1) was alert and oriented to self, and was unable to communicate ADL care needs to staff. R1 was noted to be a high fall risk at this time. A Behavior Assessment progress note, dated 06/07/2021 at 5:08 PM, showed R1 had attempted to get out from chair and bed without assistance despite staffs present in the room. Has forgetfulness and confusion and does not utilize call light., attempting to get out of bed, forgets to utilize ambulation devices, has had frequent falls, slides out of wheelchair or chair, attempts to self-transfer, forgets to utilize call light and/or notify for staff assist, including wandering. A Fall Risk Assessment, dated 06/21/2021 at 3:42 PM, showed R1 was a high fall risk with interventions including low bed at rest, floor mats, and personal alarm. The assessment shows R1 had poor bed mobility and used quarter side rails for positioning. An Admission Assessment, dated 06/21/2021 at 3:42 PM, showed R1's level of consciousness fluctuates, R1 displayed poor bed mobility, had a history of falls, and was at a high risk for falls with interventions including floor mats, and a personal alarm. A Physical Therapy Evaluation, dated 06/22/2021, showed R1 needed moderate assistance for bed mobility and rolling and had underlying impairments of balance deficits, strength impairments, and proximal instability. An Occupational Therapy Evaluation, dated 06/22/2021, showed R1 had impaired left sided strength, impaired distal reach, impaired command following, impaired problem solving, impaired safety awareness, impaired sequencing, impaired orientation, and impaired new learning. R1 requires maximum cues for initiation and sequencing of tasks. A Skilled Daily Nursing Note, dated 06/22/2021, showed R1 was oriented to self only, had a sitter in the room, was confused and difficult to reorient. A Skilled Daily Nursing Note, dated 06/23/2021, showed R1 was oriented to self only, had a sitter in the room, and a personal alarm. A hospital Surgical Critical Care Admit Note, dated 06/24/2021 at 11:53 PM, showed (R1) who was a poor historian, presented to the emergency room following a witnessed fall out of bed with a subacute subdural hemorrhage on the left side. The note included a Computerized Tomography (CT) scan report, dated 06/24/2021, which showed R1 had a left sided subdural mixed density hematoma measuring 1.8 centimeters (cm) in maximal thickness, new since the prior CT scan. Additionally, there is new hyperattenuation along the left tentorium likely due to acute blood. There is left frontal scalp swelling. Left periorbital/frontal soft tissue swelling is seen. The note included R1 was admitted to the Intensive Care Unit (ICU) This patient is critically ill with a medical condition that impairs one or more vital organ systems and there is a high probability of imminent or life-threatening deterioration the patient's condition. On 07/01/2021 at 12:12 PM, V5 (CNA) said R1 needed extensive assistance with turning in bed and had confusion, especially when he was tired. V5 said if R1 was having more confusion she would have had a second person to assist. V5 said if she had to turn R1 by herself, she would stand on the side of the bed R1 was turning toward, not away from. On 07/01/2021 at 1:02 PM, V6 (CNA) said R1 was so confused sometimes he would be screaming and hallucinating, would try to grab things and couldn't focus when V6 would tell him things. V6 said she would try to have a second person assist since it was difficult to change R1's incontinence brief because R1 couldn't follow commands. R1 would calm down when V6 explained what they were going to do, but once the staff started changing R1, he would get agitated. V6 said R1 would often put his legs out of the bed and was more agitated during the morning shift on 06/24/2021. V6 said R1 had a sitter during the evening shift. On 07/06/2021 at 1:38 PM, V11 (Therapy Director) said R1 needed moderate assistance for bed mobility, meaning when turning, the resident does half of the task and the staff member would do the other half of task. V11 said in a perfect world the staff member should be standing on the side of the bed the resident was turning toward. It's just common sense for the staff to be on the side the resident was turning toward to hopefully stop the resident for rolling further and off the bed. On 07/06/2021 at 2:05 PM, V4 (Certified Nursing Assistant/CNA) said R1 was alert and oriented to person and maybe place, but was confused, and needed extensive assistance from one person. V4 said R1 was really confused the day he fell (06/24/2021). V4 stated during incontinence care approximately 5:00 PM, V4 stood on R1's right side of the bed and told R1 to turn toward his left side, while V4 remained behind R1. R1 rolled onto his back after V4 cleaned him. While remaining on R1's right side, holding the clean incontinence brief in his hands and not touching the resident, V4 told R1 to turn to his left side again. V4 said as R1 was turning he was moving like a snake, his upper body and his lower body were all just moving, then R1 kept rolling off of the left side of the bed closest to the window. V4 said he never pulled R1 toward him on the right side of the bed before telling him to roll onto his left side. V4 said R1 had landed on his face first on the floor. After the nurse arrived, V4 said R1 had blood coming from his nose and mouth and had a scrape on the bridge of his nose. On 07/06/2021 at 3:17 PM, V7 (Registered Nurse/RN) said R1 was pleasant but confused. When V7 was informed R1 had fallen on the floor, V7 noted R1 was lying on the floor prone between the bed and the window. R1 had a little laceration on the left side of his forehead, a nosebleed and may have bit his tongue because there was some bleeding from his mouth. R1 wanted to get up right away. V7 said R1 was a tall guy but he was not obese. On 07/06/2021 at 3:28 PM, V8 (Certified Nursing Assistant/CNA) said R1 was confused, it was difficult for him to get the words out, and it frustrated him. V8 said R1 needed constant cueing, would try to get out of bed constantly, and had a sitter during the evening shift. V8 said when R1 was confused he would get frustrated and would need a second person to assist with R1's care. On 07/06/2021 at 4:09 PM, V9 (CNA) said R1 was confused and didn't really follow directions. V9 said she would always get someone else to help turn R1 because it would be very hard to turn him with just one person. On 07/06/2021 at 4:26 PM, V10 (Director of Clinical Services) said R1 had a history of [CONDITION(S)] (CVA) and subdural hematoma. V10 thought R1 was alert and could follow commands. When asked why R1 needed a sitter, V10 said because he was a restless guy, he was moving a lot, and when he was sitting up he would try to stand up. V10 said before a staff person moves or transfers a resident they should know what's going on with the resident, including knowing if the resident was more confused than usual. V10 said when turning a resident it should be away from you so you can clean the back of the resident. How else would you clean their back or bottom if the staff member was in front of them? The United States National Library of Medicine [MEDICATION(S)] Plus, dated 10/09/2019, showed the following steps should be followed when turning a patient from their back to their side or stomach: Explain to the patient what you are planning to do so the person knows what to expect. Encourage the person to help you if possible. Stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. The American Congress of Rehabilitation Medicine Caregiver Guide and Instructions for Safe Bed Mobility, dated 2017, included bed mobility refers to activities such as scooting in bed, rolling (turning from lying on one's back to side-lying), side-lying to sitting, and sitting to lying down. It also includes scooting to sit on the edge of the bed when preparing to stand or transfer. The instructions include to decide which side of the bed the patient should get out from based on their strength, and position yourself to that side of the bed. The patient should always roll toward you not away from you. Patient safety included to assist the patient on their weaker side and if you are ever unsure, get needed help. The facility's Bed Mobility policy, dated 05/2020, included to slide the resident's buttocks toward you using draw sheet, place one hand on the resident's shoulder nearest you, place your second hand under resident's buttocks, gently assist the resident to turn on their side.

Based on record review and staff interview, the facility failed to supervise a resident for one of three residents (R1) reviewed as being a high risk for falls. This failure resulted in R1 attempting to stand up form the toilet subsequently falling, and sustaining a hip fracture. The findings include; R1's [DIAGNOSES REDACTED]. R1's fall assessment dated [DATE] assessed R1 as high risk for falls. R1's care plan interventions for activities of daily living (ADL's) requires "provide total assist with all ADL tasks. 2 person assist for transfers and bed mobility. Incident report and subsequent investigation dated 05/17/11 describes that on 5/16/11, at 9:58 PM, E4 (CNA) assisted R1 to the toilet . E4 left R1 on the toilet,and left the bathroom . R1 subsequently fell , sustaining a broken hip. E4's written witness statement of 5/16/11 states "I put (R1) on the toilet...I stepped out into the hallway right by her door to call for help getting her up....I looked behind me and she had fallen." Review of the facility's telephone interview with E4, conducted on 5/19/11, shows that E4 described the incident differently. During the interview, E4 stated that R1 was becoming combative, so she stepped out into the hallway to get help. E4 claimed that she could see R1 through the crack in the door. She further stated that when E5 arrived they went into the bathroom together. E4 then stated that the resident could not transfer by herself she (R1) was unsteady. During a telephone interview with E4 on 5/31/11 at 1:30 pm, E4 claimed that she was supervising R1, but was unable to tell the surveyor whether she was in the bathroom at the time of the incident or whether she saw the resident fall. E5 (CNA) who responded to E4's call for assistance, stated on 5/31/11 at 2:00 PM that as she and E4 entered the room she had heard a 'thump' and observed R1 on the floor. Nurses notes dated 5/16/11 at 10:00 PM denote nursing was called by CNA to R1's room and observed lying on the bathroom floor on left side. R1 was assessed moved all extremities and had no complaint of pain. Assisted up from floor by 2 assist, combative to staff during transfer. Nurse notes dated 5/17/11 at 7:50 AM denotes R1 was complaining of pain during ADL's, was assessed by staff and found to have swelling to left hip and pain on palpation of left leg. R1's physician was notified and an order for [REDACTED]. R1 was transferred to hospital and admitted with [DIAGNOSES REDACTED]. Review of facility disciplinary action form for E4 denotes, "employee toileted resident who became combative. Employee stepped outside of bathroom and called for help. Per investigation when help arrived the employees heard a noise in the restroom, and found R1 on the floor." Facility suspended E4 for failure to comply with health and safety, unsafe conduct resulting in risk of injury to self or others.