Every finding on record at Cisne Rehabilitation and Health Care Center

Based on interview and record review the facility failed to administered pain medication as ordered by physician for 1 (R1) of 3 residents reviewed for pain in a sample of 11. This failure resulted in R1 experiencing unrelieved pain and having been sent to the local hospital for pain management.Findings Include:R1's admission Record documented an admission date of 6/9/2026 with the following diagnoses including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. Under section M1040 Wounds and Skin problems documented R1 had a surgical wound. Under section J0100: Received scheduled pain medication regimen documented Yes and section J0530 Pain Interference with day-to-day activities documented occasionally. R1's Care Plan documented a focus area of pain with no date initiated that included interventions of anticipating the resident's need for pain relief and respond immediately to any complaint of pain. R1's Physician Order Summary documented Oxycodone 5 Milligram (MG) tablet. Give 2 tablets every 4 hours as needed for pain with a start date of 6/9/2026. R1's Hospital Discharge summary dated [DATE] documented diagnoses including acute 1. osteomyelitis of right ankle or foot, 2. Chronic foot ulcer with fat layer exposed, left. 5. osteomyelitis of great toe of right foot. This same document had an Operative Note by V15 (Doctor of Podiatric Medicine) documented under procedure: right foot incision and drainage, right foot ulceration debridement to bone, and right foot bone biopsy with date of service of 5/29/2026.with findings of necrotic tissue. R1's Progress Note dated 6/9/2026 at 12:22 PM by V3 (Licensed Practical Nurse /LPN) documented R1 arrived at the facility via hospital transport.is non weight bearing related to right foot wound. On 7/7/2026 at 9:47 AM R1 stated, she had been at a previous facility before being placed at this facility. R1 stated, she had been in the out-of-town hospital related to an amputation of her right foot and infection. R1 stated, she was discharged from the out-of-town hospital to this facility on 6/9/2026. R1 stated, she had not been given her pain medication for about 3 to 4 days as ordered and/or when requested. R1 stated, she had been discharged from the hospital with pain medication of Oxycodone 5 milligrams (MG) 2 tablets every 4 hours as needed related to her pain from a surgical amputation to her right foot. R1 stated, when she would ask the nursing staff why she was not able to get her Oxycodone they would tell her that it was the pharmacy's fault for not having her medication available. R1 stated, on 6/12/2026 the pain from her surgery on the right foot was so bad she requested to be sent to the local emergency room so she could receive some pain medication. R1 stated, she was very upset that she could not get her pain medication and was vomiting and hurting. R1 stated, my foot was amputated, that causes pain. On 7/7/2026 at 10:51 AM V3 (Licensed Practical Nurse/LPN) stated, R1 did admit to the facility on 6/9/2026 from an out-of-town hospital post amputation of the right foot. V3 stated, R1 did arrive sometime in the afternoon with hard scripts from the hospital that were faxed over to pharmacy and included Oxycodone 5 MG, 2 tablets by mouth every 4 hours as needed for pain. V3 stated, there had been some issues with the prescriptions because the hospital had placed the wrong facility name on the scripts and V2 (Director of Nursing/DON) worked on getting this corrected. V3 stated, she did give R1 Oxycodone 5 MG 2 tablets by mouth on 6/9/2026 at 4:37 PM from the emergency kit for pain. On 7/8/2026 at 9:23 AM V5 (Registered Nurse/RN) stated, R1 did admit to the facility from the hospital related to an amputation of right foot on 6/9/2026. V5 stated, there had been issues with R1's Oxycodone 5 MG 2 tablets every 4 hours as needed for pain arriving from the pharmacy to the facility in a timely manner. V5 stated, R1 did get sent out via ambulance to the local hospital on 6/12/2026 for pain management because she had not been able to receive her pain medication as ordered since admitting to the facility. On 7/8/2026 at 9:57 AM V6 (LPN) stated, R1 had been admitted to the facility from the hospital related to an amputation of the right foot on 6/9/2026. V6 stated, her first interaction with R1 had been on 6/11/2026 in the morning when she started her shift. V6 stated, R1 had requested her pain medication of Oxycodone 5 MG 2 tablets every 4 hours as needed related to her pain. V6 stated, when she went to pull the medication, it was not available in the facility. V6 stated, she explained to R1 that she would call the pharmacy to figure out why her medication still was not in the facility. V6 stated, she called the pharmacy, and unknown pharmacist told her that R1's script was not valid. V6 stated, V9 (RN) took over from their and resent the script to the pharmacy. V6 stated, about 15 minutes later, the pharmacy told V9 that the medicine was on its way but then again returned a call sometime later and said the script was not valid. V6 stated, she could not pull the medication from the emergency kit because R1 had to have a valid script on file with pharmacy or the pharmacist must confirm with a physician over the phone. V6 stated, she does not know what happened after that because she left for the day. On 7/8/2026 at 10:17 AM V2 (Director of Nursing/DON) stated, R1 had been admitted to the facility from the hospital related to an amputation of the right foot on 6/9/2026. V2 stated, the facility had issues obtaining R1's pain medication of Oxycodone 5 MG 2 tablets every 4 hours as needed related to her pain. V2 stated, R1 did arrive at the facility in the afternoon with hard scripts from the hospital for medications. V2 stated, all scripts were faxed to the pharmacy. V2 stated, R1's pain medication was able to be pulled from the emergency kit on 6/9/2026 at 4:37 PM by V3 (LPN). V2 stated, R1 did not get her Oxycodone as ordered from 6/9/2026 after 4:37 PM until 6/11/2026 at 5:57 PM when the facility had access to the medicine in the emergency kit for a one-time dose, again. V2 stated, on the morning of 6/12/2026, R1 had been sent to the local emergency room via ambulance for pain management. V2 stated, R1 did not receive her prescribed pain medication as ordered. On 7/8/2026 at 10:53 AM V8 (Nurse Pracititioner/NP) stated, R1 did admit to the facility on 6/9/2026 from a hospital related to an amputation of the right foot. V8 stated, she is aware that R1 was unable to get her prescribed pain medication of Oxycodone 5 MG 2 tablets by mouth every 4 hours as needed for pain. V8 stated, it was her understanding that there were issues with the pharmacy delivering R1's pain medication to the facility which caused missed doses of her pain medication. V8 stated, she did give an order for R1 to be sent to the local hospital for pain management on 6/12/2026. On 7/8/2026 at 12:21 PM V7 (Director of Clinical Services) stated, the pharmacy does not document any notes on interactions with the facility. V7 stated, the pharmacist might have documented on the script, but she would have to look at the script to see if anything was documented. V7 stated, the facility did receive a refill for the emergency kit on 6/11/2026 but it was probably enough for 1 dose because that was the minimum amount set for Oxycodone. On 7/8/2026 at 12:49 PM V1 (Administrator) stated, R1 did admit to the facility on 6/9/2026. V1 stated, she was not aware of what had happened prior to 6/11/2026 when she returned to the facility from being off. V1 stated, she had been made aware on 6/11/2026 that there had been problems with the new pharmacy and R1's pain medication. V1 stated, R1 then had been sent out via ambulance on 6/12/2026 to the local hospital for pain management. V1 stated, it is her expectations that the facility has residents' medication available in a timely manner. On 7/8/2026 at 1:47 PM V9 (RN) stated, R1 had been admitted to the facility on [DATE]. V9 stated, her first interaction with R1 had been on 6/10/2026 when she came into work. V9 stated, R1 had not gotten her pain medication since her dose on 6/9/2026 and had requested her pain medication. V9 stated, she did contact the pharmacy to follow up on why R1's pain medication had not been received by the facility. V9 stated, she was told by a pharmacist that the R1's Oxycodone 5 MG had been dispensed and sent the evening of 6/9/2026. V9 stated, I explained to the pharmacist that the facility still had not received R1's pain medication at this time. V9 stated, the pharmacist was supposed to return a call back to her with more information but did not. V9 stated, she still had not received any update from the pharmacy, hours later, so she notified V2 (DON). V9 stated, V2 contacted the pharmacy company to follow up as well but not sure where things ended from that call. V9 stated, R1 did get transferred to the local hospital on 6/12/2026 for pain management. V9 stated, she is not for sure when the facility received R1's pain medication from the pharmacy. On 7/9/2026 at 1:02 PM V11 (Medical Director/MD) stated, he is the medical director of the facility. V11 stated, he had been notified regarding R1 not receiving her Oxycodone as ordered and being transferred to the local hospital for pain management around 6/12/2026. V11 stated, he does agree that the facility should be able to have access to residents' medication in a timely manner. R1's Progress Notes dated 6/10/2026 at 12:16 AM by V4 (Registered Nurse/RN) documented R1 had been requesting as needed oxycodone 5mg 2 tabs .V4 contacted pharmacy on call and was notified that the max amount that could have been pulled from the emergency kit was administered on dayshift by V3 (LPN) and there was no more available to pull.R1 notified and was noted to be upset about the situation.R1's Physician Progress Note dated 6/10/2026 at 4:09 PM by V8 (Nurse Practitioner/NP) documented a reason for visit is a new admit, right foot amputation, diabetes .R1 complains of pain 10/10 scale to right amputated foot, nursing notified and denies any current needs other than a pain pill.R1's Progress Note dated 6/11/2026 at 5:47 AM by V6 (LPN) documented R1 requested pain pill. Upon looking at R1's med there was no pain med available. R1 does have a as needed (PRN) acetaminophen order. Acetaminophen offered but R1 refused and became very agitated at nurse. Nurse explained to R1 that she would immediately contact pharmacy and try to figure out why they had not received her Oxycodone. Upon talking to pharmacy, the stated to nurse that they did not have a script for it and the pharmacy is waiting on a return call from the physician.R1's SBAR (Situation, Background, Assessment and Recommendation) Note dated 6/12/2026 at 10:17 am by V9 (RN) documented change in condition with R1 experiencing pain and nausea/vomiting. Under RN assessment of what do you think is going on with resident? unmanageable pain is documented. R1 was admitted to the facility 2 days ago. Refusing all medications until she received pain medication which is currently unavailable at the facility .R1.wants to go to local emergency room. R1's Progress Note dated 6/12/2026 at 10:58 AM by V13 (RN) documented R1 complained of significant pain related to foot amputation. Unable to receive oxycodone due to pharmacy issues. R1's Local Hospital Emergency Department notes dated 6/12/2026 at 10:59 AM by V14 (NP) documented a chief complaint of pain and vomiting.R1 presents to the emergency department via ambulance from nursing facility recent partial right foot amputation with complaints of right foot pain for the past 24 hours after the skilled nursing facility ran out of her routine pain medication.R1 feels the pain is related to her missed medication doses.Upon chart review: R1 underwent three operative procedures: right foot removal of all nonviable soft tissue and bone on 5/29/2026, 6/2/2026 and 6/4/2026, with the final procedure including possible flap closure.This same document under Progress Notes: Clinical impression as of 6/12/2026 at 1:37 PM documented right foot pain and opioid withdrawal.Plan: Patient's nausea and pain were improved with initial dose of morphine administered here. Serum laboratories are stable, she does appear mildly dehydrated as compared with most recent renal function studies, IV fluids are in progress.12:30: Patient has again requested pain medication. A smaller dose of morphine is administered with plan to resume her oral medication for a longer duration of pain relief. She is taking 10 mg of oxycodone every 4 hours at baseline. 1330: (1:30PM) Patient's pain improved. A skilled nursing facility was contacted and advises the medication should be deliver by 1500 (3:00PM) today. She will be discharge to skilled nursing facility where they will continue pain management as previously prescribed.R1's Medication Administration Record (MAR) dated June 2026 documented an order for Oxycodone HCL Oral tablet 5 MG , Give 2 tablets by mouth every 4 hours as needed for pain with a start date of 6/9/26. R1's MAR document R1 receiving a dose 6/9/2026 at 4:37 PM by V3 (LPN) and did not receive another dose until 6/11/2026 at 5:57 PM by V5 (RN).The facility's Pain Management policy (date approved 2/2025) documented under Policy: It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management.Each and every resident has a right to the assessment and management of pain.

Based on interview and record review the facility failed to administer antianxiety medication, administer sliding scale insulin and monitor blood sugars as directed per physician orders for 2 (R1, R2) of 3 residents reviewed for medication administration in the sample of 11. This failure resulted in R1 being sent to the emergency room for chest pain. Findings include:1.R1's admission Record documented an admission date of 6/9/2026 with the following diagnoses including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. This same document under Active Diagnoses: (I5700)Psychiatric/Mood Disorder: is marked with R1 having an anxiety disorder. R1's Care plan documented a focus area of a mood problem with no date initiated with an intervention to administer medication as ordered. R1's Physician Order Summary documented Lorazepam 1 MG. Give 1 tablet by mouth every 8 hours as needed for anxiety with a start date of 6/9/2026. On 7/7/2026 at 9:47 AM R1 stated, sometime last week around 6/29/2026 for about 3-4 days she did not receive her Lorazepam 1 MG every 8 hours as ordered. R1 stated, she was given the last dose on 6/28/2026 before the nursing staff had placed a refill. R1 stated, she went 3-4 days without her Lorazepam and went to the hospital for her anxiousness on 7/1/2026. R1 stated, the nursing staff notified her that the pharmacy had not delivered her Lorazepam prescription. R1 stated, without her Lorazepam she had become aggressive, upset, anxious and started having chest pain. R1 stated, she did receive Lorazepam at the local hospital then returned to the facility. R1 stated, anytime she asked staff why she was unable to get her medications the answer was always it was the pharmacy's fault. On 7/8/2026 at 9:23 AM V5 (Registered Nurse/RN) stated, he did work on 7/1/2026 when R1 had been sent out to the local hospital for complaints of chest pain. V5 stated, it could have been related to her not having her lorazepam for a few days, because they had been without her medications before. On 7/8/2026 at 10:17 AM V2 (Director of Nursing/DON) stated, R1 did go without her Lorazepam 1 MG tablet by mouth every 8 hours as needed for anxiety starting 6/29/2026 through 7/1/2026 because the pharmacy had not delivered her medication to the facility and did not have any available in the emergency kit. V2 stated, R1 did go to the local emergency room via ambulance on 7/1/2026 related to anxiety symptoms and chest pain. V2 stated, R1's Lorazepam had been delivered to the facility on 7/1/2026. V2 stated, there is no documentation in R1's EHR that she had been out of her Lorazepam or that she had been sent to the local emergency room, however, there is a note that she took meds in emergency room. On 7/8/2026 at 10:53 AM V8 (Nurse Practitioner/NP) stated, she is aware that R1 had been without her Lorazepam 1 MG tablet every 8 hours by mouth for anxiety from 6/29/2026 until 7/1/2026. V8 stated, she did give an order for R1 to be sent to the local hospital via ambulance related to chest pain. V8 stated, it was her understanding that R1's Lorazepam was not available in the facility and there had not been any in the emergency kit to pull from. On 7/8/2026 at 1:47 PM V9 (RN) stated, R1 had run out of her Lorazepam 1 MG by mouth every 8 hours as needed on 6/29/2026 through 7/1/2026. V9 stated, she arrived at work on 7/1/2026 with R1 requesting her Lorazepam and notifying her that she had not had it in a few days. V9 stated, R1 was aggressive, yelling at staff, then started to complain of chest pain. V9 stated, R1 was sent to the local emergency room via ambulance for further evaluation. V9 stated, when she contacted the pharmacy about R1's Lorazepam 1 MG refill, she said the pharmacist told her that it was sent the night before on 6/30/2026. V9 stated, she is not sure what happened but later found out that the Lorazepam supply was missed being delivered on 6/30/2026 by driver. V9 stated, there was no Lorazepam to pull from the emergency kit either. R1's local hospital Nurse's Notes dated 7/1/2026 at 9:10 AM documented under Presentation: R1 complaint of nursing home out of her lorazepam so she is having chest pain. Has not had a dose in 3 days.Documented under Triage Assessment: General: R1 appears uncomfortable.Cardiovascular: reports R1 stated having chest pain but believes its due to the fact that the nursing home ran out of Lorazepam and she is supposed to be taking it 3 times a day. R1 stated her chest pain is the same she gets when she has anxiety attacks. R1's local hospital Physician Documentation dated 7/1/2026 at 12:30 PM documented under History of Present Illness (HPI): R1 is transported to the emergency department via ambulance for local skilled nursing facility (SNF). R1 states that she has not had her anxiety mediations (Lorazepam) for several days because the SNF has run out. R1's Administration Note dated 7/1/2026 at 1:16 PM by V5 (RN) documented Gabapentin Oral 100 MG. Give 2 tablets by mouth three times a day for pain. Medication given at local emergency room. R1's Medication Administration Record dated June 2026 documented no record of Lorazepam 1 MG by mouth every 8 hours as needed for anxiety on 6/29/2026 and 6/30/2026. 2.R2's admission Record documented an admission date of 9/17/2025 with the following diagnoses including type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, other recurrent depressive disorders, anxiety disorder and insomnia, unspecified. R2's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. This same document under Active Diagnoses: I2900 Diabetes Mellitus marked with R2 having. R2's Care Plan documented a focus area of diabetes: actual/at risk and/or potential for complications with diabetes. Concern of insulin dependent-daily and/or sliding scale with a date initiated of 10/14/2025 with an intervention of finger-stick blood sugar as ordered/accepted. R2's Physician Orders documented Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u; 401+ Notify MD, subcutaneously before meals and at bedtime for diabetes with a start date of 12/24/2025. On 7/8/2026 at 10:17 AM V2 (DON) stated, she had been notified by V4 (RN) on 6/29/2026 around 7:00 PM that the facility had run out of glucometer strips and they did not have any in the building to use. V2 stated, she did go to the local store to purchase glucometer strips and brought them to the facility around 8:30 PM. V2 stated, when she arrived at the facility with the strips the strips would not work in the glucometer. V2 stated, she ended up buying a new glucometer with strips the next morning and bringing them to the facility. V2 stated, the facility did not have glucometer strips on 6/29/2026 at 7:00 PM until 6/30/2026 in the am. V2 stated, R2 was not able to get her blood sugar monitored the night of 6/29/2026 and did not receive her sliding scale dose of insulin related to this. V2 stated, V8 (Nurse Practitioner/NP) had been notified but there was no documentation in R2's electronic health record (EHR) of the notification. On 7/8/2026 at 10:53 AM V8 (NP) stated, she had been notified by the facility that they had run out of glucometer strips on 6/29/2026 and R2 would not be receiving her sliding scale insulin order. V8 stated, it is her expectation that the facility has resident's medications and supplies on hand. On 7/8/2026 at 1:47 PM V9 (RN) stated, she was aware that the facility did not have any glucometer strips on 6/29/2026. V9 stated, V2 reached out to her around 7:00 PM to see if she could go to the local store and purchase some glucometer strips and take them to the facility. V9 stated, she had been out of town and unable to do this so V2 was going to take care of it. V9 stated, the facility did have 3 bottles of glucometer strips on 6/24/2026 when cleaning the supply room. V9 stated, V2 does complete all supply orders for the facility, so she must have missed getting them ordered. R2's Medication Administration Record (MAR) dated June 2026 documented Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u; 401+ Notify MD, subcutaneously before meals and at bedtime for diabetes with a start date of 12/24/2025 with V13 (RN) documented under Blood Sugar (BS) a reading of 266 at 5:00 PM on 6/29/2026, V4 (RN) documented under BS with a 1 meaning R2 had refused blood glucose monitoring and a 6 meaning see progress note for reason at 8:00 PM on 6/29/2026. R2's blood sugar reading documented by V5 (RN) on 6/30/2026 at 6:00 AM with a reading of 400. No progress note provided by facility of V4 (RN) documenting the reason R2 did not receive her sliding scale dose on 6/292026 as referenced on R2's MAR June 2026. V4 (RN) did not return any calls during this survey from 7/7/2026 to 7/9/2026. On 7/8/2026 at 12:49 PM V1 (Administrator) stated, she did not know until today that R1 had been out of her Lorazepam from 6/29/2026 through 7/1/2026 but did know she had gone to the local emergency room on 7/1/2026. V1 stated, she was not aware the facility had been without glucometer strips on 6/29/2026 causing R2 not to be able to receive her insulin dose as prescribed. V1 stated, it is her expectation that the facility has resident's medication and supplies on hand and available in a timely manner.On 7/9/2026 at 1:02 PM V11 (Medical Director) stated, he had not been notified of R1 being without her Lorazepam 1 MG tablet from 6/29/2026 to 7/1/2026 and being sent to the local emergency room or that the facility did not have blood glucose strips to complete glucose monitoring for R2 and not receiving her insulin. V11 stated, he does agree that the facility should be able to have access to residents' medication and supplies in a timely manner. The facility's Pharmacy Name Policy and Procedure (dated 5/2024) documented under Section 5.1 Drug Administration - General Guidelines.Procedure: 2. Medications are administered in accordance with written orders of the attending physician. If an unusual dose is ordered, considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition; the physician is contacted for clarification prior to the administration of the medication. The pharmacist is also available for consultation for drug therapy concerns or questions. This interaction with the physician is documented in the nursing notes and elsewhere in the medical records as appropriate.

Based on interview and record review the facility failed to ensure medications were available as ordered by the physician for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 11. Findings include:R1's admission Record documented an admission date of 6/9/2026 with the following diagnosis including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. R1's Physician Order Summary documented Oxycodone 5 Milligram (MG) tablet. Give 2 tablets every 4 hours as needed for pain and Lorazepam 1 MG. Give 1 tablet by mouth every 8 hours as needed for anxiety with a start date of 6/9/2026.On 7/7/2026 at 9:47 AM R1 stated, she had been discharged from an out-of-town hospital to this facility on 6/9/2026. R1 stated, she had not been given her pain medication for about 3 to 4 days as ordered and/or when requested. R1 stated, she had been discharged from the hospital with pain medication of Oxycodone 5 milligrams (MG) 2 tablets every 4 hours as needed related to her pain from a surgical amputation to her right foot. R1 stated, when she would ask the nursing staff why she was not able to get her Oxycodone they would tell her that it was the pharmacy's fault for not having her medication available. R1 stated, sometime last week around 6/29/2026 for about 3-4 days she did not receive her Lorazepam 1 MG every 8 hours. R1 stated, she was given the last dose on 6/28/2026 before the nursing staff had placed a refill. R1 stated, the nursing staff notified her that the pharmacy had not delivered her Lorazepam prescription. R1 stated, anytime she asked staff why she was unable to get her medications the answer was always it was the pharmacy's fault.On 7/8/2026 at 9:23 AM V5 (Registered Nurse/RN) stated, R1 did admit to the facility from the hospital related to an amputation of right foot on 6/9/2026. V5 stated, there had been issues with R1's Oxycodone 5 MG 2 tablets every 4 hours as needed for pain arriving from the pharmacy to the facility in a timely manner. V5 stated, the pharmacy did receive R1's script on 6/9/2026 and again on 6/11/2026, however they did not receive the medication until 6/12/2026. V5 stated, the pharmacy had made a delivery with the emergency kit medications of Oxycodone to be replaced on 6/11/2026 but they did not bring R1's stock supply. V5 stated, he had signed for medications that day and explained to the pharmacy that the facility did not receive R1's Oxycodone stock supply and it does come in a separate bag. V5 stated, he does believe later the pharmacy had found the medication in the driver's car and it had been missed being brought into the facility on 6/11/2026. V5 stated, he did work on 7/1/2026 when R1 had been sent out to the local hospital for complaints of chest pain. V5 stated, it could have been related to her not having her lorazepam for a few days, because they had been without her medications before.On 7/8/2026 at 9:57 AM V6 stated, R1 had requested her pain medication of Oxycodone 5 MG 2 tablets every 4 hours as needed related to her pain. V6 stated, when she went to pull the medication, it was not available in the facility. V6 stated, she explained to R1 that she would call the pharmacy to figure out why her medication still was not in the facility. V6 stated, she called the pharmacy, and unknown pharmacist told her that R1's script was not valid. V6 stated, V9 (RN) took over from their and resent the script to the pharmacy. V6 stated, about 15 minutes later, the pharmacy told V9 that the medicine was on its way but then again returned a call and said the script was not valid. V6 stated, she could not pull the medication from the emergency kit because R1 had to have a valid script on file with pharmacy or the pharmacist must confirm with a physician over the phone. V6 stated, she does not know what happened after that because she left for the day. V6 stated, there have been issues with getting medications to the facility by the pharmacy. V6 stated, this is a new pharmacy for the facility as of 6/1/2026 and it is located out of state.On 7/8/2026 at 10:17 AM V2 (Director of Nursing/DON) stated, V2 stated, the facility had issues obtaining R1's pain medication of Oxycodone 5 MG 2 tablets every 4 hours as needed related to her pain. V2 stated, R1 did go without her Lorazepam 1 MG tablet by mouth every 8 hours as needed for anxiety starting 6/29/2026 through 7/1/2026 because the pharmacy had not delivered her medication to the facility and did not have any available in the emergency kit. V2 stated, R1 did go to the local emergency room via ambulance on 7/1/2026 related to anxiety symptoms and chest pain but no documentation was made in R1's electronic health record. V2 stated, V11 ([NAME] Director) physician group does not have electronic signatures set up and the local retail pharmacies will not accept controlled substance scripts without it.On 7/8/2026 at 10:53 AM V8 (NP) stated, she is aware that R1 was unable to get her prescribed pain medication of Oxycodone 5 MG 2 tablets by mouth every 4 hours as needed for pain. V8 stated, it was her understanding that there were issues with the pharmacy delivering R1's pain medication to the facility which caused missed doses of her pain medication. V8 stated, she is aware that R1 had been without her Lorazepam 1 MG tablet every 8 hours by mouth for anxiety from 6/29/2026 until 7/1/2026. V8 stated, it was her understanding that R1's Lorazepam was not available in the facility and there had not been any in the emergency kit to pull from. V8 stated, she is aware that there are ongoing issues with the new pharmacy on getting resident's medication and supplies to the facility in a timely manner. V8 stated, it is her expectation that the facility has resident's medications and supplies on hand.On 7/8/2026 at 12:49 PM V1 (Administrator) stated, she was not aware of what had happened prior to 6/11/2026 when she returned to the facility from being off. V1 stated, she had been made aware on 6/11/2026 that there had been problems with the new pharmacy and R1's pain medication. V1 stated, she did not know until today that R1 had been out of her Lorazepam from 6/29/2026 through 7/1/2026. V1 stated, V11 ([NAME] Director) physician group does not have electronic signatures set up and the local retail pharmacies will not accept controlled substance scripts without it. V1 stated, there is still on-going issues with the pharmacy delivering medications in a timely manner to the facility. V1 stated, it is her expectations that the facility has residents' medication available in a timely manner.On 7/8/2026 at 1:47 PM V9 (RN) stated, the facility started with a new pharmacy company on 6/1/2026 and there have been issues with getting medications delivered to the facility timely. V9 stated, R1 had not gotten her pain medication since her dose on 6/9/2026 and had requested her pain medication V9 stated, she did contact the pharmacy to follow up on why R1's pain medication had not been received by the facility. V9 stated, she was told by a pharmacist that the R1's Oxycodone 5 MG had been dispensed and sent the evening of 6/9/2026. V9 stated, I explained to the pharmacist that the facility still had not received R1's pain medication at this time. V9 stated, the pharmacist was supposed to return a call back to her with more information but did not. V9 stated, she still had not received any update from the pharmacy, hours later, so she notified V2 (DON). V9 stated, V2 contacted the pharmacy company to follow up as well but not sure where things ended from that call. V9 stated, any time she had called the pharmacy she would be transferred to different areas in different states and then put on hold while the pharmacist attempts to verify what is going on with another pharmacist in another state. V9 stated, she did attempt to pull the Oxycodone 5 MG 2 tablets from the emergency kit on 6/11/2026 at 10:16 and 10:17 AM, but the count was off and there was no Oxycodone in the emergency kit. V9 stated, R1 had run out of her Lorazepam 1 MG by mouth every 8 hours as needed on 6/29/2026 through 7/1/2026. V9 stated, she arrived at work on 7/1/2026 with R1 requesting her Lorazepam and notifying her that she had not had it in a few days. V9 stated, when she contacted the pharmacy about R1's Lorazepam 1 MG refill, she said the pharmacist told her that it was sent the night before on 6/30/2026. V9 stated, she is not sure what happened but later found out that the Lorazepam supply had missed being delivered on 6/30/2026 by driver. V9 stated, there was no Lorazepam to pull from the emergency kit either. V9 stated, she feels the pharmacy has too many stops and exchanges of medication with drivers prior to getting the residents medication to the facility.V10's (Director of Pharmacies) electronic mail dated 6/12/2026 at 1:11 PM documented.So many fails, expected and unexpected, occurred, and I take full responsibility for them.the medication from the pharmacy was originally delayed due to the tornadoes and storms last night in and around Illinois.because this medication is a scheduled II narcotic, we cannot just send it back up like we would a furosemide order. We need to have the doctor send a new script to the retail pharmacy and have it filled that way.In hindsight, I should have had this medication sent stat yesterday after the original fiasco occurred with only having a paper signature and no medication, which I sincerely apologize for.R1's Progress Note dated 6/12/2026 at 10:58 AM by V13 (RN) documented R1 complained of significant pain related to foot amputation. Unable to receive oxycodone due to pharmacy issues.R1's Progress Notes dated 6/10/2026 at 12:16 AM by V4 (Registered Nurse/RN) documented R1 had been requesting as needed oxycodone 5mg 2 tabs .V4 contacted pharmacy on call and was notified that the max amount that could have been pulled from the emergency kit was administered on dayshift by V3 (LPN) and there was no more available to pull.R1 notified and was noted to be upset about the situation.R1's local hospital Nurse's Notes dated 7/1/2026 at 9:10 AM documented under Presentation: R1 complaint of nursing home out of her lorazepam so she is having chest pain. Has not had a dose in 3 days.R1's local hospital Physician Documentation dated 7/1/2026 at 12:30 PM documented under History of Present Illness (HPI): R1 is transported to the emergency department via ambulance for local skilled nursing facility (SNF). R1 states that she has not had her anxiety mediations (Lorazepam) for several days because the SNF has run out.R1's Medication Administration Record (MAR) dated June 2026 documented an order for Oxycodone HCL Oral tablet 5 MG , Give 2 tablets by mouth every 4 hours as needed for pain with a start date of 6/9/26. R1's MAR document R1 receiving a dose 6/9/2026 at 4:37 PM by V3 (LPN) and did not receive another dose until 6/11/2026 at 5:57 PM by V5 (RN). R1's MAR documented and order for Lorazepam 1 MG by mouth every 8 hours as needed for anxiety with a start date of 6/9/26. R1's MAR does not document R1 received any doses on 6/29/2026 and 6/30/2026. The facility's Pharmacy Name Policy and Procedure (dated 5/2024) documented under Section 5.1 Drug Administration - General Guidelines.Procedure: 2. Medications are administered in accordance with written orders of the attending physician. If an unusual dose is ordered, considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition; the physician is contacted for clarification prior to the administration of the medication. The pharmacist is also available for consultation for drug therapy concerns or questions. This interaction with the physician is documented in the nursing notes and elsewhere in the medical records as appropriate.

Based on interview, observation, and record review, the facility failed to timely treat and develop/implement interventions for a pressure ulcer for 1 (R1) of 3 residents reviewed for pressure ulcers in the sample of 4. This failure resulted in R1's pressure ulcer worsening, with tunneling and developing an infection in the wound. The Findings Include:R1 admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Minimum Data Set (MDS) assessment dated [DATE] and coded as an admission assessment documents R1 has a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 has severe cognitive impairment. The MDS documents R1 is frequently incontinent of bowel and bladder, and further documents R1 has a stage 2 pressure ulcer. The MDS section for Functional Goals and Abilities documents R1 is dependent for personal and toileting hygiene. The MDS section for Skin Conditions documents R1 has one Stage 2 pressure ulcer that was present upon admission. Under Skin and Ulcer/Injury Treatment, the following are checked: Pressure reducing device for chair, Pressure ulcer/injury care, Application of nonsurgical dressings, and Applications of ointments/medications. R1's Order Summary Report documents an active order dated 4/13/26 for ENHANCED BARRIER PRECAUTIONS: (wounds) with dressing, bathing, transfers, changing linens, providing hygiene, toileting or pericare, device care, or wound care every shift. The Order Summary Report also documented active orders for (Wound Care Company) to consult for skin assessment andwound care as needed and for (Wound Care Company) to eval and treat dated 04/13/26. R1's April Treatment Administration Record documents an order to cleanse wounds on buttocks and coccyx with normal saline q (every) shift and apply medi honey and cover with bandage every shift for pressure ulcers with a start date of 4/13/26 and discontinued date of 4/15/26. R1's Electronic Health Record (EHR) contains a treatment order dated 4/15/26 documenting: TREATMENT - Cleanse wounds on buttocks and coccyx with normal saline and apply medi honey and cover with dry dressing every day shift for pressure ulcers. There are no orders noted in R1's EHR or Order Summary Report documenting a treatment to pack the tunneling to R1's wound. R1's Care Plan documents no Focus areas or interventions related to skin integrity, pressure wounds, or Enhanced Barrier Precautions prior to 5/13/26. R1's Care Plan documents an added Focus area of the resident has actual impairment to skin integrity related to buttock and coccyx pressure wound (initiated 05/13/26). Corresponding interventions include: Administer treatments as ordered and monitor for effectiveness, avoid shearing while repositioning in bed, document location of wound, size, amount of drainage, peri-wound area, pain, edema, and circumference measurements weekly and as needed, educate resident/family/caregivers of causative factors and measures to prevent skin injury, monitor dressing when providing care to ensure it is intact and adhering. Report lose [sic] dressing to nurse, monitor pressure areas for changes in color, sensation, temperature, and report any change to nurse, referral to wound specialist, wound culture results came in with ESBL (Extended-Spectrum Beta-Lactamase)/ECOLI (Escherichia coli). All interventions for this focus area were documented to be initiated on 05/13/26. R1's Care Plan also documents an added Focus area of the resident is on enhanced barrier precautions (EBP) related to pressure wound (initiated 05/13/26). Corresponding interventions include: Direct care staff and visitors to follow EBP, direct care staff to utilize gowns and gloves for all personal care, educate resident, responsible party, and direct care staff on EBP, monitor resident for signs and symptoms of infection. Document and properly report signs/symptoms of potential infections, monitor residents psychosocial and mental well-being related to EBP. Document any changes and report any symptoms promptly, and provide support and allow resident to express feeling, fears, and concerns. All interventions for this focus area were documented to be initiated on 05/13/26. R1's Progress Notes document the following skin issues: Effective Date: 04/10/26 (authored by V20-Registered Nurse/RN) Type: Braden Scale for Predicting Pressure Ulcer Risk Evaluation LATE ENTRY Braden Evaluation: Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Walks occasionally. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Probably inadequate. Friction and shear: Problem. N Adv - BRADEN Score: 14.0 Actioned Clinical Suggestions:.Comments:. The space under Actioned Clinical Suggestions and Comments is blank. Effective Date: 04/12/26 (authored by V3/RN) Skin Issues: .New skin Issue. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 14 Width (cm): 18 Depth (cm): 1.2 Undermining: No. Tunneling: No. Epithelial: 20%. Granulation: 10%. Slough: 40%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: None. Periwound: Attached. Surrounding tissue: Blanching. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 04/16/26 (authored by V2 -RN/Director of Nursing/DON): Skin Issues.Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 8 Width (cm): 11 Depth (cm): 0 Undermining: No. Tunneling: No. Odor after cleansing: None. Surrounding tissue: Erythema. Surrounding tissue: Blanching. Surrounding tissue: Fragile. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank.Effective Date: 04/17/26 (authored by V2 -RN/DON): Type: Braden Scale for Predicting Pressure Ulcer Risk Evaluation Braden Evaluation : Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. N Adv - BRADEN Score: 16.0 Actioned Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 4/19/26 (authored by V20/RN) LATE ENTRY Skin Issues:.Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer/injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Healthcare provider. Length (cm): 14 Width (cm): 18 Depth (cm): 1 Undermining: No. Tunneling: No. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 04/24/26 (authored by V2/DON) Braden Evaluation: Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. N Adv - BRADEN Score: 16.0 Actioned Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 4/27/26 (authored by V21/RN) Skin Issues: Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: Health care provider. Length (cm): 8 Width (cm): 5 Depth (cm): 1.5 Undermining: No. Tunneling: No. Epithelial: 10%. Slough: 50%. Eschar: 20%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Odor after cleansing: Moderate. Periwound: Non-attached. Surrounding tissue: Denuded. Induration: Induration, < 2cm around wound. Edema: No swelling or edema. Periwound temperature: Normal. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 04/29/26 7:26PM Type: Physician Progress Note (Authored by V4-Nurse Practitioner/NP) documents S/R (self reports) she (R1) is ok. S/R the wound on her bottom burns. Denies any current needs Admit History - Reason for admission for this Stay:(R1) in the long term care facility. She had a cerebral infarction but just has generalized weakness and is in a wheelchair. She is currently on aspirin. She has hypothyroidism and takes levothyroxine. She has a wound to her buttocks that has an odor so I ordered a woundculture. She has debility and is working with PT (Physical Therapy). Effective Date: 04/29/26 (authored by V22-Licensed Practical Nurse/LPN) Type: Health Status Note. Note Text: Received orders from V4 (NP) to obtain wound culture from buttocks to rule out infection. Effective Date: 4/30/26 (authored by V2-RN/DON) Skin Issues: Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 8.7 Width (cm): 8.4 Depth (cm): 0 Undermining: No. Tunneling: No. Odor after cleansing: None. Surrounding tissue: Normal in color. Surrounding tissue: Blanching. Surrounding tissue: Erythema. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing appearance: Saturated. Dressing saturation: Moderate 26-75% Completed Clinical Suggestions:.Comments: The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 04/30/26 (authored by V3/RN) documented lab here and the culture was sent with the lab tech (technician). No difficulties noted. Effective Date: 05/02/26 (authored by V22/LPN) documents Braden Evaluation: Sensory Perception: No impairment. Moisture: Very moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. N Adv - BRADEN Score: 16.0 Actioned Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 05/03/26 (authored by V20/RN) LATE ENTRY Skin Issues: Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 8.7 Width (cm): 8.4 Depth (cm): 2.5 Undermining: No. Tunneling: No. Epithelial: 20%. Slough: 50%. Eschar: 20%. Exudate amount: Light. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Odor after cleansing: Moderate. Periwound: Non-attached. Surrounding tissue: Erythema. Surrounding tissue: Blanching. Surrounding tissue: Normal in color. Induration: Induration, < 2cm around wound. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Saturated. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective 05/06/26 (authored by V2-RN/DON) Skin Issues: Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: Health care provider. Length (cm): 8.4 Width (cm): 7.5 Depth (cm): 2.7 Undermining: No. Tunneling: No. Odor after cleansing: Faint. Surrounding tissue: Dark reddish brown. Surrounding tissue: Blanching. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Saturated. Dressing appearance: Intact. Dressing saturation: Minimal < 25%. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. Effective Date: 05/06/26 at 10:04AM (authored by V3/RN) documented V4 (NP) was in the facility and assessed R1. New orders received. Effective Date 05/06/26 at 12:28PM Type: Physician Progress Note (authored by V4/NP) documents She (R1) has a wound to her buttocks. She has debility and is working with PT. Ordered Norco for pain and a wound consult.Wound: Chronic-stable ordered wound culture. Effective Date 05/06/26 at 5:36PM (authored by V3/RN) documented laboratory notified the facility that the wound culture for R1 had to be discarded due to the courier taking too long to send it off for results. New order received for new culture. Local Hospital Report dated 05/07/26 documented the laboratory received the culture on 05/07/26 at 8:24 PM. The report documented the culture was reported on 05/10/26 at 7:42 AM. R1's wound culture was noted to be growing Escherichia coli, ESBL, and Enterococcus Faecalis. Effective Date 05/08/26 (authored by V22/LPN) documented V4 (NP) was notified of lab results and would await sensitivity. Effective 05/13/26 (authored by V2-RN/DON) Skin Issues: Skin issue has been evaluated. Location: Coccyx. Additional location information: and buttocks Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Sharp. Wound pain interventions: Change in position. Wound pain interventions: Relaxation techniques. Wound pain interventions: Medicate prior dressing change. Relief from interventions: Yes. Staged by: Health care provider. Length (cm): 7.5 Width (cm): 8 Depth (cm): 1.8 Undermining: No. Tunneling: No. Odor after cleansing: Faint. Surrounding tissue: Erythema. Surrounding tissue: Blanching. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal < 25%. Completed Clinical Suggestions:.Comments:. The space under Completed Clinical Suggestions and Comments is blank. On 05/13/26 at 8:30 AM, during a tour of the facility, R1's room was observed to not have any signage indicating R1 was on Enhanced Barrier Precautions or isolation. R1's room did not have a Personal Protective Equipment (PPE) station outside of the room. On 05/13/26 at 8:52 AM, V8 (CNA) was observed caring for R1 and stated she was completing a bed bath. V8 did not have PPE on at this time. On 05/13/26 at 10:42 AM, R2 stated she and R1 used to be roommates. R2 stated R1 was moved because R1's wound smelled really bad, and the facility did not think that it was fair to R2 to smell it. R2 stated the facility was doing a dressing to R1's wound but R2 feels like R1 needs to see a wound specialist. R2 stated R1 was incontinent of bowel and bladder and staff did not check on R1 every couple hours, especially on night shift. R2 said R1 would not be checked on all night, then right before shift change they would change her. R2 stated R1's bed would get soaked and the housekeeping staff would have to clean it every day. R2 stated while she and R1 were roommates, the staff were not turning or repositioning R1. R2 said she would hear staff tell R1 she needs to turn, but no staff would actually assist her. R2 stated she is fearful that R1's wound is only going to get worse. On 05/13/26 at 11:46 AM, R1 stated the wound to her butt hurts her really bad. R1 said the care is terrible and she feels helpless because her pain is bad and she is incontinent now and needs changed. R1 then attempted to sit and immediately laid back down saying she hurts too much. On 05/13/26 at 11:56 AM, V4 (NP) stated R1 was admitted with the wound that she has to her coccyx. V4 stated she has been managing the wound with Medihoney and it is improving. V4 stated R1 is being referred to wound care. On 05/13/26 at 2:20 PM, V2 (DON) stated R1 was admitted with a wound and there were no orders for wound care from the hospital. When questioned about the facility not having treatment orders in place until 4/13/26, V2 stated she was not aware that R1 went 3 days with no orders for a dressing change. V2 said believes the measurements on the 04/12/26 assessment (14cm x 18cm x 1.2cm by V3) are accurate. V2 stated she completed the measurements on 04/16/26 and believes those to be accurate (8cm x 11cm x 0). V2 stated the staff are not familiar with the wound program in the electronic health record and she was at a meeting which is why there are no pictures of R1's wound upon admission in the record. V2 stated she feels like the current treatment is doing ok and there is no need to change it. V2 stated they are looking into a surgical consult for R1 for debridement. V2 stated she is not sure why the wound is coded as a Stage 2, but she was considering it unstageable from admission. On 05/13/26 at 2:50 PM, when this surveyor asked about R1's culture results, V2 (DON) stated she was trying to get R1's wound culture results from the local hospital. V2 stated she is not sure why they do not have the culture back. V2 stated one of the nurses called to check on it and it was her understanding they were told there was nothing growing. The Order Summary Report documents a treatment order dated 05/13/26 (start date 5/14/26) to cleanse wounds on buttocks and coccyx with wound cleanser, apply Medihoney to slough and calcium alginate to granulated tissue, cover with dry dressing, initial and date every day shift for pressure ulcers. Effective 05/13/26 at 4:25 PM: (authored by V2-RN/DON) documented treatment order to coccyx changed to cleanse wounds on buttocks and coccyx with wound cleanser, apply Medihoney to slough and calcium alginate to granulated tissue, cover with dry dressing, initial and date, change daily and prn (as needed) for soiled/dislodged dressing per np. Wound culture results received and sent to V12 (Nurse Practitioner). New orders to start dicloxacillin 500mg (milligrams) po (by mouth) every 6 hours x (times) 7 days and bactrim ds 800-160 mg po every 12 hours x 7 days. On 05/13/26 at 3:59 PM, V2 presented R1's wound culture from the local hospital dated 05/07/26 to this surveyor, which showed the wound growing Escherichia coli, ESBL, and Enterococcus Faecalis. V2 stated she wasn't sure why she had to call to get the results, usually they come back, but the hospital did not fax them. V2 stated they are calling the doctor now to get an order for an antibiotic. On 05/14/26 at 5:05 AM, V5 (Licensed Practical Nurse/LPN) stated R1 was moved to a room last night because she had to be put on isolation precautions for an infection in her wound. V5 stated she was not sure if R1 was on enhanced barrier precautions. On 05/14/26 at 5:50 AM, V7 (CNA) was observed walking into R1's room. V7 uncovered R1 and looked at her adult incontinence brief. V7 did not have PPE on at this time. On 05/14/26 at 6:00 AM, V7 stated she was supposed to wear a gown when she went into R1's room but didn't. V7 stated she wasn't sure why she did not wear a gown but knows that R1 is on isolation. On 05/14/26 at 07:00 AM, R1 was alert to self and time. R1 recognized this surveyor from meeting the previous day. R1 knew V8 (Certified Nurse Assistant/CNA) by name at this time. V8 (CNA) donned PPE, entered R1's room, opened a pack of incontinence wipes and folded down R1's incontinence brief. V8 used the wipes to clean R1's peri area and discarded the wipes. V8 then rolled R1 over to her right side, grabbed another wet wipe from the package, and began wiping R1's coccyx area, which was soiled with stool. V8 discarded the wipe and pulled another one from the package using the same gloves. V8 cleaned R1's coccyx area that was soiled with stool, removed the soiled incontinence brief from R1's bed and threw it in the trash. V8 then discarded her gloves and applied new ones without performing hand hygiene. V8 placed a new brief on R1, then assisted R1 with dressing and assisted her to her wheelchair. V8 then disposed of her gloves and sanitized her hands. During this time, there was no old dressing observed to be on R1 and there was not a new dressing applied before R1 was dressed and taken to the dining room for breakfast. On 05/14/26 at 7:41 AM, V8 (CNA) stated she had been reporting to the nursing staff that R1's wound had a smell to it for a while. V8 stated she would notify the nurses of the changes in the wound, and nothing was being done. V8 (CNA) stated R1 was not on isolation precautions of any kind on 05/13/2026. V8 stated R1 was placed on precautions last night after a wound culture came back. On 05/14/26 at 7:43 AM, V9 (CNA) stated she has reported wound issues/concerns to the nurse for weeks. V9 stated R1's wound had a terrible smell and she reported it to the nursing staff. V9 stated R1 was not on isolation yesterday. V9 stated R1 is on it today because of her wound culture. On 05/14/26 at 7:49 AM, V8 stated R1 does not have a wound dressing on a lot of the mornings that she provides care for her. V8 stated R1 is incontinent through the night so the dressing gets soiled, and no one puts a new one back on. On 05/14/26 at 8:07 AM, V6 (CNA) stated this morning, she completed peri care/bed check on R1 somewhere between 2:30 and 3:00 AM V6 stated at that time there was no dressing observed on R1's wound. V6 stated she made V5 (Licensed Practical Nurse/LPN) aware. On 05/14/26 at 8:58 AM, V3 (Registered Nurse/RN) stated R1 was not on Enhanced Barrier Precautions yesterday. V3 stated when R1's culture was faxed yesterday to the facility, R1 was moved to an isolation room. V3 stated R1 should have been on Enhanced Barrier Precautions for her wound. On 05/14/26 at 9:02 AM, V3 donned PPE and knocked on R1's door. V3 then explained to R1 that it was time to complete her dressing change. R1 was tearful and complained of pain at this time. V3 removed R1's pants and her incontinence brief was visibly soiled. V3 removed the tabs and pulled down the incontinence brief. R1 had been incontinent of urine. The wound was wet and had a large amount of serosanguinous drainage. V3 began to measure the wound without separating R1's buttock. When the surveyor questioned V3 about this, V3 stated he knows he has to hold the skin so the measurements are more accurate. There was no dressing observed on R1's wound at this time. V3 stated he wasn't aware R1's dressing was off. V3 measured the wound bed at 9.1cm long x 10.5cm wide x 2.8cm deep with tunneling observed at the 11 o'clock position and going up. V3 proceeded to complete the wound treatment, applied a new incontinence brief, and positioned R1 for comfort. On 05/14/26 at 11:48 AM, V2 (DON) stated R1 should have been on Enhanced Barrier Precautions related to her wound. V2 stated she thought R1 was on these precautions. V2 said for residents who meet criteria, it would be her expectation that they be on Enhanced Barrier Precautions. V2 stated there should have been signs on the door notifying staff about isolation. On 05/14/26 at 11:48 AM, V2 (DON) stated R1's wound was discussed with V12 (Nurse Practitioner) and she ordered the wound dressing to be changed after the culture came in. V2 stated V3 (RN) took the orders from V12 and V2 placed them in the computer because V3 was busy. V2 stated she was not aware that R1's wound had any drainage. V2 stated it could be the Medihoney draining. V2 stated she was not aware that R1's dressing was not on. V2 stated that she will educate the staff about making sure there is a dressing on all the time. On 05/14/26 at 5:38 PM, V3 (RN) stated the culture was first obtained on 04/30/2026 and sent with the lab courier. V3 stated he was notified on 05/06/2026 that the courier had not delivered the culture to the lab and a new one would be needed. On 05/15/26 at 8:45 AM, V5 (LPN) stated she was not aware that R1's dressing was not in place on 05/14/26. V5 stated if the staff had told her, she would have applied a new dressing. V5 stated she is unsure how long the dressing was off. On 05/15/26 at 9:15 AM, V2 (DON) stated R1's culture was completed on 04/30/26 and the lab courier took it. V2 stated no one from the facility followed up on the culture, and the lab notified the facility on 05/06/26 that the specimen was not received in time to be processed. V2 stated they immediately obtained another culture and sent it to a local hospital for processing. V2 stated the nurses should have been following up on the first one and the second one to make sure they got the results in a timely manner. V2 stated the lab never sent a sheet that said the culture could not be processed. V2 stated the order from 04/13/26 for R1 to see wound care was part of an order set and explained these were orders the nurses just click on as part of the admission. V2 stated on 05/06/2026 the facility obtained an order for R1 to see a wound care provider. V2 stated that R1 has an appointment with a wound care provider on 05/20/26. V2 stated she believes that the treatment the facility has been using was working. V2 stated she feels Medihoney was the best treatment for the slough area. V2 said that tunneling is treated with packing, but they are not doing that. V2 said she is not sure why the measurements that were taken on 05/13/26 (7.5cm x 8cm x 1.8) are so different than the measurements that were taken on 05/14/26 (9.1cm x 10.5cm x 2.8cm). V2 stated she is not sure why there are so many inconsistences with the measurements. V2 stated moving forward V3 is the only nurse who will be completing the measurements weekly. V2 stated R1 was admitted on a Friday night (4/10/26) and the nurses failed to get a treatment order. V2 said when she came in the following Monday (4/13/26) she reviewed R1's admission and realized that it was not completed. V2 stated she isn't sure when V4 (NP) saw R1's wound last but V4 was supposed to look at it this week. V2 said the facility ordered a low air loss mattress for R1 today. V2 said that R1 moves around so much she didn't think about R1 needing a different mattress. On 05/15/26 at 10:19 AM, V15 (Medical Director) stated he is not familiar with R1 and believes V17 (Physician) is following R1. V15 stated V4 (NP) is who regularly sees R1, and he would have to talk to her in order to answer any questions. V15 stated R1 not having a dressing in place is a nursing issue. V15 stated it would be expected for the facility to follow orders for wound care and dressings. V15 stated that V4 is qualified to take care of R1's wound. On 05/15/26 at 10:29 AM, V16 (Social Service Director/SSD/Transportation) stated she was made aware around 05/06/26 that R1 needed to see a wound specialist. V16 stated she called local wound specialists and R1 now has an appointment on 05/20/26. On 05/15/26 at 10:38 AM, V1 (Administrator) stated that R1's dressing should have been on, and there is no reason that the staff did not inform the nurses that it was off. V1 stated V4 (NP) should be looking at R1's wound every time she is at the facility but she is not sure that is happening. V1 stated V2 (RN/DON) will be getting wound certified to assist with wound care in the future. V1 stated she was not aware that R1 went three days after admission with no wound care orders. V1 stated she was not made aware of the issues with the lab/wound culture until 05/06/26 when they called to let the facility know they would need a new culture. V1 stated they are having issues with the lab company and are trying to use a company that is local. On 05/15/26 at 11:45 AM, V4 (NP) stated she is not sure why R1's wound would not have a dressing on it. When asked about R1 not consistently having a dressing on her wound and if that could cause the wound to deteriorate, V4 stated 7 hours without a dressing on a wound is better than having a wet (adult incontinence brief) on. V4 stated the wound should have a dressing on it. V4 stated she saw the wound on 05/13/2026 and she looks at it weekly. V4 stated she is not sure how much slough is in the wound but knows the wound had minimal drainage. V4 stated the slough is improving. V4 stated the treatment for a wound that is tunneling would be to pack the wound and V4 stated the facility is packing the wound. V4 stated the wound is getting treated with Medihoney and silver nitrate. V4 said she ordered a wound consult for R1 to see if the wound treatment needed changed so the wound can heal faster. V4 stated on admission, R1's wound should have been coded as a stage 4, the worst a wound can be staged. V4 stated she was not aware the culture that was ordered on 04/30/26 was not completed. V4 stated she knew the wound was infected by the smell and appearance which is why she ordered a culture. V4 stated not getting the results back until 05/13/26 did not delay the treatment of the wound. When asked why V4 believes the wound was improving, V4 said she was judging that by the measurements the facility has. V4 stated she does not know why one week the wound is documented as undermining of 2 cm and the next week there is no undermining. V4 stated she looked at R1's wound on 05/13/26 when staff were changing R1 but does not know the employee's name she went with. V4 stated that the wound looks much better than the day R1 was admitted . V4 stated again that the facility is using Medihoney and silver nitrate in the wound bed for packing purposes. The facility's Skin Identification, Evaluation and Monitoring policy with a date of February 2026 documented under Purpose - The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventative measures, and an individualized care plan will be formulated upon completion of findings. Under the section titled Skin Integrity treatment program documents A. Eliminate or reduce the source of pressure using positioning techniques, enhancement of mobility and circulation, support of ancillary team members, b. other sources of skin injury by ev

Based on observation, interview, and record review, the facility failed to provide adequate pain assessment and pain relief medication for 1 (R1) of 3 residents reviewed for pain management in the sample of 4. This failure resulted in R1 feeling helpless and having uncontrolled pain which was worse during wound care treatments. The Findings Include:R1's admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Care Plan includes a Focus area of the resident has actual impairment to the skin integrity related to coccyx pressure wound with an initial date of 05/13/2026. Corresponding interventions included to administer treatments as ordered, document wound size, and monitor dressing when providing care to ensure it is intact and adhering. Report loose dressing to nurse. The R1's Care Plan does not document a Focus area for pain management. R1's Minimum Data Set (MDS) assessment dated [DATE] is coded as an admission assessment and documents Brief Interview for Mental Status (BIMS) score of 07, indicating R1 has cognitive impairment. This MDS documents that R1 is occasionally incontinent of bowel and bladder and documents R1 has a stage 2 pressure ulcer. This MDS documents in section J0300 Pain Assessment Interview - Pain Presence - ask resident have you had pain or hurting any time in the last 5 days? This section is answered with a 0, indicating R1 has not had any pain. R1's Order Summary Report includes the following orders: - Acetaminophen Tablet 325 MG (milligrams) give 2 tablet by mouth every 4 hours as needed for Elevated Temp, Do not exceed 3GM acetaminophen from all sources in 24 hours, dated 4/13/26- Acetaminophen Tablet 325 MG (milligrams) give 2 tablet by mouth every 4 hours as needed for Mild Pain (1-4 on pain scale), Do not exceed 3GM acetaminophen from all sources in 24 hours, dated 4/13/26- Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain, dated 5/06/26- Ibuprofen Oral Tablet 600 MG (Ibuprofen) Give 600 mg by mouth every 6 hours as needed for pain to buttocks use between doses of hydrocodone for breakthrough pain, dated 5/13/26- Ibuprofen Oral Tablet 600 MG (Ibuprofen) Give 600 mg by mouth every 4 hours as needed for pain to buttocks use between doses of hydrocodone for breakthrough pain, dated 5/14/26- Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain, dated 5/14/26 There were no regularly scheduled or daily pain assessments found in R1's Electronic Medical Record (EMR) for review. R1's May 2026 Medication Administration Record (MAR) documented the following pain assessments along with administration of the following pain medications: 05/03/26: Pain level of 3 documented at 7:31AM with administration of Acetaminophen Tablet 325mg, give 2 tablets by mouth every 4 hours as needed for mild pain (1-4 on pain scale) with E documented for Effective. Pain level of 3 documented again at 4:48PM with administration of Acetaminophen Tablet 325mg, 2 tablets, with E documented for Effective. 05/07/26: Pain level of 7 documented at 5:04AM with administration of Acetaminophen Tablet 325mg, give 2 tablets by mouth every 4 hours as needed for mild pain (1-4 on pain scale) with E documented for Effective.05/07/26: Pain level of 6 documented at 9:43AM with administration of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth every 6 hours as needed for pain with E documented for Effective. 05/08/26: Pain level of 8 documented at 7:23PM with administration of Acetaminophen Tablet 325mg, give 2 tablets by mouth every 4 hours as needed for mild pain (1-4 on pain scale) with E documented for Effective.05/09/26: Pain level of 5 documented at 7:10AM and a pain level of 8 documented at 7:31PM both with administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective. 05/10/26: Pain level of 5 documented at 7:17AM and again at 5:04PM, both with administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective. 05/11/26: Pain level of 8 documented at 5:08AM and level of 5 documented at 4:46PM, both with administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective.05/12/26: Pain level of 6 documented at 8:08AM and again at 4:59PM, both with administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective.05/13/26: Pain level of 5 documented at 5:35AM, level of 7 at 11:53AM, and level of 6 at 6:49PM, all with administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective. 05/14/26: Pain level of 8 documented at 5:52AM, with administration of Hydrocodone-Acetaminophen Oral Tablet 5-325mg, 1 tablet by mouth with E documented for Effective. On 05/13/2026 at 10:42 AM, R2 stated she and R1 used to be roommates. R2 stated that R1 would cry out in pain when the staff would provide care for her wound. R2 was alert and oriented to person, place and time. On 05/13/2026 at 11:46 AM, R1 stated her wound to her butt hurts her really bad. R1 stated that the medication does not help with the pain. R1 said she feels helpless because her pain is so bad. R1 stated she is incontinent now and needs changed. R1 stated she tries to just sleep all day and night because her pain is so bad. R1 stated I am miserable this hurts so bad. R1 then attempted to sit and immediately laid back down saying she hurts too much. On 05/13/2026 at 11:50 AM, V3 (Registered Nurse/RN) stated R1 can have a pain pill, and he will give her one now. V3 stated he will ask if R1 can have ibuprofen in between times to help. On 05/13/2026 at 11:56 AM, V4 (Nurse Practitioner/NP) stated R1 was started on hydrocodone and it is managing her pain just fine. V4 stated R1 is being referred to wound care and she plans to order ibuprofen. On 05/14/2026 at 07:00 AM, R1 was alert to self and time. R1 recognized this surveyor from meeting the previous day. V8 (Certified Nurse Assistant/CNA) was providing incontinence care to R1 at this time and R1 knew V8 by name. R1 was observed to be tearful and crying out, stating she was hurting. On 05/14/2026 at 7:41 AM, V8 (CNA) stated R1 has been complaining of pain to her wound for a few weeks now. V8 stated she has reported this to nurses, and no one seems to be treating it. V8 stated R1 will cry out when providing care to her and say she hurts. On 05/14/2026 at 8:58 AM, V3 (Registered Nurse/RN) stated R1 often cries out and cannot relay to the staff what her concerns are. V3 stated that since the slough has come off R1's wound, she has been in more pain. V3 stated when he does the dressing change for R1, she moves around, squirming, flinching and complaining it hurts. V3 stated when he observed R1 complaining more of pain, that is why he requested the order for additional/stronger pain medications on 05/06/2026. On 05/14/2026 at 9:02 AM, V3 (RN) donned Personal Protective Equipment (PPE) and knocked on R1's door. V3 then explained to R1 that it was time to complete her dressing change. R1 was tearful and complained of pain at this time. V3 explained that it was not time for another pain medication pill, but he can call the doctor after they are finished to ask about changing the times. V3 provided incontinence care and wound care for R1 at this time. During the treatment, R1 was moaning, tearful and moving her legs. At one point, R1 let out a loud moan/cry and drew her legs up. On 05/14/2026 10:10 AM, V3 (RN) stated he called the nurse practitioner and received a new order to increase R1's pain medication to every 4 hours from every 6 hours. V3 stated he just gave R1 the medication. On 05/15/2026 at 9:05 AM, V13 (RN) stated when R1 was first admitted her wound was mostly slough and the Tylenol covered the pain she had. V13 stated once the slough started coming off and they realized there was tunneling, R1 has complained of more pain. On 05/15/2026 at 9:15 AM, V2 (Director of Nursing/DON/RN) stated when the nurse gives a pain medication, there is an alert created that the nurse has to go back and document whether the medication was effective or ineffective. V2 stated that documentation is the pain assessment that is completed when the resident asks for pain medication. V2 stated the facility does not do routine pain assessments on everyone. V2 stated she thinks there may be a few residents who have them. V2 stated that if a staff member observes a resident in pain and the pain is worsening, they should contact the doctor. V2 stated if a resident is complaining of hurting during a treatment, the nurse should provide medication prior to treatment to prevent pain or notify the physician to see if there is a change needed to the pain medication regimen. On 05/15/2026 at 10:38 AM, V1 (Administrator) stated there are times when R1 does cry out even when not receiving care. V1 stated she expects staff to rule out all causes of the crying and just not assume it's behavioral. V1 stated there are times R1 can tell you what is hurting and other times R1 states the word hurt and can't say where. On 05/15/2026 at 11:45 AM, V4 (Nurse Practitioner) stated when she is in the facility, she looks at R1. V4 stated that when R1 is given a pain medication she seems to be comfortably resting after it is given, and that is why she felt R1's pain was controlled. V4 said she gave an order for ibuprofen to help with the breakthrough pain. V4 stated she also evaluates the pain medication effectiveness by the nurse's documentation. V4 stated the nurses have documented that V4's pain is controlled. The facility's policy titled Pain Management with a date of 02/2025 documented It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management. This facility recognizes that residents may have decreased sensations or perceptions of pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness.

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices, including Enhanced Barrier Precautions were implemented for 1 (R1) of 3 residents reviewed for infection control in the sample of 4.The Findings Include:R1's admission Record documented an admission date of 04/10/2026 and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema.R1's Minimum Data Set (Minimum Data Set) assessment dated [DATE] and coded as an admission assessment documents a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 has severe cognitive impairment. The same MDS documents R1 is occasionally incontinent of bowel and bladder and further documents R1 has a stage 2 pressure ulcer.R1's Order Summary Report documents an active order dated 4/13/26 for ENHANCED BARRIER PRECAUTIONS: (wounds) with dressing, bathing, transfers, changing linens, providing hygiene, toileting or pericare, device care, or wound care every shift. R1's Care Plan documents no Focus areas or interventions related to Enhanced Barrier Precautions prior to 5/13/26.R1's Care Plan documents an added Focus area of the resident has actual impairment to skin integrity related to buttock and coccyx pressure wound (initiated 05/13/2026). Corresponding interventions include: wound culture results came in with ESBL (Extended-Spectrum Beta-Lactamase)/ECOLI (Escherichia coli) (initiated on 05/13/26). R1's Care Plan also documents a Focus area added of the resident is on enhanced barrier precautions (EBP) related to pressure wound (initiated 05/13/2026). Corresponding interventions include: Direct care staff and visitors to follow EBP, direct care staff to utilize gowns and gloves for all personal care, educate resident, responsible party, and direct care staff on EBP, monitor resident for signs and symptoms of infection. Document and properly report signs/symptoms of potential infections, monitor residents psychosocial and mental well-being related to EBP. Document any changes and report any symptoms promptly, and provide support and allow resident to express feeling, fears, and concerns. All interventions for this focus area were documented to be initiated on 05/13/2026. On 05/13/2026 at 8:30 AM during a tour of the facility, R1's room was observed to not have any signage indicating R1 was on isolation. R1's room did not have a Personal Protective Equipment (PPE) station outside of the room.On 05/13/2026 at 8:52 AM, V8 (Certified Nurse Assistant/CNA) was observed caring for R1 and stated she was completing a bed bath. V8 did not have PPE on at this time. On 05/14/2026 at 5:05 AM, V5 (Licensed Practical Nurse/LPN) stated R1 was moved to a room last night because she had to be put on isolation precautions for an infection in her wound. V5 stated she was not sure if R1 was on enhanced barrier precautions.On 05/14/2026 at 5:50 AM, V7 (CNA) was observed walking into R1's room. V7 uncovered R1 and looked at her adult incontinence brief. V7 did not have PPE on at this time.On 05/14/2026 at 6:00 AM, V7 stated she was supposed to wear a gown when she went into R1's room but didn't. V7 stated she wasn't sure why she did not wear a gown but knows that R1 is on isolation.On 05/14/2026 at 07:00 AM, V8 (CNA) donned PPE and entered R1's room. V8 opened a pack of incontinence wipes, folded down R1's incontinence brief, used the wipe to clean the left side of R1's peri area, and discarded the wipe. With the same gloves on, V8 pulled another wipe from the package and wiped the right side of the peri area and discarded the wipe. V8 pulled another wipe from the package and wiped down the middle of R1's peri area. V8 then rolled R1 over to her right side, grabbed another wet wipe from the package, and began wiping R1's coccyx area, which was soiled with stool. V8 discarded the wipe and pulled another one from the package using the same gloves. V8 cleaned R1's coccyx area that was soiled with stool, removed the soiled incontinence brief from R1's bed and threw it in the trash. V8 then discarded her gloves and applied new ones without performing hand hygiene. V8 placed a new brief on R1, then assisted R1 with dressing and assisted her to her wheelchair. V8 then disposed of her gloves and sanitized her hands. On 05/14/2026 at 7:41 AM, V8 (CNA) stated R1 was not on isolation precautions of any kind on 05/13/2026. V8 stated R1 was placed on precautions last night after a wound culture came back.On 05/14/2026 at 7:43 AM, V9 (CNA) stated R1 was not on isolation yesterday. V9 stated R1 is on it today because of her wound culture.On 05/14/2026 at 8:56 AM, V1 (Administrator) stated she was not sure if R1 was on Enhanced Barrier Precautions or not. V1 stated she would ask V2 (Registered Nurse/RN - Director of Nursing/DON) when she gets here.On 05/14/2026 at 8:58 AM, V3 (Registered Nurse/RN) stated R1 was not on Enhanced Barrier Precautions yesterday. V3 stated when R1's culture was faxed yesterday to the facility, R1 was moved to an isolation room. V3 stated R1 should have been on Enhanced Barrier Precautions for her wound.On 05/14/2026 at 11:48 AM, V2 (DON) stated R1 should have been on Enhanced Barrier Precautions related to her wound. V2 stated she thought R1 was on these precautions. V2 said for residents who meet criteria, it would be her expectation that they be on Enhanced Barrier Precautions. V2 stated there should have been signs on the door notifying staff about isolation.On 05/14/2026 at 9:30 AM, V2 (DON) stated the facility does not have a policy on perineal care. V1 stated the facility just uses the checklist for a procedure guide for performing perineal care. V2 stated she expects staff to follow the checklist on providing care.A facility form titled Skills Checklist perineal care female documented staff should remove gloves, wash hands and apply clean gloves and apply clean brief or preferred underclothes.The facility policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions with no date documented Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and may residents colonized with a MDRO are asymptomatic or not presently known to be colonized.

Based on interview and record review, the facility failed to provide opioid pain medication to a resident with chronic and acute pain for 1 of 4 residents (R1) reviewed for pain in the sample of 10. This failure resulted in R1 experiencing opioid withdrawal symptoms and pain at a level of ten on a zero to ten scale, R1 signing herself out of the facility AMA (Against Medical Advice), and R1 calling 911 to have an ambulance take her to the ER (Emergency Room) for treatment. Findings include:R1's admission Record documented an admission Date of 4/3/26 and listed diagnoses including Unspecified Fractures of the First and Second Thoracic Vertebrae, Traumatic Pneumothorax, Bilateral Contusions of the Lungs, Multiple Rib Fractures to the Right Side, One Rib Fracture to the Left Side, Major Laceration of the Liver, Moderate Laceration of the Spleen, Hemoperitoneum, Fracture of the Superior Rim of the Right and Left Pubis, a Displaced Fracture of the Lateral Condyle of the Left Humerus, a Severely Displaced Zone 2 Fracture of the Sacrum, and an Unspecified Fracture of the Ilium.R1's Physicians Orders documented a 4/3/26 order for Ibuprofen 800mg (milligrams) one tablet every 8 hours as needed for pain, and Oxycodone Acetaminophen (Percocet) 5-325mg one tablet every 8 hours as needed for pain.R1's April 2026 Medication Administration Record (MAR) documented 800 mg of Ibuprofen was given on 4/3/26 at 11:06pm by V2, Director of Nurses, for a pain level of 4, and that the medication was 'Ineffective in controlling the pain. There was no documentation on the MAR to indicate that Oxycodone Acetaminophen was given.R1's Hospital Summary of Care document dated 4/3/26 documented, Encounter Diagnosis: Closed fracture of multiple ribs of both sides, trauma. Outpatient medications (R1 was taking before hospitalization): Percocet (Oxycodone Acetaminophen) 5-325mg. (milligrams) take one tablet three times daily.R1's Hospital Discharge Packet dated 4/3/26 documented: Surgical History: Bilateral chest surgery, 3/9/26. Left humerus fracture surgery, 3/10/26. Irrigation and debridement of left elbow, 3/8/26. Bilateral pelvic fracture surgery, 3/8/26. Thoracoscopy, 3/9/26.R1's Hospital Physical Therapy documentation dated 4/1/26 stated, Therapy recommendations: Patient would benefit from continued therapy at a facility level. Barriers to discharge: Does not have assist needed for safe mobility/balance.R1's After Visit Summary dated 4/3/26 documented, Take these medications: Ibuprofen 800mg one tablet every 8 hours as needed for pain. Percocet 5-325mg one tablet three times daily (scheduled). There was no documentation in R1's record to indicate when the last doses of these medications were given at the hospital.R1's Nursing Progress Notes authored by V2 documented the following:4/4/26 at 1:35am: (Late entry) (R1) newly admitted to facility. Resident complains of pain, PRN (as needed) ibuprofen given per order, as other medications have not been delivered at this time. This nurse contacted pharmacy related to narcotic pain medication. Pharmacy states they have not received hard scripts. Contacted hospital due to scripts not being sent to pharmacy on discharge. Awaiting a call back from hospital. Explained this situation to resident, resident not pleased with hospital or care received while there. Resident remains awake at this time, on cell phone. Transferred to recliner per resident request, approximately 10 minutes later, resident used cell phone to call facility phone and ask to be transferred back to bed. Resident educated on use of call light, which was in reach. Resident transferred back to bed via mechanical lift and 2 staff. Appears comfortable at this time. Call light and fluids within reach.4/4/26 at 4:27am: (Late entry) Received phone call from local dispatch at 3am that resident had called 911 requesting ambulance transport to hospital. Resident assessed and no distress noted, vital signs within normal limits. Complains of pain and not being able to sleep. PRN ibuprofen had been administered per order as hospital did not send hard scripts for narcotics on discharge and unable to pull narcotics from e(mergency) kit without script. Hospital was notified of need for scripts to be sent to pharmacy, pharmacy stated had still not received scripts at that time. Attempted to notify on call physician at 3:02am. This nurse called (V8, Medical Director) at 03:57am due to no return call from on call physician. (V8 ) gave orders to send to ER for eval and treat due to resident request. Ambulance arrived at 4am. Resident states she is going to the hospital and then going home and will not be returning to the facility. Resident requesting AMA (Discharge Against Medical Advice) paperwork. Resident educated of potential dangers related to leaving AMA and continues to request AMA paperwork. AMA papers signed by resident and witnessed by this nurse, 2 EMTs (Emergency Medical Technicians) and CNA (Certified Nursing Assistant) present as well. Ambulance left with resident at 4:20am. On call physician returned call at 4:30am and notified of resident transfer and decision to leave AMA.R1's Hospital ER (Emergency Room) Nurses Note dated 4/4/26 at 5am documented, Presentation: Patient states: Pain management, opioid withdrawal symptoms. Triage Assessment: Triage note: Patient arrived to ED (Emergency Department) via (local ambulance service) from (the facility). Patient signed out of (the facility) AMA and presented to hospital for pain management from injuries from MVA (Motor Vehicle Accident) that occurred in March (2026). Patient was admitted to (the facility) from (regional hospital) on 04/03(26) around 1700 (5pm) where no pain medication had been administered between then and the time of arrival to ED (approximately 12 hours). Patient complains of nausea, vomiting, and diarrhea, and pain in bilateral legs, pelvis, back, and buttocks that is described as sharp, and rated 10/10. Blood pressure 130/89, pulse 96, respirations 16, temperature 98.1 (degrees Fahrenheit) pulse oxygenation 98 percent on room air. Medications administered: Percocet 5-325mg one tablet R1's Hospital ER Physician Note dated 4/4/26 at 5:46am documented, This [AGE] year-old female presents to ED via EMS with complaints of pain all over. Patient was involved in MVA about a month ago, was hospitalized at (regional hospital) and discharged to (the facility) yesterday afternoon. She signed herself out AMA this morning, called 911 and (was) transported here with complaints of pain, nausea, vomiting, and diarrhea. The patient has been recently seen by a physician at (regional hospital). Patient says she is in chronic pain, has been in pain management several years. Data reviewed: Vital signs, nurses notes, EMS record, nursing home records. Counseling: I had a detailed discussion with the patient and/or guardian regarding the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnoses, the need for outpatient follow up with the patients primary care provider. Disposition Summary: Discharge ordered. Diagnosis: Chronic pain syndrome. Prescriptions: Percocet 5-325 mg oral tablets, take one tablet oral route every 6 hours as needed, 20 tablets, refills zero, product selection permitted.On 4/28/26 at 9:30am via phone interview R1 was alert and oriented. R1 stated in early March 2026, she was in the car with her [AGE] year-old son driving and they were hit head on by a semi tractor trailer. R1 stated she sustained multiple fractures and internal injuries, was comatosed and intubated for several days, and had several orthopedic surgeries in the days following. R1 stated previous to the accident, she had been followed by pain management for several years due to an old back injury and was taking Percocet. R1 stated she was admitted to the facility via ambulance on 4/3/26 around supper time and had been discharged on Percocet at the same dose and directions she had been on in the hospital, one tablet three times daily. R1 stated she does not recall the time of the last dose of the Percocet was given to her at the hospital. R1 stated as the evening went on, she was experiencing pain and was told by V2 that the hospital had not sent written prescriptions for her Percocet, but they would be able to give her Ibuprofen. R1 stated she can't remember what her pain was on a ten scale at that time, but the Ibuprofen was not effective in controlling her pain, which then later escalated to a 10. R1 stated she continued to ask for the Percocet and was, Given different excuses-they needed to call the pharmacy, the doctor hadn't called them back, etcetera. R1 stated at about 1am to1:30 am she couldn't stand the pain any longer, she had been yelling out in pain, and called 911 and asked for transport to the ER. R1 stated she informed the facility she would not be coming back due to their failure to manage her pain, and she signed the facility AMA paperwork. R1 stated she was given Percocet at the hospital and 20 tablets to take home until she could follow up with her primary care provider.On 4/28/26 at 11:45am, V5 (CNA) stated she was working day shift when R1 was admitted around supper time. V5 stated R1 ate supper and was ready to go lay down. V5 stated she was aware there was a problem with R1 not being able to get her pain pill and R1 was upset about it. V5 stated she left the facility at 6pm and did not interact with R1 further.On 4/28/26 at 2:55pm, V2 stated R1 arrived via ambulance a little after 5:30pm on 4/3/26. V2 stated R1 had been hospitalized due to a bad car accident and was admitted to the facility for continuing care. V2 stated R1 was asking for her narcotic pain medication but the hospital had not sent a prescription with her. V2 stated R1 told her she had been given one pain pill that day by the hospital and she couldn't remember when. V2 stated R1's family came and brought all her home meds except for the narcotic pain medication, so they were able to give her R1 8pm medications. V2 stated the family brought 800mg Ibuprofen, which there was an order for, so she gave that around 11pm. V2 stated the Ibuprofen and frequent repositioning were ineffective in controlling R1's pain, although V2 stated she could not recall if she did any further pain scales with R1. V2 stated as the night went on R1, Was having behaviors-hollering, and calling the facility phone with requests although she knew how to use the call light. She said she was in horrible pain, but her vital signs were all normal and she was able to talk on her cell phone all night. V2 stated around 1:30am she got a call from EMS dispatch that R1 had called 911 wanting to go to the ER. V2 stated said there was no medical indication that R1 needed hospitalization, and she tried the on-call physician, who didn't answer. V2 stated at some point later she contacted V8, who gave the order to send R1 to ER. When the ambulance arrived R1 stated due to the issue with her pain meds not being available she would not be returning from the ER, and she signed AMA paperwork.On 4/28/26 at 3:30pm, V9 (CNA) stated she worked with R1 on the evening of 4/3/26. V9 stated R1 was complaining about needing pain pills, was on the call light constantly asking for pain pills, was threatening to sign out AMA, and was yelling out, which V9 felt was behavioral in nature. On 4/29/26 at 9:40am, V7 (Pharmacist/Pharmacy Director) stated the facility did call their after-hours service about the resident on 4/3/26 at 8:12pm, and the facility was told with a written prescription they could send the pain medication out STAT from a local pharmacy, but staff said the hospital had not sent written prescription and they were going to try to get ahold of their on call physician. V7 stated the facility had the correct dose of Percocet in the emergency kit which also would have been available with a written prescription. On 4/29/26 at 10:55am, V8 (Physician/Medical Director) stated he didn't specifically recall the facility contacting him at 3am on 4/4/26 about R1. V8 stated if the facility had contacted him sooner, he could possibly have given them a verbal order to access the Percocet from the emergency kit, or failing that, given the order to send her to the ER. V8 stated he felt the failure in the situation was totally on the hospital not sending the scripts, and felt the facility was not at fault. On 4/29/26 at 12:05pm, V2 stated she was not sure how long she waited back to hear from the on call physician before contacting V8, and she said she wasn't sure of the exact times of making phone calls that night. When asked why V2 didn't contact a provider when she first realized R1 arrived without scripts, V2 stated there was a lot going on that night. When told V8 was of the opinion he could have given her a verbal order to access the emergency kit, V2 stated she was not aware that was an option. When asked why the facility POS stated the Percocet was to be given three times daily prn and the hospital discharge documentation said it was to be given three times daily scheduled, V2 stated she had not been aware of the discrepancy.On 4/30/26 at 9:45am, V2 stated she did recall R1 having two loose stools the evening of 4/3/26 but she did not think they were related to opioid withdrawal. On 4/30/26 at 11:45am, V7 clarified that if a provider had contacted them with an emergency verbal order for the medication, they could have given the facility a code to access the emergency kit to obtain the pain medication. The facility's Pain Management Policy dated 12/24 documented, It is the policy of this facility to respect and support the residents right to optimal pain assessment and management. Use of opioids for pain management: See Opioid Use Policy and Procedure.

Based on interview and record review, the facility failed to follow it's policy to obtain emergency controlled medications for 1 of 7 residents (R1) reviewed for pharmacy services in the sample of 10.R1's admission Record documented an admission Date of 4/3/26 and listed diagnoses including Unspecified Fractures of the First and Second Thoracic Vertebrae, Traumatic Pneumothorax, Bilateral Contusions of the Lungs, Multiple Rib Fractures to the Right Side, One Rib Fracture to the Left Side, Major Laceration of the Liver, Moderate Laceration of the Spleen, Hemoperitoneum, Fracture of the Superior Rim of the Right and Left Pubis, a Displaced Fracture of the Lateral Condyle of the Left Humerus, a Severely Displaced Zone 2 Fracture of the Sacrum, and an Unspecified Fracture of the Ilium.R1's Physicians Orders documented a 4/3/26 order for Ibuprofen 800mg (milligrams) one tablet every 8 hours as needed for pain, and Oxycodone Acetaminophen (Percocet) 5-325mg one tablet every 8 hours as needed for pain.R1's April 2026 Medication Administration Record (MAR) documented 800 mg of Ibuprofen was given on 4/3/26 at 11:06pm by V2, Director of Nurses, for a pain level of 4, and that the medication was 'Ineffective in controlling the pain. There was no documentation on the MAR to indicate that Oxycodone Acetaminophen was given.R1's Hospital Summary of Care document dated 4/3/26 documented, Encounter Diagnosis: Closed fracture of multiple ribs of both sides, trauma. Outpatient medications (R1 was taking before hospitalization): Percocet (Oxycodone Acetaminophen) 5-325mg. (milligrams) take one tablet three times daily.R1's After Visit Summary dated 4/3/26 documented, Take these medications: Ibuprofen 800mg one tablet every 8 hours as needed for pain. Percocet 5-325mg one tablet three times daily (scheduled). There was no documentation in R1's record to indicate when the last doses of these medications were given at the hospital.R1's Nursing Progress Notes authored by V2 (Director of Nurses) documented the following:4/4/26 at 1:35am: (Late entry) (R1) newly admitted to facility. Resident complains of pain, PRN (as needed) ibuprofen given per order, as other medications have not been delivered at this time. This nurse contacted pharmacy related to narcotic pain medication. Pharmacy states they have not received hard scripts. Contacted hospital due to scripts not being sent to pharmacy on discharge. Awaiting a call back from hospital. Explained this situation to resident, resident not pleased with hospital or care received while there. Resident remains awake at this time, on cell phone. Transferred to recliner per resident request, approximately 10 minutes later, resident used cell phone to call facility phone and ask to be transferred back to bed. Resident educated on use of call light, which was in reach. Resident transferred back to bed via mechanical lift and 2 staff. Appears comfortable at this time. Call light and fluids within reach.4/4/26 at 4:27am: (Late entry) Received phone call from local dispatch at 3am that resident had called 911 requesting ambulance transport to hospital. Resident assessed and no distress noted, vital signs within normal limits. Complains of pain and not being able to sleep. PRN ibuprofen had been administered per order as hospital did not send hard scripts for narcotics on discharge and unable to pull narcotics from e(mergency) kit without script. Hospital was notified of need for scripts to be sent to pharmacy, pharmacy stated had still not received scripts at that time. Attempted to notify on call physician at 3:02am. This nurse called (V8, Medical Director) at 03:57am due to no return call from on call physician. (V8 ) gave orders to send to ER for eval and treat due to resident request. Ambulance arrived at 4am. Resident states she is going to the hospital and then going home and will not be returning to the facility. Resident requesting AMA (Discharge Against Medical Advice) paperwork. Resident educated of potential dangers related to leaving AMA and continues to request AMA paperwork. AMA papers signed by resident and witnessed by this nurse, 2 EMTs (Emergency Medical Technicians) and CNA (Cerified Nursing Assistant) present as well. Ambulance left with resident at 4:20am. On call physician returned call at 4:30am and notified of resident transfer and decision to leave AMA.R1's Hospital ER (Emergency Room) Nurses Note dated 4/4/26 at 5am documented, Presentation: Patient states: Pain management, opioid withdrawal symptoms. Triage Assessment: Triage note: Patient arrived to ED (Emergency Department) via (local ambulance service) from (the facility). Patient signed out of (the facility) AMA and presented to hospital for pain management from injuries from MVA (Motor Vehicle Accident) that occurred in March (2026). Patient was admitted to (the facility) from (regional hospital) on 04/03(26) around 1700 (5pm) where no pain medication had been administered between then and the time of arrival to ED (approximately 12 hours). Patient complains of nausea, vomiting, and diarrhea, and pain in bilateral legs, pelvis, back, and buttocks that is described as sharp, and rated 10/10. Blood pressure 130/89, pulse 96, respirations 16, temperature 98.1 (degrees Fahrenheit) pulse oxygenation 98 percent on room air. Medications administered: Percocet 5-325mg one tablet R1's Hospital ER Physician Note dated 4/4/26 at 5:46am documented, This [AGE] year-old female presents to ED via EMS with complaints of pain all over. Patient was involved in MVA about a month ago, was hospitalized at (regional hospital) and discharged to (the facility) yesterday afternoon. She signed herself out AMA this morning, called 911 and (was) transported here with complaints of pain, nausea, vomiting, and diarrhea. The patient has been recently seen by a physician at (regional hospital). Patient says she is in chronic pain, has been in pain management several years. Data reviewed: Vital signs, nurses notes, EMS record, nursing home records. Counseling: I had a detailed discussion with the patient and/or guardian regarding the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnoses, the need for outpatient follow up with the patients primary care provider. Disposition Summary: Discharge ordered. Diagnosis: Chronic pain syndrome. Prescriptions: Percocet 5-325 mg oral tablets, take one tablet oral route every 6 hours as needed, 20 tablets, refills zero, product selection permitted.On 4/28/26 at 9:30am via phone interview R1 was alert and oriented. R1 stated in early March 2026, she was in the car with her [AGE] year-old son driving and they were hit head on by a semi tractor trailer. R1 stated she sustained multiple fractures and internal injuries, was comatosed and intubated for several days, and had several orthopedic surgeries in the days following. R1 stated previous to the accident, she had been followed by pain management for several years due to an old back injury and was taking Percocet. R1 stated she was admitted to the facility via ambulance on 4/3/26 around supper time and had been discharged on Percocet at the same dose and directions she had been on in the hospital, one tablet three times daily. R1 stated she does not recall the time of the last dose of the Percocet was given to her at the hospital. R1 stated as the evening went on, she was experiencing pain and was told by V2 that the hospital had not sent written prescriptions for her Percocet, but they would be able to give her Ibuprofen.On 4/28/26 at 2:55pm, V2 stated R1 arrived via ambulance a little after 5:30pm. V2 stated R1 had been hospitalized due to a bad car accident and was admitted to the facility for continuing care. V2 stated R1 was asking for her narcotic pain medication but the hospital had not sent a prescription with her. V2 stated R1 told her she had been given one pain pill that day by the hospital and she couldn't remember when. V2 stated R1's family came and brought all her home meds except for the narcotic pain medication, so they were able to give her R1 8pm medications. V2 stated the family brought 800mg Ibuprofen, which there was an order for, so she gave that around 11pm. On 4/29/26 at 9:40am, V7 (Pharmacist/Pharmacy Director) stated the facility did call their after-hours service about the resident on 4/3/26 at 8:12pm, and were told with written prescription they could send it the pain medication out STAT from a local pharmacy, but staff said the hospital had not sent written prescription and they were going to try to get ahold of their on call physician. V7 stated the facility had the correct dose of Percocet in the emergency kit which also would have been available with a written prescription. On 4/29/26 at 10:55am, V8 (Physician/Medical Director) stated he didn't specifically recall the facility contacting him at 3am on 4/4/26 about R1. V8 stated if the facility had contacted him sooner, he could possibly have given them a verbal order to access the Percocet from the emergency kit, or failing that, given the order to send her to the ER. V8 stated he felt the failure in the situation was totally on the hospital not sending the scripts, and felt the facility was not at fault. On 4/29/26 at 12:05pm, V2 stated she was not sure how long she waited back to hear from the on call before contacting V8, and she said she wasn't sure. When asked why V2 didn't contact a provider when she first realized R1 arrived without scripts, V2 stated there was a lot going on that night. When told V8 was of the opinion he could have given her a verbal order to access the emergency kit, V2 stated she was not aware that was an option. On 4/30/26 at 11:45am, V7 clarified that if a provider had contacted them with an emergency verbal order for the medication, they could have given the facility a code to access the emergency kit to obtain the pain medication. The facility's Stat Safe Policy and Procedure dated March 2024 documented, The facility may use electronic first dose kits (example given, stat safe) for first dose and emergency medications where permitted by regulation or law. Procedure, facility: G. If a controlled substance is needed, facility staff should contact the pharmacy/after hours service to retrieve an access code to remove doses from the electronic first dose kit.

Based on interview and record review, the facility failed to document a physician's order for treatment of a skin tear and to obtain physician's order for monitoring of the wound until it was healed for 1 (R1) of 3 residents reviewed for wounds in a sample of 8.R1's admission record dated 2/4/26 documents an admission date of 1/2/26. Same admission record documents diagnoses including but not limited to end stage renal disease, type II diabetes, and epilepsy.R1's minimum data set/MDS dated [DATE] documents R1 has a brief interview for mental status/BIMS score of 11 indicating resident has moderately impaired cognition.R1's most recent care plan undated has a focus area for R1 indicating he has potential for impairment of skin integrity dated 2/2/26. Interventions for this focus area include but aren't limited to avoid scratching and keep hands and body parts from excessive moisture and to keep fingernails short dated 2/2/26.R1's skin issue risk assessment form dated 1/16/26 documents R1 had obtained a skin tear to his right forearm the same day by getting his right arm caught in between two rails in the bathroom that were near the toilet. The same form documents the treatment administered by V10; Registered Nurse (RN) was she cleansed the skin tear with normal saline and applied three steri-strips. Same form documents V8, Nurse Practitioner (NP) was notified same date, but not that any orders were received for treatment/monitoring of the skin tear.R1's discontinued and completed orders for the month of January 2026 do not document an order for treatment/dressing to the skin tear to R1's right forearm obtained on 1/16/26 or an order to monitor the area for signs/symptoms of infection until healed. R1's current physician order sheets dated 2/4/26 do not document any such order.R1's treatment administration record (TAR) for the month of January does not contain any documentation any treatments were done to a skin tear of the right forearm or to monitor the skin tear daily for healing or signs/symptoms of infection.On 2/2/26 at 155 PM, R1, after returning from dialysis, was observed lying in bed covered with a sheet up to his waist and a long sleeve shirt on his torso. When asked R1 about the scabbing/scarring area to his right forearm R1 states he doesn't remember how he obtained the injury. Same wound of right forearm appears to be healing well without any signs/symptoms of infection. On 2/4/26 at 9:42 AM, V10, Registered Nurse (RN) stated R1 had obtained a skin tear to his right forearm while using the bathroom. V10 stated she did not actually see R1's skin break but did see his right forearm caught between the two bars in the bathroom. V10 stated she does remember cleaning the skin tear with normal saline and applying three steri-strips to it. V10 stated she notified R1's power of attorney (POA), nurse practitioner (NP), and facility administration of the R1's wound and how he had obtained it. V10 stated the NP had indicated the dressing she had done on the R1's skin tear was appropriate. V10 stated she did not document the order for the dressing change/treatment to the skin tear and did not obtain an order to monitor the area until healed for signs/symptoms of infection and/or not healing. V10 stated she did not think it was necessary to write an order for the above because it was common sense and a one-time need for a dressing/treatment.On 2/4/26 at 10:09 AM, V8, NP stated she does remember being contacted by V10 in relation to R1's skin tear on his right forearm. V8 stated V10 had told her how she had cleaned and dressed the wound and V8 had responded the treatment provided was appropriate. V8 did state however, that the dressing/treatment for the wound should have been documented as a physician's order in R1's electronic health record and an order for monitoring the area daily should have been obtained as well.On 2/4/26 at 2:36 PM, V1, Administrator stated she wasn't sure if there should have been an order placed for the dressing/treatment of R1's skin tear because it was so minor.On 2/5/26 at 10:26 AM, V2, Director of Nurses stated her expectations for when a nurse receives physician's orders would be for the nurse to document them in the resident's electronic health record, notify POA, and document a progress note of what had led to obtaining the doctor's order and who was notified. V2 stated she would have expected V10 to document the order for the dressing/treatment to R1's skin tear in his electronic health record and treatment administration record/TAR and to have obtained another order to monitor the skin tear daily until healed and placed that order on the treatment administration record as well for a daily reminder it needed to be done. Facility's Skin Identification, Evaluation, and Monitoring Policy dated 1/25 documents if a new wound is identified initiate a protective dressing, notify the healthcare provider of findings and for further treatment orders.

Based on interview and record review the facility failed to have a licensed administrator licensed in accordance with state law. This failure has the potential to affect all 19 residents residing in the facility.Findings include:V1's (Administrator) Illinois Department of Financial and Professional Regulation (IDFPR) Lookup Detail View documented a Licensed Nursing Home Administrator Temporary with a First Effective Date of [DATE], Effective Date of [DATE], and an Expiration Date of [DATE]. On [DATE] at 12:12 PM, V14 (Administrator In Training/ AIT) stated she had only been working in the facility for 3 to 4 weeks and was not sure about the history of V1's Administrator License. V14 said on the IDFPR website V1's Licensed Nursing Home Administrator Temporary documented an Active Status but was expired. V14 said she did not have a Licensed Nursing Home Administrator Temporary yet. V14 stated that V1 was currently unavailable due to a hospitalization. V1 was unable to be reached for interview during the survey. On [DATE] at 12:32 PM, V15 (Regional Director of Operations/ RDO) stated V1 had a Temporary Administrator License and V1 told V15 that V1 had taken the Licensed Nursing Home Administrator test but was unsure if V1 had passed or failed. V15 said a Temporary Administrator License was eligible to be extended if the person had attempted the Licensed Nursing Home Administrator test. V15 said V1 had applied for a licensure extension but due to IDFPR being slow to process any applications for licensure since COVID V1 had not received any notice of extension. V15 said he had called IDFPR to inquire about V1's licensure extension and was told it was being processed. On [DATE] at 2:45 PM, V14 stated she was not aware of any other Administrator License being connected and active in the facility. V14 was not able to provide any reproduceable documentation V1 had recently attempted to take the Licensed Nursing Home Administrator testing or of V1 filing for an extension on the Licensed Nursing Home Administrator Temporary. The facility's Resident Matrix printed [DATE] documented 19 residents residing in the facility.Illinois Administrative Code title 77, 399.510 documents .a) There shall be an administrator licensed under the Nursing Home Administrators licensing and Disciplinary Act .full-time for each licensed facility .

Based on observation, interview, and record review, the facility failed to implement care plan interventions and dietitian recommendations as ordered for 1 (R12) of 1 resident reviewed for nutrition in a sample of 22. This failure resulted in R12 experiencing a 10.26 percent weight loss within three months. Findings include: R12's admission Record documented an admission date of 7/12/2022 and included diagnoses of dementia in other diseases classified elsewhere, chronic diastolic (congestive) heart failure, type 2 diabetes mellitus, major depressive disorder, and end stage renal disease. R12's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating R12 had moderate cognitive impairment. Under the section titled Mood, R12 was documented as having little interest or pleasure in doing things and feeling down, depressed or hopeless for several days. Under the section for Functional Abilities and Goals, R12 was assessed as needing setup or cleanup assistance for eating. R12's Dietitian Progress Note dated 5/6/2025 by V13 (Registered Dietitian/RD) documented May wt (weight): 136# w/ (with) a sig wt loss (significant weight loss) noted x (times) 1 mo (month) (5.56%), x 3 mo (12.82%) and x 6 mo (12.26%). BMI (Body Mass Index): 24.9 (WNL) (within normal limits). Diet rx (prescribed): Regular, NAS (No added salt) w/ Thin Liquids, 1500 cc (cubic centimeters) Fluid Restriction, Magic Cup 1x/day and 60 cc 2.0 cal (calorie) Supplement TID (3 times per day). PO (by mouth) intake is reported as varied ~0-100% of meals w/ most meals reported as ~26-50% per the look back report. Meds reviewed- insulin rx in place to support glycemic control; antidepressant rx may alter appetite/wt (weight); diuretic rx may alter fluid balance/wt/electrolytes. Labs dated 4/8/25 reviewed: Cholesterol (H = high), HDL (L = low), LDL (H), Hgb/HCT (hemoglobin/hematocrit) (L), Iron (WNL), TIBC (total iron binding capacity) (L). Iron supplement and atorvastatin rx in place. Practitioner notified of labs. Staff report poor acceptance of the 2.0 cal (calorie) supplement rx to this RD and state that Magic Cup acceptance is hit or miss. At this time will recommend to d/c (discontinue) the 2.0 cal supplement rx, add Mighty Shake BID (twice per day) and recommend MD (medical doctor) to consider an appetite stimulant d/t (due to) generally poor appetite. RD to follow-up PRN (as needed). R12's Care Plan documented a focus area of NUTRITION/HYDRATION: At Risk for Complications with Nutrition and hydration r/t (related to) fluid restriction, diuretic use, impaired cognition, psychotropic med use. Current weight is 154 Height is 62 BMI is 28.2 initiated on 9/18/24 and revised on 12/20/24. The goal listed documents Will have no significant wt changes noted through review date initiated on 12/20/24 with a target date of 8/31/25. The corresponding interventions are documented as follows: Meds /Labs/Treatments as ordered/accepted, initiated 12/20/24; Provide diet as ordered, initiated on 12/20/24; Record weights a minimum of monthly or per MD/RDN, initiated on 9/18/24; Set up meal per resident direction and assist with eating as/if needed and Honor food requests as able, initiated on 12/20/24; and Supplement as ordered, initiated on 9/18/24 and revised on 10/24/24. R12's Weight Log with print date of 6/5/2025 documents R12's weight on 2/27/2025 was 156 lbs (pounds) and her weight on 5/30/2025 was 140 lbs, which equals a significant weight loss of 10.26 percent in three months. On 06/04/25 at 12:50 PM, R12 was sitting at the lunch table with a regular meal of garlic and herb pork chop, sweet potatoes, peas, two snickerdoodle cookies and supplement. R12 was observed sleeping at the dining room table with no food touched on her plate while staff were sitting at another table assisting other residents with lunch. No staff were observed encouraging R12 to eat nor offering R12 assistance to feed herself. On 06/04/25 at 1:11 PM, V7 (Certified Nursing Assistant/CNA) and V8 (CNA) both stated, if they have a resident who is not eating or starts to have a decline in feeding themselves, they will encourage resident to eat or attempt to help feed them. V7 and V8 both stated, they would also notify the nurse. On 06/04/25 at 1:13 PM V10 (Licensed Practical Nurse/LPN) stated, she will be notified by the CNA staff if a resident is not eating or declines in feeding self. V10 stated she would notify the provider and Registered Dietitian of resident change/decline. V10 stated R12 has not been wanting to eat and this started around the end of April 2025. V10 feels R12 is a failure to thrive since her husband passed away over a year ago. V10 stated, R12 will go back and forth with her intake of food depending on her mood. V10 stated R12' s Dietary Note by V13 (RD) dated 5/6/2025 is sitting in V11 (Nurse Practitioner/NP's) folder for review. V10 stated, V11 had been in the facility today (6/04/2025) and did not sign V13's recommendations. V10 stated the facility did have a lapse in weekly NP coverage coming into the facility that started around the first of May 2025. V10 stated, she had not worked the week of 5/6/2025, but the nursing staff should have contacted V12 (Medical Provider) or the on-call telehealth service via phone to review V13's progress note and recommendations for R12 prior to today. On 06/04/25 at 1:19 PM, R12 was sitting at the dining room table with a new tray served with garlic and herb pork chop, mash potatoes, peas, snickerdoodle cookie and her magic cup. R12 was again observed sleeping at the dining room table with no food touched on her plate. No staff were observed encouraging R12 to eat nor offering assistance to feed her. On 06/05/2025 at 7:42 AM, R12 was sitting in the dining room with her breakfast in front of her. R12 was not eating and there were staff at another table assisting other residents with breakfast. On 06/05/2025 at 8:12 AM, R12 was observed sitting in the dining room with her breakfast still untouched. R12 had drank her milk and started eating her cereal R12 was observed eating approximately half the bowl of cereal. On 06/05/25 at 9:15 AM, V6 (Dietary Manager) stated R12 had started showing signs of not wanting to eat at meals around the last week of April 2025. V6 stated, R12 started with not wanting to eat some items at meals to then gradually not wanting to eat at any meals over the last 4 weeks. V6 stated R12 does have periods where she will eat and not eat depending on her mood. V6 stated, staff should encourage residents to eat when observed not eating or have a decline in intake. V6 stated, the process for communication with diet changes/recommendations starts with V13 (RD) coming in once a month to review residents. V6 stated that herself, V1 (Administrator) and V2 (Director of Nursing) will receive a copy of V13's progress notes with recommendations. V6 stated, V2 will then take the note with recommendations and put them in the folder for the Nurse Practitioner (NP) to see weekly. V6 stated, once the NP signs the orders, the nursing staff will then make the updates/changes in the resident's electronic health record (EHR). V6 stated, once the changes are made in the resident's EHR, she can update dietary information on her end. V6 stated she did receive V13's progress notes with recommendations on 5/6/2025 via email. V6 stated, to her knowledge V2 did put the progress note in the NP folder to be reviewed. V6 stated the facility did have a lapse in weekly in-person NP coverage at the facility that started the first week of May 2025. V6 said in her opinion, V12 (Medical Provider) should have been contacted via phone to review V13's progress notes and recommendations by the nursing staff prior to today. V6 stated 4 weeks is too long of a period to wait on reviewing recommendations. On 06/05/25 at 10:23 AM, V11 (Nurse Practitioner/NP) stated, she started weekly in-person visits in the facility on 5/29/2025. V11 stated, the facility did have a lapse of a NP coming into the facility weekly for a few weeks and that did start around the first of May. V11 stated however, the facility did have coverage by an on-call telehealth company or V12 (Medical Provider). V11 stated, in her opinion the facility should have contacted the telehealth service or V12 (Medical Provider) to review V13's progress notes and recommendations for R12 that was dated 5/6/2025, prior to today. V11 stated she did not review R12's recommendations dated 5/6/2025 when she was in the facility on 6/4/2025. On 06/05/25 at 12:19 PM, V2 (Director of Nursing/DON) stated, she does receive V13's monthly notes via email. V1 stated, she did receive R12's progress note with recommendations on 5/6/2025 from V13, however, she was on vacation until 5/12/2025. V2 stated, V6 (Dietary Manager/DM) should have printed out V13's progress note, with her recommendations and given it to the nurse to contact a provider to review. V2 stated V6 noticed the recommendations had not been reviewed and printed them 6/2/2025 for V11 (NP) to review at her weekly visit this week. V2 (DON) stated, if the CNA staff notices a resident who is not eating, they should give them verbal cues, notify V6 (Dietary Manager) and Nurses. V2 stated, the CNA staff should assist to feed the resident as well, if the resident will allow. V2 stated, in her opinion V12 (Medical Provider) should have been notified via phone to review V13's progress note with recommendations in a timely manner. On 06/05/25 at 10:46 AM, V1 (Administrator) stated his expectation would be the nursing staff should have contacted telehealth or V12 (Medical Provider) by phone to review recommendations by V13 for R12. On 06/06/25 at 09:25 AM, V13 (Regional Dietitian) stated the process of communication for her recommendations on residents starts with her emailing them to V1 (Administrator), V2 (DON) and V6 (DM). V13 stated, from there V2 (DON) will print out her progress note with recommendations for a provider to review and sign. V13 stated, then the nursing staff will enter the providers orders into the residents EHR (electronic health record). V13 stated, she did send R12's progress note with her recommendations via email to V1 (Administrator), V2 (DON) and V6 (DM) on 5/6/2025. V13 stated, in her opinion, the facility should have contacted V12 (Medical Provider) to review R12's status and recommendations in a timely manner. R12's Physician Order Summary documented Megestrol Acetate Oral Suspension 200 mg (milligrams) by mouth two times a day for weight loss and liquid supplement two times a day with a start date of 6/5/2025. The facility's Resident Weight Monitoring policy and procedure (revised 3/19) documented under Procedure: 7. If there is an actual significant weight change (i.e. +/-5% x 1 month, +/- 7.5% x3 months, +/- 10% x 6 months), the resident, POAHC (Power of Attorney for Health Care)/family/guardian, physician, and dietitian are notified. The physician shall be notified using the MD notification of weight change form.

Based on observation and interview, the facility failed to ensure that dishes were effectively sanitized in the dish machine. This failure has the potential to affect all 17 residents residing in the facility. The Findings Include: On 6/3/25 at 9:45 AM, V3 (Cook) was observed using a quaternary test strip on the chlorine sanitizer. V3 stated at this time that she wasn't sure why the strip wasn't showing any sanitizer in the water. V3 asked V4 (Dietary Aide) about the the testing of the sanitizer level and V4 stated that the bucket needed to be checked first to see if it is empty because they have been having problems getting it delivered. V4 stated that the jug is empty, and they need to go to the store to get bleach to use in the interim until a delivery is made. V4 stated that is what was recommended to use if they ran out. V4 is unsure of which test strip to use because he does not regularly check the sanitizer in the dish machine, he just fills the dish machine when he starts in the morning and gets it ready for use. On 6/3/25 at 10:30 AM, V3 stated that she could check the level of sanitizer in the dish machine because they have bleach now. At this time, V3 used a quaternary strip to check the level of the machine's chlorine sanitizer. The test strip did not change colors. V3 then used the chlorine strip to check the level of sanitizer, but was not sure the level that it needed to be. V3 stated that she thought it needed to be 200 PPM (Parts Per Million). On 6/3/25 at 11:00 AM, V6 (Dietary Manager) stated that she had determined even though the log is filled out for the dish machine sanitizer level, no one is actually checking it, which is why V3 didn't know the correct strip to use or what the recommended PPM level is for chlorine. The facility policy for Ware-washing dish machine with a revision date of 10/09 documented .It is the policy of (name of corporation) that utensils and dishes washed by mechanical dishwasher will be cleaned and sanitized .3. For low temperature dish machines (temperature of water shall not be less than 120 degrees Fahrenheit). Before washing anything use a test strip to check the sanitizer level. A: for chlorine sanitizers, the level should be 50-100 PPM. B: for quaternary sanitizers, the level should be 200 PPM .4. Record either the temperatures or sanitizer level on the Dishmachine Temperature/Sanitizer log 10. Wash dishes according to equipment directions. The Long Term Care Facility Application for Medicare and Medicaid, dated 6/2/25, reports 17 residents reside in the facility.

2. On 06/04/25 10:00 AM, while passing ice to residents, V7 (Certified Nurse Assistant/CNA) was observed bending down to pick up a bag off the hallway floor, then placed the ice scoop in the bag and attached it back to the ice cart. On 06/04/25 10:10 AM, V7 (CNA) stated, she did pick the scoop bag up off the floor because it fell off the ice cart. V7 stated, she did put the ice scoop back in the scoop bag and secured it to the ice cart to be used. V7 stated, she should not have put the scoop bag back in use once it had been on the floor. On 06/04/25 10:36 AM, V2 (Director of Nursing/DON) stated her expectation for staff is to follow standard infection control practices. V2 stated V7 (CNA) should have replaced the ice scoop bag instead of putting it back on the ice cart. On 06/04/25 11:30 AM, V1 (Administrator) stated his expectation is for all staff to follow standard infection control practices. V1 stated, V7 (CNA) should have discarded the ice scoop bag that fell on the floor. The Long Term Care Facility Application for Medicare and Medicaid, dated 6/2/25, reports 17 residents reside in the facility. Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent contamination. This failure has the potential to affect all 17 residents residing in the facility. Findings Include: 1. R16's admission Record documented R16 was admitted to the facility on [DATE] and included diagnoses of Alzheimer's disease, dementia, chronic kidney disease, stage 3, major depressive disorder, anxiety disorder, hyperlipidemia, sleep apnea, history of falling, gastro esophageal reflux disease, vitamin d deficiency, delusional disorder, obstructive sleep apnea, essential primary hypertension, syncope and collapse, and other cervical disc degeneration. R16's Order Summary Report with a print date of 06/05/2025, documented a physician's order to cleanse R (right) lateral ankle with wound cleanser, apply calcium alginate then cover with bordered gauze dressing every day shift and as needed. R16's Care Plan documents a focus area of R16 is at risk for pressure injury and impaired skin integrity related to bowel and bladder incontinence, poor safety awareness. Skin tear to right lateral ankle. Interventions included to assist with turning and repositioning every two hours and as needed, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, use lotion on dry skin, provide pressure relieving mattress and wheel chair cushion, provide treatments as ordered, skin assessments as per facility policy, and weekly treatment documentation to include measurement of each area of skin breakdowns width, length, and depth, type of tissue and exudate and any other notable changes. R16's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R16 has severe cognitive impairment. On 06/04/2025 at 11:54 AM, V10 (Licensed Practical Nurse/LPN) completed wound care treatment for R16. V10 was observed cleaning R16's ankle and laid R16's leg back on the bed sheet with no barrier. V10 then raised R16's leg again to pat dry the wound to the ankle and laid R16's leg back on the bed sheet with no barrier. V10 again raised R16's leg, applied the calcium alginate and a bordered dressing, then laid R16's leg back on the bed sheet. On 06/04/2025 at 12:13 PM, V10 (LPN) stated I usually place a barrier down, but I must have forgotten. V10 stated she had changed the resident, and her sheets were clean. V10 stated she had the barrier on the bedside table and just forgot to place it down. On 06/04/2025 at 12:16 PM, V2 (Director of Nursing) stated that she would expect staff to have a barrier down under wounds when doing cleaning. V2 stated that you would not clean a wound and lay it on the bed without a barrier. Facility policy titled Aseptic Wound and Skin Treatment Procedure with a date of 01/2018 under purpose documents To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort.

Based on interview and record review, the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 17 residents residing in the facility. Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last modified 9/23/23 stated, .CMS (Centers for Medicare & Medicaid Services) has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2025 (October 1 - December 31), documented No RN hours on the following dates: 11/17/2024, 11/24/2024, 12/21/2024, 12/22/2024 and 12/29/2024. Nursing schedules reviewed for RN coverage on 11/17/2024, 11/24/2024, 12/21/2024, 12/22/2024 and 12/29/2024 documented coverage was provided by V2 (Director Of Nursing), who was a contracted Registered Nurse at the facility during that time. On 06/05/24 at 10:54 AM, V2 confirmed that she did work the days in question as the Registered Nurse at the facility, although the origination of discrepancy in the PBJ hours reported cannot be determined at this time, other than she doesn't clock in due to being in a salaried position. The Long Term Care Facility application for Medicare and Medicaid dated 6/3/24, documented 17 residents reside in the facility.

Based on observation, interview and record review, the facility failed to ensure treatment and services for range of motion were provided for 1 (R11) of 1 resident reviewed for mobility in the sample of 22. Findings Include: R11's admission Record documented an admission date of 12/10/2000 and included diagnoses of unilateral primary osteoarthritis of left knee, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, peripheral vascular disease, chronic kidney disease, unspecified Dementia, anxiety, essential hypertension, localized edema, atherosclerosis of native arteries of extremities with ulceration and diastolic (congestive) heart failure. R11's physician orders with a print date of 06/05/2025 does not document an order for passive or active range of motion restorative nursing program. R11's Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R11 has moderate cognitive impairment. The MDS section for Functional Abilities and Goals documented under functional limitation in range of motion that R11 has impairment on both sides of lower extremities. This MDS section for self-care documents R11 is dependent for toileting, shower/bathing, upper body dressing, lower body dressing, putting on and off footwear and personal hygiene. The MDS Section for Special Treatments, Procedures and programs documented that R11 received 0 days of active range of motion and 0 days of passive range motion (with a look back period of 7 days.) R11's Care Plan with an initiation date of 12/12/2024 documented a focus area of ADL (Activities of Daily Living) Actual/At Risk for Complications with Deficits with ADL's R/T (related to) current medical/physical status. Has meds/diagnosis that can/may affect ADL's. Interventions listed are dependent on two assist with transfers, max assist of one for bathing, max assist of one with bed mobility, supervision with upper body dressing, max assist of one with lower body dressing, dependent on one for putting on footwear, max assist of one with toileting needs, monitor document report any changes in ADL ability, any potential for improvement, reason for inability to perform ADL's, observe pain as prn (as needed), medications as ordered, and note effectiveness. R11's Physical Therapy Discharge Summary with date of service range of 01/22/2025 - 02/12/2025, documented that R11 received therapeutic exercises to improve lower extremity range of motion. On 06/04/2025 at 10:30 AM, V1 (Administrator) stated that the facility does not have designated staff to do restorative care. V1 stated that all certified nurse assistants are responsible for making sure restorative is done. On 06/04/2025 at 10:36 AM, V2 (Director of Nursing/DON) stated that R11 has no contractions or limited range of motion in her lower extremity. V2 stated that R11 just has weakness in her lower extremities. V2 stated that if R11 was to have a decline in range of motion, then she would start either a passive or active range of motion range of motion program. V2 stated that she is not sure why the physical therapy discharge summary stated that R11 had lower extremity range of motion problems. V2 stated that she is not sure why the physical therapist would not recommend a range of motion program for R11 if they observed R11 having range of motion issues. On 06/04/2025 at 11:20 AM, V9 (Certified Occupational Therapy Assistant) stated that R11 has pain in her hips and knees which causes her issues during transfers. V9 stated that R11 doesn't like to do transfers because of the pain. V9 stated R11 can move both her lower extremities but has pain in them. V9 stated that R11 could participate in a range of motion program. V9 stated that the therapy department does not have to recommend a program, that can be done on nursing judgement. V9 stated a range of motion program would help and be beneficial to R11's knees and hips. On 06/05/2025 at 1:00 PM, V2 (DON) stated that the facility does not have a policy for range of motion. V2 stated that if the nurse thinks the resident needs it, they write a program for it. V2 stated that the IDT (interdisciplinary team) will review it and leave it or change it if it needs to be changed. V2 stated she was not aware that R11's MDS and PT (physical therapy) notes documented issues with lower extremity range of motion.

Based on interview and record review the facility failed to promptly notify the resident representative of a fall for 1 (R1) of 3 residents reviewed for notification of changes in a sample of 7. Findings Include: R1's Admission Record documented an admitted to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. A Skilled Progress Note for R1 dated 10/05/2024 , authored by V2 (Director of Nursing), documented on 10/06/2024 at 2:30 A.M. R1 had a fall in the bathroom and that the day shift nurse would notify POA (Power of Attorney) of the incident due to non-emergent situation and being early in the morning. R1's (Name of Company) Quality Care Reporting Form under the section titled Responsible Party Notified it is documented as son with no date or time documented on the form. On 11/20/2024 at 8:39 A.M., V3 (Registered Nurse) stated on 10/06/2024 when she got shift report from V2 (Director of Nursing), V3 was informed that R1 had had a fall in the bathroom and hit his head. The fall caused him to have a scratch on his head that bled. V3 stated that V2 was going to finish all the paperwork and call the POA (Power of Attorney). V3 stated that she completed her shift and once she was home, she received a text message from V2 stating that she had forgotten to call the POA for R1 to notify them of a fall. V3 stated that it was her understanding from shift report that V2 was going to call and notify the POA. V3 stated that she doesn't think the family had ever been notified of the fall form 10/06/2024. On 11/21/2024 at 10:07 A.M., V2 (Director of Nursing) stated that R1 fell off the toilet and hit his forehead. V2 stated that she gave report to V3 and let her know about the fall and that she would attempt to make all notifications prior to V2 leaving. V2 stated that before she left, she verbally told V3 that she had not called the POA and asked her to do so. V2 stated that she then wrote on the 24-hour report to call the POA regarding R1's fall. V2 stated that she sent V3 a text later in the day on 10/06/2024 apologizing for V3 having to make notifications for her. V2 stated that several days after the fall she heard a rumor that V3 was telling other nursing staff that she didn't call the POA of R1 because it was V2's responsibility. V2 stated at this point she spoke to V1 (Administrator) about the concern of R1's POA not being notified. V2 stated that R1's family was in the facility one day and she notified them then. V2 stated she did not chart that she had done it and she also does not remember the day she talked to R1's POA. V2 stated that it is her expectation for staff to notify the POA's of a resident fall as soon as possible. V2 stated that it has been a facility policy for staff to wait until later in the morning to notify family of a fall if it occurs in the middle of the night or early morning hours. On 11/22/2024 at 12:40 P.M., V1 stated he was unaware that the POA was not notified on R1's fall until it was brought to his attention by V3. V1 stated that it was his understanding the V3 was supposed to call the POA because V2 had asked her to do it before she left the faciity on [DATE]. V1 stated that it is his expectation for staff to notify POA's of any type of change as soon as possible. The facility policy titled Accidents and Incidents with a revision date of 09/06/2023 documents, Responsibility: It is the responsibility of the charge nurse to complete the incident report, notify attending physician, and responsible parties and document information accordingly.

Based on interview and record review, the facility failed to protect and safeguard controlled substances for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. Findings Include: R1's Admission Record documented an admitted to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of [DATE], documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. R1's Order Summary Report with a print date of [DATE] documented an order for Hydrocodone ,d+[DATE] mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of [DATE]. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on [DATE] by V17 (Licensed Practical Nurse). The same form also documented R1 received Hydrocodone on [DATE] and [DATE] at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. On [DATE] V1 (Administrator) and V2 (Director of Nursing) were unable to produce the Controlled Drug Administration Record for the deliveries of Hydrocodone that were delivered on [DATE], [DATE], and [DATE]. R1's [DATE] MAR (Medication Administration Record) documented no doses of Hydrocodone were given on [DATE] or [DATE]. R1's Progress Note dated [DATE] and timed 12:54 P.M. documented, Upon doing narc (narcotic) count with (V11 Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed (R1's) slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. DON (V1) was notified as well. A facility incident report titled IDPH (Illinois Department of Public Health) Notification Form documented on [DATE] staff reported an allegation of misappropriation of resident property. Investigation initiated and follow up will be sent within 5 days. A pharmacy delivery slip dated [DATE] documented R1 had 5 Hydrocodone delivered to the facility and signed by V18 (Licensed Practical Nurse) at 11:39 P.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V4 (Registered Nurse) at 11:43 A.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 8:13 P.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 11:16 P.M. On [DATE] at 12:06 P.M., V7 (Pharmacy Operator) stated that R1 had Hydrocodone delivered to the facility on [DATE]. V7 stated that it was delivered at 11:16 P.M. and signed by V17 (Licensed Practical Nurse). On [DATE] at 8:39 A.M., V3 (Registered Nurse) stated that on [DATE] she was completing the narcotic count. V3 said she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON's box at the nurses station and did not find any sheets for R1's narcotic. V3 stated that she called V1(Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift on [DATE], she thought there was some in there but cannot remember 100 percent. V3 said that V1 instructed her to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. V3 stated she called the pharmacy, and the pharmacy told her that the script expired the end of October and there was not a new one on file to fill. On [DATE] at 10:05 A.M. narcotic count was completed with V4 (Registered Nurse). The cards that were present had the correct number of medications on them matching the count sheets. There were not narcotics in the narcotic box for R1. On [DATE] at 12:00 P.M., V4 (Registered Nurse) stated that there is an order for R1 to have Hydrocodone but she never gives him any. V4 verified that there were no narcotics in the lock box for R1 and that there was no count sheet. V4 repeated she is unsure if R1 had any because she never gives him any. V4 did not recall the last time that there were narcotics in the locked box for R1. On [DATE] at 2:17 P.M., R1 was sitting in his recliner rolling around in his room. R1 stated that he has no pain. R1 stated that if he did he would tell the nurse and she will ask the doctor for something. R1 stated he does not know what medications he takes because he takes a hand full of them. R1 stated that he does not have pain and doesn't ask for any pain medication. On [DATE] at 10:00 A.M., V6 (Registered Nurse) stated she never gives R1 any pain medication. V6 stated that R1 never complains of pain and never appears to be in pain. V6 stated that she thought the order for R1's narcotic was discontinued after a hospital visit. V6 then checked the EMAR (Electronic Medication Administration Record) and noted that R1 has an order. V6 stated that she assumes that the medication was destroyed and is not sure where it is. On [DATE] at 10:07 A.M., V2 (Director of Nursing) stated she was off with COVID from [DATE]-[DATE]. V2 stated that V17 sent her a message on [DATE] about the narcotic sheet of R1 because V16 found it folded up under supplies in the bottom of the medication cart. V2 stated that when she returned on [DATE] she was working on investigating the diversion and the medication error. V2 stated that she had kind of forgot about it because she was so sick when she had COVID. V2 stated that she found the narc sheet yesterday in her office and it jogged her memory about it. V2 stated that it was reported to police, physician, POA (Power of Attorney) and IDPH (Illinois Department of Public Health) yesterday. V2 stated that when a card is empty the name sticker should be removed, and the card thrown away. V2 stated the narcotic count sheet is then placed in her mailbox for review and to store. V2 stated that she thought she had the Controlled Drug Administration Record for August, and she cannot find it. She thought it was on her desk in a red folder, but she cannot find it now. V2 stated that she keeps all the count sheets in her office in boxes but cannot find the ones for R1. V2 stated that V1 was starting the investigation and the facility had put different methods in place of counting to ensure nothing is being missed. V2 stated that the facility will now count the sheets, the cards and the medication to ensure the accuracy of all controlled substances. On [DATE] at 10:40 A.M., V1 (Administrator) stated he was notified on [DATE] that there could be a potential drug diversion. V1 stated that once her and V2 arrived to work on [DATE], they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found, they knew they had a big issue and reported it. On [DATE] at 9:45 A.M., V11 (Licensed Practical Nurse) stated that R1 is occasionally in pain due to having a toe amputation. V11 stated that he never asks for pain medication, but she will ask him because she knows with R1's diagnosis that he could be in pain. V11 stated she has asked the day shift nurses if they ever give R1 any pain medication and she got told they do not. V11 stated that she knows she has given the medication to R1, but she must not sign that it has been given on the MAR. V11 stated that there was a card in the narcotic box, and she wasn't sure the last time that she saw it. V11 stated that she could recall there were pills remaining on the far right of the card. V11 stated that she always does the narcotic count with the off going nurse. V11 stated the policy was to only count the number of pills, not the actual number of cards. V11 stated that she could have received narcotics from the pharmacy for R1 in the past but has not recently. V11 stated that when she receives narcotics, she counts them and puts them in the narcotic box. V11 stated the pharmacy deliveries usually come around 7:00 P.M. - 11:00 P.M. V11 stated that occasionally the pharmacy will deliver medications around 6:00 A.M., but it is usually in the evening / nighttime. V11 stated again that she is bad about signing off medications in the MAR but verifies times on the narcotic sheet to make sure it is not too soon. On [DATE] at 9:56 A.M., V12 (Licensed Practical Nurse) stated she works PRN (as needed) in the facility and has only worked three days since September being [DATE], [DATE], and [DATE]. V12 stated that the procedure for checking in narcotics, is the pharmacy will deliver, typically on night shift, and the nurse will verify the count is right and sign the delivery sheet and give it back to the pharmacist. Once it is checked in, V12 stated the narcotic sheet goes in the book and the card with the medicine goes in the locked narcotic box. V12 stated that when she gives as needed medications, she will sign the narcotic count sheet and the MAR that the medication was given. V12 stated that R1 has never complained of pain to her and she has never given R1 any as needed pain medication. On [DATE] at 10:26 A.M., V13 (Licensed Practical Nurse) stated she can't remember ever giving R1 and as needed pain medications. V13 stated she only works one day a week on Wednesday nights but had been off for vacation. Prior to working [DATE], V13 stated the last time she worked prior to that was [DATE]. V13 stated that she can't remember there being a card with medication on it for R1 at that time or not. V13 stated that when she gives as needed medications, she knows to sign out the MAR and the narcotic count sheet. V13 stated that typically if she receives a pharmacy delivery it is around 10 P.M. at night. V13 doesn't remember the last time that there was a delivery of narcotics for R1. V13 stated that she has been educated on the new way of signing in narcs and counting the cards not just the pills. On [DATE] at 11:31 A.M., V14 (Licensed Practical Nurse / Business Office Manager) stated that she will occasionally work the floor when there is a call in. V14 stated that she has worked partial shifts twice in the last couple weeks. V14 stated she has never given R1 any pain medications. V14 stated that R1 has never asked her or complained about pain when she was working. V14 stated that she always does the narcotic count but does not remember when R1 had narcotics in the drawer last. V14 stated that when she does give as needed medications, she will document it on the MAR and on the narcotic sheet. On [DATE] at 11:38 P.M., V15 (Licensed Practical Nurse) stated she is a full-time night shift nurse for the facility. V15 stated that she has never given R1 any as needed pain medication. V15 stated she does narcotic counts prior to starting her shift. V15 stated she has never known a count to be wrong. V15 stated she never realized that the card was missing for R1. V15 stated that she does remember there being narcotics in the locked box for R1 but is unsure when the last time they were there. V15 stated that she never counted the cards, she would just always count the pills. On [DATE] at 11:54 A.M. V17 (Licensed Practical Nurse) stated she was working her shift on [DATE]. It was after midnight, and she started cleaning the medication cart. It was about 12:20 am on [DATE] that she was cleaning the bottom drawer and noted R1's pink narcotic sheet folded and under some dividers. V17 stated that she then took a picture and notified V2. V17 stated that V2 asked her to verify if the order was still active in the computer and to see if there was a card in the narcotic box. V17 stated that she checked, and the order was active in the computer for R1. V17 then stated she checked the narcotic box and there was not a card for R1's Hydrocodone. V17 stated that she then placed the narcotic sheet in V2's box for review. V17 stated she has given R1 pain medication before, but it has been several months. V17 stated that she left for vacation on [DATE] and the card was in the narcotic box then. V17 stated that she was not good about charting on the MAR when she did give R1 pain medication, but she would always document it on the narcotic count sheet. A Final Incident Report received by IDPH dated [DATE] documented Based on the results of the investigation, the facility has found no evidence to support abuse. The facility has determined the 22 Norco were probably accidentally thrown away due to disorganization and lack of attention. The facility has determined V11 administered Norco to R1 on ,d+[DATE] and after that administration, the card was accidentally thrown in the trash. Ms. V18 supports this by confirming she didn't count the Norco on [DATE]. The facility has contacted pharmacy and instructed pharmacy to bill the facility for any unaccounted-for Norco. The facility has conducted an Ad Hoc QA meeting related to counting narcotic and narcotic management. All licensed staff were in-serviced on counting cards, count sheets and pills with appropriate sign off. DON or designee will conduct audits 3 times per week for 4 weeks to ensure compliance. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of [DATE] documented , The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation .This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and secure environment. Under the section titled Definitions it documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property within the required time frames for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. The Findings Include: R1's Admission Record documented an admitted to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's Order Summary Report with a print date of [DATE] documented an order for Hydrocodone ,d+[DATE] mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of [DATE]. A Progress Note dated [DATE], timed 12:54 P.M., authored by V3 (Registered Nurse) documented, Upon doing narc (narcotic) count with V11 (Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed R1's slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. I spoke with pharmacy regarding this medication, and they stated that they have not received any new orders, and previous order was last filled in August. DON was notified as well. On [DATE] at 8:39 A.M. V3 (Registered Nurse) stated that on [DATE] she was completing the narcotic count. V3 said she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON box and did not find any sheets for R1's narcotic. V3 stated that she called V1(Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift, she thought there was some in there but cannot remember 100 percent. V3 said that V1 instructed her to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. V3 stated she called the pharmacy, and the pharmacy told her that the script expired the end of October and there was not a new one on file to fill. On [DATE] at 10:07 A.M. V2 (Director of Nursing) stated she was off during COVID from [DATE]-[DATE]. V2 stated V16 sent her a message on [DATE] about the narcotic sheet of R1 because V16 found it folded up under supplies in the bottom of the medication cart. V2 stated that when she returned on [DATE] she was working on investigating the diversion and the medication error. V2 stated that she had kind of forgot about it because she was so sick when she had COVID. V2 stated that she found the narc sheet yesterday in her office and it jogged her memory about it. V2 stated that it was reported to police, physician, POA (Power of Attorney) and IDPH (Illinois Department of Public Health) yesterday ([DATE]). V2 stated that V1 was starting the investigation and the facility had put different methods in place of counting to ensure nothing is being missed. V2 stated that the facility will now count the sheets, the cards and the medication to ensure the accuracy of all controlled substances. V2 stated she did not notify the admin at that time of a potential diversion. V2 stated that she was off with COVID when she was told by V17 about finding the narcortic slip in the bottom of the drawer. V2 stated V1 was off with COVID at the same time so she did not think there was anyone [NAME] who could do the investigation. V2 stated that once she came back to work on [DATE], she was working on other issues and forogt about the potential diversion. On [DATE] at 10:40 A.M. V1 (Administrator) stated he was notified on [DATE] that there could be a potential drug diversion. V1 stated that once her and V2 arrived to work on [DATE], they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found, they knew they had a big issue and reported it. An IDPH Notification Form documented on [DATE] staff reported an allegation of misappropriation of resident property. Investigation initiated, notification of physician, ombudsman and police done. Follow up will be sent within 5 days. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of [DATE] documented , Employees are required to immediately report any occurrences if potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. , Supervisors shall immediately inform the administrator of all reports of potential / alleged mistreatment. The same policy under the category External Reporting of Potential Abuse documents 1. Initial reporting of Allegations: The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. The report must be made not later than 24 hours after forming the suspicion.

Based on interview and record review, the facility failed to timely initiate an investigate of an allegation of missing controlled substances for 1 of 3 residents (R1) reviewed for misappropriation of property in a sample of 7. Findings Include: R1's Admission Record documented an admitted to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment , documented a Brief Interview for Mental Status Score of 13, indicating that R1 is cognitively intact. R1's Order Summary Report with a print date of 11/22/2024 documented an order for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of 10/29/2024. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on 09/17/2024 by V17 (Licensed Practical Nurse). The same form also documented R1 received Hydrocodone on 11/01/2024 and 11/02/2024 at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. R1's November 2024 MAR (Medication Administration Record) documented no doses of Hydrocodone were given on 11/01/2024 or 11/02/2024. On 11/20/2024 at 8:39 A.M. V3 (Registered Nurse) stated that on 11/16/2024 she was completing the narcotic count. V3 said that she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON (Director of Nursing) box and did not find any sheets for R1's narcotic. V3 stated that she called V1 (Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift, she thought there was some in there but cannot remember 100 percent. V1 instructed V3 to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. On 11/22/2024 at 9:55 A.M. V2 (Director of Nursing) stated that she was notified by V17 (Licensed Practical Nurse) on 11/12/2024 at 12:20 A.M. via text message that she found a narcotic sheet for R1 folded in the bottom of the medication cart under supplies. V2 stated she did not start investigating until she found the narcotic sheet on her desk 11/20/2024. V2 stated she was out with COVID which is why she did not immediately investigate it. On 11/21/2024 at 10:40 A.M. V1 (Administrator) stated he was notified on 11/16/2024 that there could be a potential drug diversion. V1 stated that once he and V2 arrived to work on 11/18/2024, they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found on 11/20/2024, they knew they had a big issue and reported it. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of 11/28/2016 documented, Supervisors shall immediately inform the administrator of all reports of potential / alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation.

Based on interview, observation, and record review the facility failed to account for, maintain records of, and document the administration of controlled substances for two (R1 and R3) of three residents reviewed for pharmacy services in the sample of 7. Findings Include: 1. R1's Admission Record documented an admitted to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. R1's Order Summary Report with a print date of 11/22/2024 documented an order dated 10/29/2024 for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on 09/17/2024. The same form also documented R1 received Hydrocodone on 11/01/2024 and 11/02/2024 at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. On 11/27/2024 V1 and V2 stated they were unable to produce the Controlled Drug Administration Record for the deliveries of Hydrocodone that were delivered on 08/06/2024, 08/14/2024, and 09/02/2024. R1's November 2024 MAR (Medication Administration Record) documented no doses of Hydrocodone were given on 11/01/2024 or 11/02/2024. R1's Progress Note dated 11/16/2024, timed 12:54 P.M., authored by V3 (Registered Nurse) documented, Upon doing narc (narcotic) count with (V11 Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed (R1's) slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. DON (V2) was notified as well. A pharmacy delivery slip dated 08/06/2024 documented R1 had 5 Hydrocodone delivered to the facility and signed by V18 (Licensed Practical Nurse) at 11:39 P.M. A pharmacy delivery slip dated 08/14/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V4 (Registered Nurse) at 11:43 A.M. A pharmacy delivery slip dated 09/02/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 8:13 P.M. A pharmacy delivery slip dated 09/17/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 11:16 P.M. On 11/20/2024 at 10:05 A.M. narcotic count was completed with V4 (Registered Nurse). There were not narcotics in the narcotic box for R1 and there were no count sheets in the narcotic book for R1. On 11/20/2024 at 12:00 P.M., V4 (Registered Nurse) stated that there is an order for R1 to have Hydrocodone but she never gives him any. V4 verified that there were no narcotics in the lock box for R1 and that there was no count sheet. V4 kept repeating she is unsure if R1 had any because she never gives him any. V4 did not recall the last time that there were narcotics in the locked box for R1. On 11/21/2024 at 10:00 A.M., V6 (Registered Nurse) stated she never gives R1 any pain medication. V6 stated that R1 never complains of pain and never appears to be in pain. V6 stated that she thought the order for R1's narcotic was discontinued after a hospital visit. V6 then checked the EMAR (Electronic Medication Administration Record) and noted that R1 has an order. V6 stated that she assumes that the medication was destroyed and is not sure where it is. On 11/22/2024 at 9:45 A.M., V11 (Licensed Practical Nurse) stated that R1 is occasionally in pain due to having a toe amputation. V11 stated that he never asks for pain medication, but she will ask him because she knows with R1's diagnosis that he could be in pain. V11 stated she has asked the day shift nurses if they ever give R1 any pain medication and she got told they do not. V11 stated that she knows she has given the medication to R1, but she must not sign that it has been given on the MAR. V11 stated that there was a card in the narcotic box, and she wasn't sure the last time that she saw it. V11 stated that she could recall there were pills remaining on the far right of the card. V11 stated that she always does the narcotic count with the off going nurse. V11 stated the policy was to only count the number of pills, not the actual number of cards. V11 stated that she could have received narcotics from the pharmacy for R1 in the past but has not recently. V11 stated that when she receives narcotics, she counts them and puts them in the narcotic box. V11 stated the pharmacy deliveries usually come around 7:00 P.M. - 11:00 P.M. V11 stated that occasionally the pharmacy will deliver medications around 6:00 A.M., but it is usually in the evening / nighttime. V11 stated again that she is bad about signing off medications in the MAR but verifies times on the narcotic sheet to make sure it is not too soon. On 11/22/2024 at 11:38 P.M., V15 (Licensed Practical Nurse) stated she is a full-time night shift nurse for the facility. V15 stated that she has never given R1 any as needed pain medication. V15 stated she does narcotic counts prior to starting her shift. V15 stated she has never known a count to be wrong. V15 stated she never realized that the card was missing for R1. V15 stated that she does remember there being narcotics in the locked box for R1 but is unsure when the last time they were there. V15 stated that she never counted the cards, she would just always count the pills. On 11/21/2024 at 10:07 A.M., V2 (Director of Nursing) stated it is her expectation for all nursing staff to count the narcotic box each shift with the off going nurse to ensure that the narcotic count for all residents are accurate. V2 stated that it is her expectation for licensed staff to not take, discard, or misuse the narcotics in the narcotic box. V2 stated that all staff should count the narcotics with the other nurse to make sure the counts are accurate. V2 stated that when a card is empty the name sticker should be removed, and the card thrown away. V2 stated the narcotic count sheet is then placed in her office mailbox for review and to store. V2 stated that she thought she had the Controlled Drug Administration Record for August, and she cannot find it. V2 said she thought it was on her desk in a red folder, but she cannot find it now. V2 stated that she keeps all the count sheets in her office in boxes but can not find the ones for R1. 2. R3's Admission Record documented an admitted to the facility of 08/06/2024 with diagnoses including nondisplaced comminuted fracture of shaft of humerus, atherosclerotic heart disease of native coronary artery, diastolic heart failure, essential hypertension, chronic atrial fibrillation, muscle weakness and hypothyroidism. R3's MDS (Minimum Data Set) with an Assessment Reference date of 11/13/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 08, indicating that R3 has moderate cognitive impairment. R3's Order Summary Report with a print date of 11/27/2024 documented an order dated 08/19/2024 for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 6 hours as needed for pain. A pharmacy delivery slip dated 09/02/2024 documented R3 had 30 Hydrocodone delivered to the facility and signed by V18 at 8:13 P.M. On 11/27/2024 at 2:00 P.M., R3 stated she does not take her pain medicine as much as she was. R3 stated that she was taking it more frequently but as her broken bone is healing, she doesn't need it as often. R3 stated that if her pain gets bad, she knows she can ask the nurse and they will get her a pain pill. R3's September MAR (Medication Administration Record) documented on the back, R3 was given Hydrocodone on 09/03/2024 at 09:00 A.M., 09/06/2024 at 07:30 A.M., 09/07/2024 at 09:00 A.M, 09/09/2024 at 7:30 A.M., 09/10/2024 at 07:30 A.M., 09/13/2024 at 12:00 P.M., and 09/13/2024 at 3:30 P.M. On 11/27/2024 at 1:38 PM, a narcotic count was observed and completed by V4 (Registered Nurse). During the narcotic count it there was a card for R3 in the narcotic box with pills on it and there was a narcotic count sheet in the book for R3. On 11/27/2024 at 3:46P.M. V2 stated she cannot find the controlled drug count sheet that matches the delivery slip of 09/02/2024. V2 stated she will continue to look in her office as she knows she has it there. The facility policy titled Storage of Controlled Substances with an effective date of 09/2018 documented, 2. Schedule II through V medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications. 4. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications, including those in emergency supply.5. A. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. 6. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately and/ or in accordance with facility policy. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The Facility policy titled (Name of Company) Storage of Controlled Substances with a revision date of 08/2020 documented 8. Completed accountability sheets are submitted to the Director of Nursing and kept on file for five years at the facility in accordance with facility policy and state regulations. The facility policy titled (Name of Company) Administrations Procedures for All Medications with a revision date of 08/2020 documented under section IV. Administration 7. After administration, return to cart, replace medication container (if multi dose and doses remain), and document the administration in the MAR or TAR (Treatment Administration Record) and the controlled substance sign out record.

Based on interview and record review, the facility failed to ensure chemical products were stored per current standards of practice and failed to ensure person centered fall interventions were implemented after a fall incident for 2 (R15 and R12) of 2 dementia care residents reviewed for accidents/hazards in the sample of 22. This failure resulted in R15 experiencing nausea and vomiting. Findings Include: 1. R15's Profile Face Sheet documented an Original admitted to the facility as 12/31/22. This form also documented R15 as being a [AGE] year old female. R15's Cumulative Diagnosis Log documented a diagnosis of Early onset Alzheimer's Dementia with Behavioral Disturbance. A Nurses Note dated 1/16/24 at 5 PM documented R15 was observed in her room with a bottle of (Odor Eliminator) in hand and large emesis on the floor. No signs of distress were noted and vital signs are documented as being stable. 30% of the liquid in the bottle is documented as remaining. V5 is documented as being contacted with orders to monitor R15's Vital Signs every 4 hours x 3, push fluids and send to the emergency room if any change in status is noted. On 05/01/24 at 11:40 AM, V2 (Director of Nursing) stated that she was working at the time R15 ingested (Odor Eliminator). V2 stated that R15 couldn't have drank much of the product, because it was a small trial size bottle that had been left in her bedside table, she assumes for staff convenience as R15 had been experiencing loose stools. V2 stated immediately V5 (Medical Director) and the Poison Control Center were contacted. R15 experienced a large emesis following injection of the product with no further concerns noted. V5 had ordered for Vital Signs to be monitored for 3 days and send to the emergency room for evaluation and treatment should R15 experience any change in condition. V2 stated R15 experienced no ongoing ill effects from the consumption of the product and fluids were encouraged to help do a system flush. V2 stated all resident rooms and areas were checked to ensure potentially hazardous liquids were not obtainable by residents. V2 stated the product is no longer used by the facility. V2 confirmed that the product should not have been stored where R15 could obtain and consume it. R15's Minimum Data Set (MDS) with an Assessment Reference Date of 9/6/23 documented in Section C0500 a Brief Interview for Mental Status (BIMS) score of 99 indicating R15 was unable to complete the interview. Section C1000, Cognitive Skills for Daily Decision Making documented a score of 3, indicating Severely Impaired - never/rarely made decisions. R15's Current Plan of Care documented a Problem/Need area with a stated date of 6/6/23 for having Risk factors that require monitoring and intervention to reduce potential for self injury. (Consider medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medications, restrictions, restraints) Approach/Interventions listed for this area include, Review quarterly and prn (as needed) Resident's ADL *activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary Team) review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. A Safety Data Sheet found via https://dermarite.com/wp-content/uploads/2015/05/ByeBye-Odor-Rev-03.pdf with a most recent date prepared of 2/2/23, documented the recommended use for (Odor Eliminator) was to use as an air and fabric freshener. The same safety data sheet listed in Section XI - Toxicology Information: ingestion may cause nausea, vomiting, and diarrhea; you should drink water. Skin; flush skin with water. An undated facility policy titled, Hazardous and Toxic Substances stated, .8. Hazardous and toxic substances shall be stored in locked cabinets or in a similar physically separate placed (sic) and used for no other purpose which is not accessible to residents. 2. R12's Profile Face sheet documented R12 as [AGE] years old with an admitted to the facility of 05/20/2022. Diagnoses listed on Cumulative Diagnosis Log include Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia. R12's Nurse Note dated 03/29/24 with a time of 2:45 PM documented that R12 had a fall in her bathroom. R12 was reminded and encouraged to use call light and wait for assistance before transferring. R12's care plan lists a Category of Falls with a start date of 06/06/2022 and documents R12 has risk factors that require monitoring and intervention to reduce potential for self injury. Risk factors include diagnosis of dementia causing episodes of forgetfulness and unawareness of safety limitations at times. The Goal documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. Interventions listed, all with start dates of 06/06/2022 include: Review quarterly and prn (as needed) Resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary Team) review of changes and needs w/ (with) Resident and/or Responsible Party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Review quarterly and as needed during daily care and services of Resident's plan for safety, giving verbal cues as needed to gain Resident participation in minimizing risk factors and injury. IDT review of function and referral to PT (Physical Therapy) as needed for change in function, and IDT review of function and referral to OT (Occupational Therapy) as needed for change in function. R12's care plan does not include information regarding the fall that occurred on 3/29/2024, nor were any updated, person centered fall interventions added after the fall incident. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated she was rushing trying to complete the care plans and must have forgotten to finish them. On 05/01/24 at 03:05 PM, V6 stated that the most up to date care plan was in R12's chart. V6 stated if there were interventions they would be documented on the page under the specific section on the care plan. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being a. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team).

Based on interview and record review the facility failed to ensure a resident's wheelchair had foot rests in place when transporting a resident for 1 (R1) of 3 residents reviewed for accidents in a sample of 3. This failure resulted in R1 falling forward out of the wheelchair, sustaining a head laceration requiring R1 to be transferred to the hospital, and receiving sutures to close the wound. This past noncompliance occurred from 11/18/23 to 11/20/23. Findings include: 1. R1's face sheet documented an admitted [DATE]. R1's Cumulative Diagnosis Log documented diagnoses including: anemia, osteoarthritis, basal cell carcinoma of lower lip, history of falls, obesity, Parkinson's disease, history of stroke, dementia, intraventricular hemorrhage. R1's 11/18/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. R1's 11/18/23 MDS documented R1 used a wheelchair with supervision and touching assistance. R1's 11/17/23 Activities of Daily Living (ADL) Plan of Care documented identified safety risks of: poor safety awareness, fall history, gait, and balance. R1's 11/15/23 Physical Therapy Plan of Care documented in part .being referred to skilled therapy due to recent hospitalization with diagnosis of intraventricular hemorrhage with significant decline in mobility. Patient is requiring increased time and cueing due to difficulty following commands . due to weakness continues to require extensive assistance . On 12/7/23 at 11:26 AM, V3 (Certified Nursing Assistant/ CNA) said on 11/18/23 R1 was sitting in his wheelchair ambulating around the dining room. V3 said R1 was starting to get fidgety, and she was going to assist R1 to the nurse's station. V3 said she was pushing R1 down the hall in his wheelchair with no foot pedals present when R1 put his feet down and fell forward out of his wheelchair onto the floor. V3 said R1 was wearing a new pair of house shoes that had a good amount of grip. V3 said she called for a nurse to assess R1. V3 said R1 had a laceration to his forehead and was sent to the hospital. V3 said 11/18/23 was the first time she had cared for R1 and was not familiar with his needs. V3 said R1 was hard to understand and was not sure R1 could follow commands. On 12/7/23 at 12:40 PM, V10 (Registered Nurse/ RN) said on 11/18/23 she was standing at the nurse's station giving change of shift report when she heard a commotion in the hall. V10 said she found R1 to be lying in the floor in the hallway. V10 said she assessed R1 and found a laceration to R1's forehead. V10 said R1's forehead laceration was bleeding so she cleaned it with a washcloth and applied pressure. V10 said Emergency Medical Services (EMS) were called and R1 was transported to the hospital. V10 said if a resident does not propel themselves in the wheelchair they should have foot pedals on the wheelchair. V10 said R1 was propelling himself around the facility earlier in the day and was seen abruptly stopping his wheelchair with his feet and grabbing the hand rails. On 12/7/23 at 11:37 AM, V4 (Physical Therapy Assistant) said she had evaluated R1. V4 said R1 was able to propel himself in his wheelchair. V4 said R1 sometimes was able to follow commands. V4 said if a resident was able to propel themselves, she would expect staff to remove the foot pedals from the wheelchair. V4 said if staff were propelling a resident she expected the foot pedals to be on the wheelchair. On 12/7/23 at 1:42 PM, V2 (Director of Nursing/ DON) said she had completed the investigation for R1's 11/18/23 fall. V2 said R1 was in the dining room blocking the exit and other residents were trying to get by. V2 said V3 (CNA) was assisting R1 out of the exit when R1 slammed his feet down and fell forward out of his wheelchair. V2 said she had reeducated all staff foot pedals were to be on the wheelchair with the resident's feet on the foot pedals if they are being propelled by staff. V2 said if R1 had foot pedals on his wheelchair on 11/18/23 the fall may not have happened. On 12/7/23 at 1:15 PM, V9 (Licensed Practical Nurse/ LPN) said she had cared for R1 once. V9 said R1 was oriented to self only and was not able to follow directions. R1's 11/18/23 at 6:00 PM Skilled Progress Note documented in part .Resident being assisted by CNA (V3) down the hall to the nurses station. Resident abruptly put his feet down which caused him to be propelled forward. Resident landed on the floor. Laceration above (left) eyebrow . Wash cloth administered to slow bleeding . 911 called . resident bound for (hospital) . R1's 11/18/23 at 10:30 PM Skilled Progress Note documented in part . Brain bleed found via CT (Computerized Tomography) scan. Resident being flown to a larger hospital . R1's 11/18/23 hospital record Physician Documentation documented in part . reports injury, a laceration, 5 cm (s), complex irregular, ragged, left eyebrow and left eyelid, pain, swelling, tenderness Resulted from a fall . impacting a hard surface . Pertinent positives: headache, injury. Severity of symptoms: At their worst the symptoms were severe, just prior to arrival . Wound Repair of 5cm (2.0 inch) subcutaneous laceration to left upper eyelid and left supraordital ridge. Profuse bleeding noted . Skin closed with 12 4-0 Ethilon using Simple sutures . (CT scan of head without contrast) . Impression: Small amount of interventricular hemorrhage (IVH). Recommend clinical correlation follow-up as clinically warranted .Diagnosis: Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness . laceration without foreign body of left eyelid and periocular area . R1 was then transferred to another hospital for a higher level of care. R1's 11/19/23 Neurosurgery Consult documented in part . recent admission to (hospital) 11/7/23 - 11/14/23 with (Intraventricular Hemorrhage) who presented to the hospital after sustaining a fall . The patient was seen in consultation . during his recent admission. Findings were non-surgical and patient was advised to hold his (aspirin) for 7 days . The patient returns to the hospital after sustaining a fall at his nursing home. He has a laceration to his forehead . CT head was completed redemonstrating blood in the right lateral ventricle slightly increased in size, thus the reason for neurosurgical consultation . R1's 11/19/23 History and Physical documented in part . reportedly had a fall at the nursing facility where he resides. He did hit his head . He was previously on (aspirin) and Plavix, but has been on hold for 2-3 days, per report. Trauma evaluation . revealed IVH. He has a laceration to the left forehead, sutured . He was recently admitted to (hospital) after sustaining a fall and found to have IVH. He was evaluated by Neurosurgery, findings were found to be non surgical. He was to hold (aspirin) for 7 days. CT on 11/7/23 with no significant changes and trace amount of layering hemorrhage with the right lateral ventricle persists . On 12/8/23 at 11:04 AM, V6 (Neurosurgery Nurse Practitioner) said she had completed the consult for R1 on 11/19/23 after R1 ' s hospital admission. V6 said it would be very difficult to determine if the worsening of the intraventricular hemorrhage was caused by R1 ' s 11/18/23 fall or the use of blood thinners. R1's 11/18/23 Investigation Report for Falls documented in part . Root Cause Analysis: Resident's feet went under the (wheelchair) and it caused (R1) to fall out when (R1) put feet down suddenly causing chair to abruptly stop . What new intervention was implemented to prevent any further falls? (Wheelchair) to have foot pedals be placed and being utilized (at) all (times) while being propelled in (wheelchair) . The facility's 11/20/23 QAC Progress Notes documented in part . (Interdisciplinary team) discussed (R1) incident (with) significant injury. All documentation reviewed with root cause of fall determined. Care plan reviewed and updated with new interventions. (Administrator) and DON to continue internal investigation . Prior to this survey date, the facility took the following actions to correct the non-compliance: 1. Immediate Corrective Action: All nursing staff were educated by the DON/Director of Nurses that all residents that require a wheelchair and are being transported via facility staff should have wheelchair legs attached to the wheelchair during transport. 2. Systemic Changes to Ensure Compliance: All nursing staff were educated on ensuring that all residents have leg rest prior to facility transport, QAPI meeting was held on 11/20/23. 3. System Maintenance: DON or designee will do random checks daily for 3 week to ensure leg rest was attached prior to transport. 4. Other Residents with the Potential to be Affected: All residents have the potential to be affected by the alleged deficient practice. The facility's Daily Wheelchair Audit Form documented daily checks for footrests from 11/20/23 through 12/7/23.

Based on observation, interview, and record review the facility failed to 1. Isolate residents displaying symptoms of Covid-19 until a negative test result was obtained. 2. Implement contact and droplet isolation precautions for residents displaying signs and symptoms of Covid-19. 3. Conduct a Covid-19 screening on surveyors entering the facility. These failures have the potential to affect all residents residing in the facility and resulted in R2 contracting Covid-19, experiencing ill effects with evaluation and treatment sought at the local hospital for medication infusion. Findings Include: 1. On 10/5/21 at 8:39 AM, V2 (Director of Nursing) states the current facility census is 26. V2 states that the facility has 3 (R1, R2, R3) current resident Covid-19 cases. V2 states all 3 cases have had a hospital admission or received hospital treatment. V2 states that the facility has 2 (R4, R5) residents residing in the facility who are not vaccinated for Covid-19. V2 states that the facility has no other residents on isolation precautions for any reason other than R1, R2, and R3 who are on precautions for Covid-19. Review of the policy titled, Facility Testing of Staff and Residents dated 9/14/20 documents, Testing of Residents with Covid-19 Symptoms .3. Residents with symptoms must be placed on TBP (transmission based precautions) until the test results are received. Review of an undated article titled Transmission published by the CDC and found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Transmission states that, based on existing literature, the incubation period of [CONDITION(S)]-CoV2 and other coronaviruses ranges from 2-14 days. On 10/5/21 at 8:39 AM, V2 states the facility recently experienced the start of their current outbreak when a staff member V6 (Certified Nurse Assistant, CNA) tested positive for Covid-19. V2 states at the time she tested positive, the facility was being tested weekly and wearing surgical masks as personal protective equipment (PPE). V2 states V6 had tested negative during her routine test that week, and the next day became ill while at work (9/17/21). A rapid test was then conducted at that time with a positive result. V2 states V6 was immediately sent home. V2 states after V6 tested positive, the facility implemented N95 grade masks, eye protection, and twice a week testing for staff and residents. V2 states staff receive rapid testing for Covid-19 and resident tests are sent to a lab. V2 states R1 began displaying respiratory symptoms during the evening on 9/23/21 with V5 (Physician) coming to the facility to examine her on 9/24/21. V2 states V5 prescribed antibiotics, treating her for [CONDITION(S)]. V2 states R2, who had no concerning symptoms, remained in the same room as R1 during the time she was displaying respiratory symptoms, due to not having a positive Covid-19 test on either resident at that time. V2 states their last test results were negative, and the most recent collection results which were obtained on 9/23/21 were not yet available. V2 states after later receiving R1's positive Covid-19 results on 9/26/21, R1 was immediately removed from the room with R2. V2 states R2 was not put on any special quarantine precautions or again tested for Covid-19 because her test for Covid-19 collected 9/23/21 had come back negative. V2 states standard precautions were used, as with any resident. V2 states she was notified by facility staff on 9/29/21 that V4 (Family Member) had called the facility upset. V2 states V4 expressed R2 had been left in the room with R1 while ill, and V4 had called an ambulance to have R2 evaluated at the hospital as R2 had reported to her that she wasn't feeling well. V2 states R2 was transported to the local hospital where she tested positive for Covid-19, received an infusion for Covid treatment, then returned to the facility. On 10/1/21 at 9:15 AM, V3 (Registered Nurse) acknowledges R1 had been displaying a new onset cough which initiated the referral for her to be seen by V5 (Physician) resulting in antibiotics being ordered. Review of the document titled (Facility) Resident Infection Control and Antimicrobial Log dated September 2021 documents on 9/24/21, R1 s documented under the column Infection Related Dx (diagnosis), Resp. (Respiratory). Under the column Isolated Yes/No, No is indicated. Laboratory reports both having a collection date of 9/23/21 document results being reported on 9/26/21, with R1 testing positive and R2 testing negative for Covid-19. On 10/1/21 at 8:40 AM, V4 (Family Member) states she frequently speaks with R2 and visits when allowed. V4 states R2 had reported that her roommate (R1's name) was sick. V4 states R2 reported to her that R1 had been sick, kept getting worse, coughing more and more. V4 states 3 days later she believes when tested , R1 tested positive for Covid-19 and then was removed from the room with R2. V4 states a short time later, R2 reported to her that she was she was feeling ill. V4 states she called an ambulance to take R2 to the hospital for evaluation because she was worried about her having a positive Covid-19 result. V4 states R2 was then tested , and determined to also be positive. V4 states R2 was given an infusion in the hospital, then transported back to the facility where she is residing on the Covid unit. R2's Nurse's Notes dated 9/29/21 at 7:05 AM documents, Daughter called requested resident be sent to (local hospital) for eval related to being roommate of positive Covid 19 resident. Vital signs are documented as being within normal limits. Additional notes made on the same document dated 9/29/21 at 7:15 AM state, Ambulance here to transport to (local hospital). A Patient Report from the local hospital documents Covid-19 test results as being positive for R2 when tested at the hospital on 9/29/21. Review of R2's Hospital Records note on the Physician Documentation dated 9/29/21 at 8:46 AM documents R2's Roommate has Covid and was admitted to hospital September 27th for Covid. Pt (Patient) symptoms started Tuesday September 28th with fever, chills, cough, and body aches. Additional review of Nurses Notes in the Hospital Records documents on 9/29/21 at 1:07 PM, R2 was given an infusion of BAM (bamlanivimab and etesevibab) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/1/21 at 1:55 PM, R2 is observed within the Covid-19 unit. R2 is lying in bed, and when asked how she is doing, states grouchy and irritated. R2 is observed as having an I-pad set up on her bed side table. R2 states she doesn't feel well as she has tested positive for Covid-19. R2 states she is congested, has a cough, no taste, and just feels bad. R2 states her daughter is upset that she contracted Covid-19 after being left in the same room as her roommate who was sick, later testing positive for Covid-19. R2 states her daughter insisted she be sent to the hospital as she began not feeling well after the facility learned of her roommate's positive status. R2 states she felt horrible for her roommate, R1, as they are friends and R1 just kept getting more and more sick. R2 states R1 kept her up some during the night with her horrible coughing spells. When asked if she was satisfied with the care she received by staff R2 states, it could be better. When asked what they could do better, R1 returns to the conversation regarding being left in a room with her ill roommate and now is sick herself. R2 appears weak lying in bed as she does not lift her head off the pillow during this conversation. Resident states she is thankful for technology as she frequently speaks with her daughter on the I-Pad. R2 is alert and oriented to person, place, and time. On 10/1/21 at 2:00 PM, R1 was observed lying in bed within the Covid-19 unit. R1 states she just returned to the facility today from the hospital and states she does not feel well, but a little better than she had and hopes she is on the road to recovery. R1 appears pale, very soft spoken, and drowsy as she closes her eyes when not being spoken to. R1 states she cannot recall if she began displaying symptoms of illness the day the physician saw her, or prior to that. R1 states she did continue to get worse though after seeing the physician. R1 states she was being given medicine that staff told her would help her feel better but didn't. R1 acknowledges she has had coughing throughout the duration of her illness and feels overall poorly. R1 is alert and oriented to person, place, and time. Review of R1's Clinical Record documents the following non titled note completed by V5 (Physician), dated 9/24/21 which states the resident's Chief Complaint is nausea, diarrhea, dry cough, drainage and would like an allergy pill daily. Resident vital signs documented on this form note that R1 at this time had a 99.9 degree Fahrenheit temperature. The Assessment is listed as [CONDITION(S)] with orders for [MEDICATION(S)] 1 gram intramuscular now, Z-pack by mouth x1, defer labs & chest x-ray at this time. Continued review of R1's Clinical Record documents a note made on 9/25/21 at 1:30 PM, which states R1 was reporting feeling a little better but continued to have a productive cough. An entry dated 9/27/21 at 4:35 AM documents that isolation precautions are maintained related to Covid positivity. No notation acknowledging the positive Covid result or actions then implemented at the time of receiving the positive result are noted. An entry dated 9/27/21 at 8:00 AM, documents R1's oxygen level is 89% on room air. Oxygen was applied per nasal canula at 2 liters, appetite poor, pale, and R1 reporting she doesn't feel well. The next entry is made 9/27/21 10:30 AM, which states a new order was received to send R1 to the local hospital emergency room for evaluation and treatment. Review of R1's Hospital Records notes on the Discharge Summary R1 was admitted to the hospital on 9/27/21 and discharged back to the facility on [DATE]. R1's Admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The same form documents while in the hospital, R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the same records documents on Physician Notes dated 9/27/21 at 3:54 PM, that R1 presents with shortness of breath at rest, with symptoms being steady and getting worse. It is documented R1's shortness of breath is aggravated by nothing and is alleviated by the application of supplemental oxygen. On 10/5/21 at 11:25 AM, V5 states he is the medical director at the facility. V5 states that he was notified by the facility that R1 was not feeling well and having respiratory symptoms. V5 states he was under the impression for R1 that the Covid-19 test performed 9/23/21 was a rapid test that was negative. V5 states he was not aware when seeing R1 on 9/24/21 that the results from the 9/23/21 test were pending at that time. V5 states he would expect R1 to have been isolated per current standards of practice for Covid-19 precautions until a negative test result received. R2's Clinical Record documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Clinical Record documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the policy titled, (Facility) Covid-19 Control Measures with a revision date of 4/20/21 documents, Contact Precautions- Post signage on door, 1. Implement when a resident is suspected of having any fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell. Review of this same policy also documents, Droplet Precautions- Post Signage on door, 1. Implement when a resident is suspected of having any fever, respiratory illness, sore throat, nausea, vomiting, extreme fatigue, muscle pains, loss of taste/smell. The same policy goes on to state under section Monitoring and Surveillance- Residents, .2. Initiate Contact and Droplet Precautions for residents with respiratory symptoms, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell, regardless of vaccination status. Review of the policy titled, (Facility) Covid-19 Control Measures with a revision date of 4/30/21 states, .6. If residents are cared for by a HCP (health care professional) with known Covid-19 or suspected of having Covid-19, regardless of vaccination status, these residents should be quarantined and be cared for by using all recommended Covid-19 PPE for a period of 14 days after the last known exposure. In an article published by the Illinois Department of Public Health, titled, Updated Interim Guidance for Nursing Home and Other Long-Term Care Facilities Incorporating New Masking Requirement last updated 8/6/21 states, When the positive case is identified in a staff member that rotates on multiple units, facilities must determine which units are affected based upon the infectious period: 48 hours prior to the positive test and whether an exposure occurred (15 min. cumulative exposure in 24 hours). Review of an article published by the Centers for Medicare and Medicaid services, revised 9/10/21 with the subject listed as, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements states the term close contact is defined as, someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. On 10/5/21 at 2:10 PM, V2 acknowledges resident beds are less than 6 feet apart. On 10/5/32 at 8:39 AM, V2 states that the facility entered outbreak status on 9/17/21 when V6 (CNA) became ill during her shift. V2 states that a rapid test was performed on V6, with positive results. V2 states at that time the facility was utilizing surgical masks as personal protective equipment for Covid-19 prevention. V2 states no additional precautions were implemented for Covid-19 infection control after V6 tested positive, standard precautions remained. V2 states the facility has red and green units implemented for positive and negative Covid residents as instructed by corporate. Due to a lack of space no yellow unit/rooms for precautionary Covid-19 isolative measures are in place. On 10/5/21 at 11:10 AM, V1 (Administrator) states that V6, who tested positive for Covid-19, worked all throughout the building and was not assigned to a specific area. V1 states the facility is smaller, so staff work everywhere. Review of lab results documents that specimens collected on 9/23/21 with results reported to the facility on [DATE] determined R1 and R3 were positive for Covid-19. On 10/5/21 at 8:36 AM, V2 states that R1 and R2 had been roommates prior to R1 testing positive for Covid-19. V2 states that R1 began displaying respiratory symptoms on 9/23/21, also having a routine specimen collection for Covid-19 obtained that day. It was not until 9/26/21 that the results of that specimen were reported as being positive, in which at that time R2 was removed from the room and placed in isolation. V2 states that R2 was not placed in any sort of Covid-19 isolation precaution as her test, also collected on 9/23/21 had come back negative. V2 states although R2 had been residing within close contact of R1, no isolation measures were implemented as a precautionary measure for R1. 3. Review of the facility policy titled (Facility) Covid-19 Control Measures revised 4/30/21 under section Monitoring and Surveillance- Employees, .2. Screen all essential consultants, contracted staff upon entrance to the facility. If the facility is in outbreak status, consultants and contracted staff must also be screened every 4 hours. If any are identified as being ill, ask them to return home and contact their employer and primary physician. On 10/1/21 at 8:25 AM, 10/5/21 at 8:16 AM, 10/6/21 at 8:45 AM surveyor 1 was let into the locked front door of the facility by ringing the doorbell, with it being answered by V9 (Housekeeping). No screening process for Covid-19 was conducted. On 10/5/21 at 9:45 AM, 10/6/21 at 10:00 AM surveyor 2 was let into the locked front door of the facility by ringing the doorbell, with it being answered by V1. No screening process for Covid-19 was conducted. On 10/6/21 at 12:00 PM, V1 states that surveyors have not been screened during this survey as he states he was previously instructed that surveyors do not get screened. A resident Matrix provided by the facility on 10/5/21 documents the facility census as being 26.