Every finding on record at Coulterville Rehab & HCC

Based on interview, observation, and record review, the facility failed to transfer with safety devices for 1 out of 10 residents (R5); reviewed for accident hazards/supervision/devices in a sample of 10.Findings include:R5's Facesheet with a print date of 7/16/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, encounter for other specified aftercare, hypothyroidism, abdominal aortic aneurysm, gastrointestinal hemorrhage, and heart failure.R5's Care Plan dated 7/3/26 documented she was at risk for falls and had an activity of daily living self-care performance deficit requiring staff participation with transfers.Fall Risk assessment dated [DATE] documented R5 was unable to independently come to a standing position, requires hands-on assistance to move from place to place and uses an assistive device. R5's assessment also documented that she had fallen in the last 90 days and was a score of 27 making her a high fall risk. On 7/15/26 at 11:28 AM, R5 stated she wanted to get in bed as she wheeled down the hallway and was requesting help. V5 (Housekeeping) stated she thinks R5 needs assistance to transfer and told R5 to wait for her to get help. V5 went and got V3 Certified Nursing Assistant (CNA) and V4 Licensed Practical Nurse (LPN) to assist R5 back to bed. V3 asked R5 if she needed help standing, or if she is able to do it on her own. V4 stated this was the first time on this hallway and didn't know what R5 needed assistance with. V3 and V4 then had R5 stand up from her wheelchair next to her bed using their hands to support R5 without a gait belt to pivot her to her bed. V4 stated I don't know anything about this lady before leaving the room.On 7/15/26 at 2:15 PM, V1 (Administrator) stated gait belts are to be used unless contraindicated for transfers but does not have a policy on transfers or gait belts.On 7/16/26 at 10:13 AM, V6 (LPN) stated if a resident's transfer status is unknown, they need to verify the status first before transferring and always use a gait belt.On 7/16/26 at 10:20 AM, V8 (LPN) stated transfer status should be verified before transferring a resident and a gait belt used.On 7/16/26 at 10:21 AM, V7 (LPN) stated transfer status should be verified first before transferring a resident and to use a gait belt.7/16/26 at 11:20 AM, V2 Director of Nursing stated she expects staff to verify transfer status orders before transferring any resident and to use a gait belt during transfers.The facility's Skill Fall Policy approved 5/2025 documented each resident residing at the facility receives adequate supervision and assistive devices to prevent accidents. The policy continued to document every resident will be assessed for causal risk factors for falling at the times of admission/readmission.

Based on observation, interview and record review the facility failed to provide supervision to prevent elopement. This failure resulted in R1 leaving the facility without staff knowledge and a family member (V6) observing (R1) in her wheelchair in the parking lot, with active cars coming and going. The family member (V6) brought (R1) back inside the facility. No staff knew how long (R1) was outside, or how far (R1) had gotten or where (R1) had gone.This failure resulted in an Immediate Jeopardy (IJ) which began on 3/21/2026 when R1 was able to get out of the facility unnoticed by staff and found by a family member in the parking lot in her wheelchair. Staff were unaware when R1 got out and or how long she had been outside. On 4/2/2026 at 2:28 PM, V1, Administrator, was notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 4/3/2026 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include:On 4/2/2026 at 9:00 AM, the parking lot is off the main road of the city. The Parking lot has cars pulling in and out as visitors and family members and staff are coming and going all day in and out of the facility.On 4/2/2026 at 10:42 AM, (R1) was in her wheelchair and was attempting to open the doors to exit and was pulling on the doors. (R1) stated repeatedly (five times) she wanted to leave the building. (V23), receptionist, came and redirected her away from the door.On 4/2/2026 at 11:15 AM, (R1) pushed on the doors continuously, and the doors would not open and beeped, but the doors would not open. (R1) stated, I want to go home, I want out of here. V23 then went and redirected her away from the door. R1's Physician Order Sheet (POS) for March, 2026 documents a diagnosis of Alzheimer disease, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, unspecified anxiety disorder; unspecified psychotic disorder with delusions due to known physiological condition, major depression disorder, recurrent severe with psychotic symptoms; unspecified dementia; unspecified severity, with agitation, unspecified dementia, unspecified severity with other behavioral disturbance; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's Minimum Data Set (MDS) dated [DATE] document R1 was severely impaired for cognition for activities of daily living. She uses a wheelchair and needs substantial to maximal assistance for most activities of daily living. R1's MDS also documents that she has an elopement alarm, and it is used daily. R1's Care Plan does not address eloping. R1's Elopement assessment dated [DATE] documents, R1 has a desire to leave the facility, and is exit seeking with a purpose. R1 was identified as an elopement risk by the facility. R1's Progress Notes for 3/21/2026 do not document anything related to her leaving the facility unsupervised. R1's Health Status Notes dated 3/22/2026 at 2:07 PM, Note Text: Resident very tearful this afternoon, exit seeking and looking for her children. This nurse redirected resident x3 with no success. Call placed to daughter, to speak with resident. Daughter unable to soothe resident at this time. Will continue to observe. R1's Health Status Notes dated 2/2/2026 at 7:56 AM, (R1) is often tearful and agitated. (R1) often thinks she is young and that she needs to leave to go take care of her children, so she wants to go outside to the parking lot because she thinks her car is there (sometimes she is satisfied if you tell her someone in her family had to borrow it for work). On 3/24/26 at 6:27 PM, V6, Family member of R3 stated on Saturday March 21 she was here visiting her mother and that (R1) is always sitting by the door crying that she wants out of here and wants to go home. V6 stated that (R1) does not have family that visit to take her out that she knows of, so she knew she should not have been outside alone. V6 stated that with this new alarm on the door she has found that it sometimes doesn't lock after someone passes through the doors. V6 stated that she had taken R3 back to her room and needed to go get some things out of her truck and was going to bring them back in. On 3/21/2026 around 3 PM. (R1) was outside the facility had made it halfway down/around the driveway because it is slightly downhill and she walks well with her feet while in the wheelchair. The parking lot has cars coming and going and she figured that (R1) made it approximately 20 yards, which is basically halfway around the circle drive. (V6) stated that this happened around 3 PM. stated that when she told the nurse (V16) that she found (R1) outside, alone, she replied with 'why was she outside? On 4/2/2026 at 10:39 AM, V16, Licensed Practical Nurse (LPN) stated, the day (R1) got out I was working, but I was down the hall giving treatment. I only learned of it when (V6, Family of R3) told me that (R1) had gotten out and (V6) had to help (R1) get her back inside the building. I did not know anything about it until (V6) told me. I cannot say how long (R1) was outside and/or how (R1) got out. It was crazy that day and we had to send three people out to the hospital and on top of that we had some special music, and people were coming and going. I cannot say I heard any alarms. I know (R1) had an elopement alarm on, but I do not remember it going off and/or hearing any alarms. Again, I was doing treatments, and the door was closed. As soon as I found out I reported it to (V1). (R1) is constantly trying to leave and is exit seeking. (R1) did not sign herself out that day, she is not capable of signing herself out. On 4/2/2026 at 11:00 AM, V22, Pulmonary Nurse/LPN stated, I was working the day (R1) got out of the building. I was up front and I was doing charting that day. They (Facility) had just installed a new alarm system, and I was going up and down assisting with people coming and going out of the doors. I did not see (R1) go out the doors and she does have an elopement alarm, but I do not remember hearing any alarm going off. I cannot tell you how long she was out and/or how far she got or where she went. I could only tell you (V6) brought her back in and I saw her in between the two doors when (V6) was pushing the button trying to bring her back in. We did not even know (R1) had left. I reported it to (V16) and she called (V1). (R1) is not capable of signing herself out. (R1) is very confused. On 4/2/2026 at 12:02 PM, V1, Administrator stated, I was told (R1) got out the front door. (V6) found (R1) in the parking lot and pushed her between the two doors into the vestibule and she was ringing the door alarm for staff to let her in. We believe (R1) followed a family member out the door when he was leaving. We do not have cameras. (R1) did have an elopement alarm on. We cannot say how long (R1) was outside or how far she had gotten. On 4/2/2026 at 1:28 PM, V25, Aide stated, I remember the day (R1) got out it was a Saturday. I was at the nurse's station, and I looked up and I saw (R1) out the first set of doors in between the doors with (V6). To be honest, it was a crazy day, it was super busy, call lights were going off and I just looked up and saw her coming back into the building. I know she has an elopement alarm, but I do not remember any alarm going off and the elopement alarms sound different than the door alarms. We know (R1) was outside alone and we do not know for how long and/or where she was at, only that a family member brought her back inside. On 4/2/2026 at 12:14 PM, V10, Certified Nursing Assistant stated, I was not working the day (R1) got out of the building. She is constantly exit seeking and is always going to the front door trying to get out. I am not sure how she got out and how long she was outside. On 4/2/2026 at 12:11 PM, V24, Medical Director stated, I cannot recall if they facility notified me that (R1) got out of the building without staff knowing it. (R1) is not of sound mind and she has poor safety awareness and poor judgment. It would not be good if (R1) got out of the facility and was unsupervised. She would not know how to watch for cars and/or navigate traffic. On 4/3/2026 at 10:33 AM, V2, Director of Nursing (DON) stated, I was not here when (R1) got out of the facility. When I came in on Monday, they told me (R1) had gotten out, but I was under the impression she was only between the two doors, and she had never gone outside and or family member had found her. I only learned later that a family member found (R1) and brought her back into the facility. The elopement alarm sounds different than the door alarm, but we have just gotten and new alarm systems. I would expect staff to respond to any door alarms immediately and ensure no residents ever got out. If the residents set off the alarm, I would expect staff to go and check and if they do not see any residents, I would expect them to step outside and look. If they find a resident, then they should bring them back inside the building. If they still do not see any residents than I would expect staff to start a head count and see who is missing starting with the residents at risk for elopement. I would expect this to be charted. I guess it was not charted because nobody realized she got out. The Facility Elopement Policy date approved 9/25 documents, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. An elopement is generally characterized as any unplanned departure from a designated safe environment. For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. The Immediate Jeopardy and deficiency practice that began on 3/21/26 was corrected/removed after the facility took the following actions to correct the noncompliance. On 4/2/26 at 5:15pm the Regional Nurse Consultant completed education with the Administrator and Director of Nursing regarding the Elopement Policy and Procedure, door alarm policy with emphasis on not shutting off the alarm until reason has been identified. On 4/2/26 at 4:00pm (V1), Administrator, (V2), DON, (V26), Payroll, (V27), ADON (Assistant Director of Nursing), (V28), BOM (Business Office Manager) initiated education with all staff regarding the Elopement Policy and Procedure, door alarm policy with emphasis on not shutting off the alarm until reason has been identified and was completed 4/3/26. On 4/2/2026 at 5:53pm licensed staff completed a Head-to-Toe assessment of resident R1 noting no changes. V1, Administrator, notified Physician at 3:00pm on 4/2/26 and Responsible party on 4/2/26 at 6:38pm. Ad Hoc QAPI was completed on 4/2/26 at 3pm. The Medical Director was notified of the event. On 4/2/26 at 3:30pm, (V3) SSD (Social Service Director), (V27) ADON, and(V29), Wound Care Nurse (WCN) completed an audit of all residents' risk for elopement to ensure current. On 4/2/26 at 5:30pm V3, SSD reviewed all residents' care plans that are identified at high risk for elopement and are current. Review completed on 4/2/2026 at 6:00pm.On 4/2/2026 at 6:00pm the elopement binder was reviewed by V3 and determined to be current.V1 checked all door alarms on 4/2/26 at 4:30pm to ensure they were functioning properly. No issues were identified. Beginning 4/2/2026 V1 will complete all education for newly hired staff on the Elopement Policy, door alarm policy with emphasis on not shutting off the alarm until reason has been identified. Door alarm function is checked weekly by the maintenance director and will continue indefinitely. Beginning on 4/3/2026 (V1) will complete Elopement drills weekly for 6 weeks, followed with quarterly scheduled drills. Beginning on 4/3/2026 (V3) will conduct 5 random questionnaires for 6 weeks regarding the elopement policy and procedure and timely response to door alarms with emphasis on not shutting off the alarm until reason has been identified. Any areas of concern identified will be addressed immediately and reviewed in the QAPI process.

Based on interview and record review the Facility failed to ensure sexual abuse did not occur for 5 of 5 residents (R4, R5, R6, R7, R9) reviewed for abuse in the sample of 18. Utilizing the reasonable person concept, R4, R6 and R7, who are all cognitively impaired, would not expect to be sexually abused, causing them to feel fear, anxiety, embarrassment and anger.Findings include:R5's Physician Order Sheet (POS) dated March 2026 documents a diagnosis of Chronic atrial fibrillation unspecified, unspecified sexual dysfunction not due to a substance or known physiological condition, unspecified hearing loss, bilateral, and low back pain. R5's Care Plan with a date initiated of 1/9/2021 documents, (R5) has impaired cognitive function/dementia or impaired thought processes. R5 has a behavioral problem. Goal: (R5) will have no incidents related to identified offense through next review. Date Initiated: 09/04/2025 Revision on: 01/07/2026 Target Date: 04/15/2026. Intervention date initiated 3/19/2026: Velcro stop sign across doorway to prevent confused residents from entering room. R5's Minimum Data Set (MDS) dated [DATE] documents R5 was cognitively intact for decision making of activities of daily living.R5's MDS dated [DATE] documents R5 was moderately impaired for cognition for activities of daily living. He has impairments on both sides to his lower extremities and uses a wheelchair. R5 had three episodes where he was touching women underneath their clothing: (1) on 11/30/2024 with (R6); (2) on 1/9/2026 with (R4); and (3) on 3/26/2025 with (R7), for a total of three separate incidents. 1-R6's Physician Order Sheet (POS) dated May 2025 documents a diagnosis of hyperlipidemia, edema, depression, presence of cardia pacemaker, urinary tract infection, cystitis, disorder of bilirubin metabolism, chronic obstructive disease, chronic respiratory failure, muscle weakness, lack of coordination, abnormal posture, unsteadiness on feet and cognitive communication deficit. R6's MDS dated [DATE] documents R6 was moderately impaired for cognition for activities of daily living. She has impairment on one side of her upper extremity; and uses a wheelchair.R6's Care Plan documents, (R6) has an ADL (Activities of Daily Living) Self Care Performance Deficit. R6's Care Plan does not document anything related to abuse. R6's Health Status Notes dated 11/30/2024 documents, Note Text: Co-nurse (name-V12) informed this nurse that pt (patient) was in the DR (dining room) sitting at a table, when another pt that was sitting by her (R5) had reached over and placed his hand on pts right thigh, which was witnessed by dietary aid (V15). Dietary aid (V15) states, I immediately moved this pt away from the table and as I turned the pt around in her W/C (wheelchair), (R5) reached over and placed his hand on (R6's) left breast, and (R6) pushed his hand away. (R6) was removed from the DR (dining room) and taken to her room. Skin check done and no areas noted to right thigh or left breast, no redness, scratching and bruising noted. Pt denies pain when asked. This nurse asked pt, What happened in the DR? Pt states, that man almost touched me. V15's statement undated documents, I was in the middle of lunch serve out. I heard (R6) yelling and when I looked out, I saw (R5) grabbing (R6's) right thigh. (R5) was on the right side of (R6) facing the outside window behind (R8). I ran out there to separate them and as I was pushing (R6) out (R5) went to grab the left side of her chest and before I could stop him (R6) used both hands to push his left arm away. On 3/31/2026 at 4:58 PM, V15, Former Dietary Cook/CNA stated, (R5) has a history of grabbing staff and residents. I remember that day because that was the first time I had seen (R5) actually grab someone. (R5) is in a wheelchair. I think he can propel himself but honestly, I am not sure. I know he barely picks his feet up. I was working at that time as a dietary cook. I am now a CNA. (R5) loves to reach for female body parts and if a female is near him, he will grab them. You cannot leave (R5) alone in the dining room. He likes to grab female breast and butts. I know he grabbed (R7) too. I remember (R6) yelling that day, and I ran out to separate them. As I was pushing (R6) (R5) went to grab her chest area and (R6) used her hands to push him away. R6's Incident Report dated 12/5/2024 documents, On 11/30/24 at approximately 12:15pm resident (R6) age [AGE], told staff that resident (R5), age [AGE], had grabbed her breast. Residents were in the dining room and immediately separated. Skin assessment done on (R6) revealed no marks to chest. At time of skin assessment, (R6) told V16, Licensed Practical Nurse (LPN), 'A man almost touched me.' Review of (V15's) statement and interview reveal that she heard (R6) yell and saw (R5) had his hand on (R6's) thigh by her knee. (V16) states as she pushed (R6) away from (R5) he raised his hand toward her chest and (R6) pushed his hand away, (V6) stated she did not see (R5) touch (R6's) breast. Interviews of alert residents in the dining room interviewed all deny seeing (R5) touch the chest area of (R6). No other staff witnessed the episode. When questioned about the episode (R5) would not respond. R5's Health Status Notes dated 11/30/2024 at 1:35 PM, documents, Note Text: dietary aide brought to this nurse's attention that resident had inappropriately touched another resident in the dining room during lunch. dietary aide stated that (R5) was sitting at the table by the kitchen serving window facing the outside window and resident (R6) was sitting on the left side of (R5) dietary aide stated that she heard yelling coming from (R6) and when she approached residents (R5) had his hand on her right thigh. Dietary aide ran out to separate residents. As dietary aide was pulling (R6) away from (R5), (R5) went to grab (R5's) left side of her chest and before aide could stop him (R6) used both hands to push (R5's) left arm away. 100 Hall nurse had asked resident what had happened, and resident stated he almost touched me this nurse asked resident what was going on resident did not respond to this nurse. Dietary manager called and reported incident to the Administrator. Dietary aide (V15) had written a statement of what had happened. Incident reported to 100 Hall nurse. (V13), Physician called, no answer, (V14, Medical Director) called and incident reported to him, no new orders at this time. (R5) to sit on restorative side in dining room per administrator.R5 Incident Report dated 12/5/2024 documents, On 11/30/2024 at approximately 12:15 PM, it was reported that resident (R6), age [AGE], told staff that resident (R5), age [AGE], had grabbed her breast. Residents were in the dining room and immediately separated. Review of (V15's) statement and interview reveal that she heard (R6) yell and saw (R5) put his hand on (R6's) right thigh by her knee. (V15) states as she pushed (R6) away from (R5), he raised his hand toward her chest and (R6's) breast and (R6) pushed his hand away. (V16) stated she did not see (R5) touch (R6's) breast. No other staff witnessed the episode. When questioned about the episode (R5) would not respond. On 12/3/2024 (R6) denied feeling unsafe at the facility and has no recall of the episode in the dining room. Social Service will meet with (R6) 2x/week for a month to ensure her psychosocial well-being. (R5) was moved to the restorative dining area for closer supervision during meals. (This is the same intervention for 12/3/2024). After full investigation (R5) was unable to state what he was doing and seemed unaware of his actions. Due to his cognitive and understanding of the event the facility determined there was no substantial abuse and have updated (R5's) care plan to include: potential for inappropriate touching of other residents with inventions to include close monitoring during the dining process in the restorative dining room, social service to ensure psychosocial review for behaviors and medication management, and behavior tracking. R5's Intervention for the incident with R5 and R6 dated 11/30/2024 documented (R5) to sit on restorative side in dining area for closer supervision. On 3/27/2026 at 9:33 AM, V1 stated (R5's) restorative dining for closer supervision is on all male dining, and there are no females. 2-R4's Minimum Data Set (MDS) dated [DATE] documents R4 has memory problems and is severely impaired for cognition for activities of daily living. She has an impairment on one side to her lower extremities. She uses a walker and wheelchair and needs partial to moderate assistance with most ADLS's (Activities of Daily Living). R4's Care Plan with a revision date of 1/9/2026 documents (R4) uses wheelchair for locomotion. Staff propels resident to areas of choice. (R4) is an elopement/risk wanderer. History of getting outside at her previous Long Term Care Facility and frequent exit seeking since admit to our facility. (R4) has a behavior problem; Interventions: Behavior #1: physically aggressive toward staff, approach in a calm professional manner. Explain to (R4) what you are going to assist her with and give time for (R4) to process. Attempt to redirect by talking to her while performing care. Walk away for 5-10 mins and then reattempt care. Date Initiated: 08/13/2025; with a revision date of 2/17/2026. R4's Elopement assessment dated [DATE] at 1:48 PM, documents, (R4) was at risk for elopement and documents, The resident will remain safe during periods of wandering. R4's Progress Notes dated 3/18/2026 at 10:09 AM, Note Text: administrator came to this nurse and stated that resident was in another resident's room (R5), and resident had hand down this resident's pants. This nurse filled out incident report, performed a skin assessment on resident, as well as notified NP (Nurse Practitioner) and family. R4's Initial Report dated 3/18/2026 documents, Staff observed resident to resident physical touch (R4) and (R5). R4's Final Report dated 3/18/2026 documents, The IDT (intradisciplinary Team) updated (R4's) Care Plan with the following: Resident to resident incident occurred. (R4) has no recollection of the incident and no harm was noted.V10, Certified Nursing Assistant (CNA) statement dated 3/18/2026 at 10:00 AM, documents, I walked into another room to pull out other resident. Then I see (R5) put his hand down (R4's) pants. I removed (R4) from (R5's) room. On 3/31/2026 at 5:31 PM, V10, Certified Nursing Assistant stated, I was working a different hallway, I saw (R5's) bathroom light was on, and the aid was giving a shower, so I went inside his room, and I saw (R4) in his room and saw (R5) had his hand in (R4's) pants. I removed her immediately. (R4) cannot talk and she is severely impaired and cannot tell you anything. (R4) is a wanderer and I think she wandered into his room. (R4) cannot tell you anything. (R5) can answer yes or no questions. We have been instructed to make sure there are no women around (R5). He has a history of touching staff and residents. R4 did not have any interventions documented for her incident on 3/18/2026 even though she was identified as an elopement risk and wanderer. The intervention for the incident on 3/18/2026 documents an intervention for R5 nothing for R4. Velcro stop sign on (R5's) door to prevent confused residents from wandering in. R4's Physician Order sheet (POS) for March 2026 documents a diagnosis of Alzheimer's Disease with early onset; Dementia in other diseases classified elsewhere, unspecified severity without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has memory problems and is severely impaired for cognition for activities of daily living. She has an impairment on one side to her lower extremities. She uses a walker and wheelchair and needs partial to moderate assistance with most ADLS's (Activities of Daily Living). R4's Care Plan with a revision date of 1/9/2026 documents (R4) uses wheelchair for locomotion. Staff propels resident to areas of choice. (R4) is an elopement/risk wanderer. History of getting outside at her previous Long Term Care Facility and frequent exit seeking since admit to our facility. On 3/27/2026 at 9:33 AM, V1, Administrator stated, This is the first incident of sexual nature we have had with (R4). She is confused and has a history of wandering. She propels herself with her feet in her wheelchair and she is exit seeking and on occasion has wandered into other residents' room. (R4) wandered into (R5's) room and while she was there (R5) put his hands down (R4's) pants. 3-R7's POS for March 2026 documents a diagnosis of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance and anxiety; dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance, major depression disorder and anxiety. R7's MDS dated [DATE] document R7 was severely impaired with memory problems for her cognition level. She uses a wheelchair and has no impairment and needs substantial/maximal assistance for most activities of daily living. R7's Care Plan: Does not address abuse and or inappropriate resident to resident behavior. R7's Incident Report dated 3/4/2026 documents, (R9) was observed by CNA touching (R7) inappropriately. Residents were immediately separated, and Administrator notified. (R7) is an [AGE] year-old female who admitted to the facility on [DATE]. She is wheelchair bound and propels herself about the facility. At 7:45 AM, on 2/25/26 V18, CNA observed (R9) with his right hand up the front of (R7's) shirt. (R7) was unable to answer questions related to her cognitive dysfunction. Statement from V18, Certified Nursing Assistant (CNA) dated 2/25/2026 at 8:40 AM, I took another resident out of the dining room. As I turned the corner (R9) had his right hand up and inside (R7's) shirt fondling her. I separated the residents made the nurse aware that I was leaving the floor to call the administrator.Statement from V19, Licensed Practical Nurse (LPN), I was passing out medication when (V18) came and stated that (R9) was foundling (R7's) breast by the dining room. (R9) was taken to his room and (R7) taken to sit by nurse's station, Administrator notified. R7's Progress Notes dated 2/25/2026 at 2:24 PM, Late Entry:Note Text: SSD (Social Service Director) attempt to complete a trauma informed assessment with resident. Resident was unable to participate in assessment, resident did not understand content of assessment due to cognitive deficits and answered nonsensical. R7's Health Status Notes dated 2/26/2026 at 12:39 AM, Note Text: Follow up for incident with another resident; No injuries noted.4-R9's POS for March 2026 documents a diagnosis of hyperlipidemia, obstructive sleep apnea, benign prostatic hyperplasia without lower urinary tract symptoms, anemia, altered mental status, cognitive communication deficit, abnormalities of gait, muscle weakness, abnormal posture, type 2 diabetes mellitus R9's MDS dated [DATE] document R9 was cognitively intact for decision making of activities of daily living. He has no impairment and uses a wheelchair. R9's Care Plan with date initiated of 2/25/2026 documents, (R9) has behavior problems. Behavior #1: Behavior of sexually inappropriate behavior toward peers. 1. Remove peer away from (R9). 2. Sit (R9) at an all-male table during meals. 3. Assist in escorting (R9) out of the dining room and back to his room after all meals. R9's Progress Notes dated 2/28/2026 at 12:25 PM, (R9) is alert and has no memory problems. (R9) can recall person, place and time. (R9) does not have delusions, does not have hallucinations, and decision making is not impaired. Signs of delirium: none. Other cognitive concerns: none. R9's Progress Notes do not document anything related to the incident on 2/25/2026. R9's Incident Report dated 2/25/2026 documents (R9) was interviewed by the DON (Director of Nursing) and Administrator. He stated he did not recall touching anyone. (R7) was unable to answer questions related to her cognitive function. Staff interviewed: No other staff member observed this interaction. Staff interviews also reveal no other noted behaviors from (R9). Interviews conducted with residents. No one witnessed the interaction. Residents also were asked if they had experiences any inappropriate advances by this resident, with all denying such. (R9) has not previous behaviors. The IDT reviewed the incident and the resident care plans. Based on statements from the residents involved, the facility is unable to determine the exact root cause of the incident. The IDT updated (R9's) care plan with the following: Resident will now be sitting at an all-male table for meals. Staff will assist him from the dining room to his room after meals. Behavior tracking was initiated. The IDT updated (R7s') Care Plan with the following: Resident to resident incident occurred. (R7) has no recollection of the incident and no harm was noted. Social services completed a trauma assessment noting no changes. Social Service will conduct visits with resident twice a week for two weeks. On 4/1/2026 at 5:28 PM, V18, Certified Nursing Assistant stated, I remember the incident. (R7) cannot tell you anything. I was taking a resident to the dining room and (R7) was just outside of the restorative dining room for those residents that need assistance. (R7) was parked there in her wheelchair. (R9) came along and I saw him putting his hands up her shirt and was touching her. I told (R9) he was not supposed to be doing that, and I separated them because I do not think (R7) even knew what was going on because she is so confused. I got another staff member and then I reported it. This is the first time I am aware of (R9) sexually touching anyone. I am not sure about (R7). (R7) was not in the dining room she was waiting to be taken into the dining room. R9's Intervention was documented as Resident will now be sitting at an all-male table for meals. Staff will assist him from the dining room to his room after meals. Behavior tracking was initiated.On 4/2/2026 at 12:11 PM, V24, Medical Director stated, I would not expect any resident to be touched by staff and or any other resident in a sexual manner while residing in the facility. The Facility Abuse, Prevention and Prohibition Policy dated November 2025 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. This facility prohibits mistreatment, neglect, or abuse of residents. The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse: corporal punishment and involuntary seclusion. Sexual abuse is non-consensual sexual contact of any type with a resident including but not limited to: unwanted intimate touching of any kind, especially of breast or perineal areas.

Based on observation, interview, and record review the facility failed to ensure rooms were kept clean for 4 of 4 (R1-R4) residents reviewed for a safe homelike environment in the sample of 10. Findings Include:1.R1's admission Record with a print date of 12/12/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include anxiety, irritable bowel syndrome, morbid obesity, and fracture of humerus. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating R1 is cognitively intact. On 12/12/25 at 10:48 AM, R1 stated the floors in her room were dirty and there were brown and red stains on the pull cord in her bathroom. On 12/12/25 at 10:30 AM, R1's bathroom was observed with brown/black substance where the floor and the wall trim meet and on the wall trim. There were no stains observed on the pull cord in the bathroom. 2. R2's admission Record with a print date of 12/12/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include fracture of sacrum, diabetes, and hypertension. R2's MDS dated [DATE] documents a BIMS score of 15, indicating she is cognitively intact. On 12/12/25 at 10:08 AM, R2 denied concerns with the cleanliness of her room. On this same date at this same time, R2's room and bathroom were observed with some brown/black substance on the floor near the wall trim and on the wall trim. 3. R3's admission Record with a print date of 12/12/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease. R3's MDS dated [DATE] documents a BIMS score of 13, indicating R3 is cognitively intact. On 12/12/25 at 9:54 AM, R3 denied concerns with how the facility cleans her room. On this same day and time, R3's room was observed and the bathroom floor was dirty with brown/black substance on the floor and on the wall trim. 4. R4's admission Record with a print date of 12/15/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia, and cognitive communication deficit. R4's MDS dated [DATE] documents a BIMS score of 14, indicating R4 is cognitively intact. On 12/12/25 at 9:51 AM, R4 denied concerns with the cleanliness of her room. On 12/12/25 at 1:33 PM, V6 (Housekeeping Director) stated she had not had any complaints/concerns brought to her related to the cleanliness of the facility. This surveyor walked with V6 to observe R1-R4's room. Upon entering R4's bathroom there was brown/black substance noted on the floor and wall trim and what appeared to be dried blood on the handrail. V6 took a dry paper towel and confirmed the blood was dried and had probably been there for a while. V6 stated the areas on the floor should have been cleaned. V6 stated the floors, and trim should be cleaned daily and with each deep clean. The facility Procedure for Cleaning Non-Isolation Rooms dated 11/2020 documents .Clean all surfaces and high touch surfaces .High Touch Areas Daily .Other areas if visibly soiled- walls, trash cans, doors

Based on observation, interview, and record review, the Facility failed to ensure the dish machine had the chemical level required for effective sanitation and failed to store food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents residing in the Facility. Findings include: 1. On 8/27/24 at 12:02 PM, V5, Dietary Aid, removed a tray of dishes from the dish machine after the cleaning cycle was completed and placed the tray next to the machine on the clean side of the machine. V5 then placed a tray of dirty dishes in the machine and began another cleaning cycle. When the wash cycle began, V5 placed a sanitizer test strip in the dish water reservoir on the front of the machine. V4, Dietary Manager, was in the room and stated, Not yet prompting V4 to wait before attempting the test. V5 waited until the final rinse cycle began, then placed the strip in the reservoir. The test strip did not change color and remained white. V4 stated the dish machine was tested earlier that morning. On 8/27/24 at 12:15 PM, V4, Dietary Manager, brought a different test strip package into the dish room. She stated they were the sanitizer test strips, because the other strips were not working. V4 placed a test strip in the reservoir during the final rinse cycle. The strip turned light orange which correlated to 100 ppm (parts per million) on the test strip package. V5 stated it was supposed to be 200 ppm. On 8/27/24 at 12:21 PM, V4, Dietary Manager, stated she located a different kind of test strip, because they should be turning purple. V4 placed the strip in the water reservoir during the final rinse, and the strip remained white. V4 stated she would call the maintenance technician who comes monthly, because there is not much sanitizer coming out of the tubing during the rinse. 2. On 8/27/24 at 12:12 PM, There was a box of uncooked pork loin fritters on a shelf directly above a box of cookie dough. There was a box of uncooked beef loin fritters on a shelf directly above another box of cookie dough. There was a box of uncooked beef Philly steak that was placed on top of a box of pizza dough. There was a box of frozen uncooked shrimp on a shelf directly above a box of nutritional shakes. On 8/27/24 at 12:40 PM, V4, Dietary Manager, stated I was thinking it would be ok (to store uncooked animal protein on higher shelves) since they're frozen. On 8/28/24 at 2:30 PM, V1, Administrator, stated she was unable to find the dish machine specifications and may have to order a new user manual. On 8/30/24 at 9:45 AM, V2, Director of Nursing (DON), stated she expects dietary staff to follow all dietary policies. The Facility's Undated Dish Machine Operation Policy documents, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Check the dishwashing machine each morning before first set of dishes are to be washed. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. The Facility's Undated Food Storage (Dry, Refrigerated, and Frozen) Policy documents, Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/27/24 documents there are 70 residents living in the Facility.

Based on interview and record review the facility failed to follow the Renal Therapeutic Diet for 1 of 2 residents (R32) reviewed for therapeutic diets in the sample of 35. Findings Include: R32's Minimum Data Set (MDS) dated [DATE] documents R32 is cognitively intact. R32's Physician Order Sheet dated 7/1/24 documents diet order Renal, CCD (Consistent Carbohydrate) regular texture, Regular liquid, and no added salt. R32'S Face Sheet dated 4/9/23 documents R32's has the diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus without complications. R32's End Stage Renal Failure Care Plan dated 11/5/23 documents compliance with treatment plan, fluid restrictions, and dietary restrictions. R32's Meal Card does not reflect a Renal, CCD (Consistent Carbohydrate) no salt added diet. For breakfast her meal card documents 4 ounces of ham and potato casserole, sausage links, oatmeal, fresh cantaloupe, rye toast. For lunch the meal card documents garden salad, Italian wedding soup, salami sandwich, potato chips, and frosted vanilla cupcake. On 8/29/24 at 3:30 PM, two CNA's (Certified Nursing Assistants) were on the 200 hall with meal cards asking the residents what they want to eat for dinner. V11, CNA stated I'm sorry I don't know what a renal diet is. I couldn't tell you. I know she is diabetic. V12, CNA stated a renal diet means you should watch their salt and fluids. On 08/30/24 at 9:25 AM, V13, Assistant Manager/Day Shift [NAME] stated you limit potatoes, tomatoes, and bananas. I give them what they order on their ticket, which usually shows different choices for the renal diet. (the diet card does not show different choices for the renal diet.) On 08/30/24 at 9:35 AM, R32 stated a renal diet is when you eat less salt. I can have tomatoes; potatoes and I only eat one banana. R32 had a bag of potato puffs lying on her bed. R32 stated that's my snack for dialysis. My kids give me that. The Facility policy titled Therapeutic Diets dated 1/2017 documents: A therapeutic diet must be prescribed by the resident's attending physician. The Physician's diet order should match the terminology used by food services.

Based on interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents (R13) reviewed for supervision to prevent falls in a sample of 44. This failure resulted in R13 falling twice in one day and sustaining a right inferior orbital blowout fracture and minimally displaced left nasal bone fracture. Findings include: R13's Admission Record, printed on 7/21/23, documents R13 had history of falling, unspecified dementia, unspecified severity, with agitation, unspecified abnormalities of gait and mobility and abnormal posture. R13's Minimum Data Set (MDS), dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. The MDS documents that R13 requires limited assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS documents that R13 requires supervision of one person for locomotion on unit and locomotion off unit. The MDS documents that R13 is not steady, only able to stabilize with staff assistance. R13's Care Plan Focus, dated 2/22/2022 documents, (R13) has impaired cognitive function/dementia or impaired thought processes. R13's Care Plan, dated 05/17/23 documents (R13) remains at risk for falls with injury r/t (related to) her impaired cognition, new admission and hx (history) of actual falls with need for monitoring. Care Plan goal revised on 5/3/23, documented continues with repeated falls, with all interventions reviewed. Care Plan intervention, dated 6/24/22, documented Re-educated resident on safety and using call light to summon staff to give her stand-by assistance with transfers and toileting. R13's Health Status Note dated 04/28/23 at 5:52 AM documents CNA (Certified Nursing Aide) reported to this nurse that resident was found on floor between bed and wheelchair. This nurse went to resident's room to assess her and on assessment found no injuries. Resident states 'I fell when I was trying to get in bed.' Resident denies hitting her head. MD (V16) notified via fax, POA (Power of Attorney) also notified. Vitals 97.4 (temperature) 107 (pulse) 20 (respiration) 143/80 (blood pressure) 94%RA (room air). R13's Fall Investigation dated 04/28/23 documents CNA reported that resident was found on the floor between bed and wheelchair. No injuries found during assessment. Conclusion: Elder frequently attempts to complete task without assistance. Staff educated elder to use call light for assistance. Root cause: No fault. R13's Health Status Note dated 04/28/23 at 9:00 AM documents CNA reported to this writer that R13 was having a slight left sided droop and some slurred speech after a fall this morning. This nurse went to assess resident and resident's vitals were 142/80 BP (blood pressure), 91 BPM (beats per minute), 93 o2 (oxygen saturation), 18 resp (respiration), 98.1 temp. This writer then notified DON (Director of Nursing) of resident's condition and DON advised this writer to call (V16). (V16) was notified and advised this writer to keep an eye on the resident and call back if residents condition worsens. R13's Health Status Note dated 04/28/23 at 9:45 AM documents CNA reported to this writer that resident was on the floor. This writer assessed resident and resident had swelling and a hematoma to her right eye. Resident had and an episode of emesis. This nurse helped CNA get resident up into wheelchair this writer took residents vitals which were 166/82 BP, 124 BPM, 100.2 temp, 92 o2. This nurse then notified DON and was advised to send resident to the hospital. This writer then called 911 and asked for transport. this nurse then notified MD of resident being sent out. POA notified of transport. Resident transported to (local hospital) via EMS (Emergency Medical System). R13's Fall Investigation dated 04/28/23 documents CNA reported that resident was on the floor. Swelling and hematoma noted to right eye. CNA and nurse assisted resident into wheelchair and vitals obtained. Conclusion: Elder was immediately sent to ED for evaluation and 1-hour visual checks initiated upon return from the hospital. Root cause: No fault. R13's Hospital Report dated 04/28/23 documents Right inferior orbital blowout fracture and minimally displaced left nasal bone fracture. On 07/20/23 at 12:32 PM, V16, Medical Director stated that he feels the facility did everything that they could do to prevent R13 from falling. He stated that R13 has tendency of getting up without any help. On 07/21/23 at 10:47 AM, V2, Director of Nursing (DON) stated that R13 fell and then they had her up at the nurses' station. The nurse did not realize she wheeled herself back to her room, by the time they figured it out, she was on the floor. Facility's Fall Policy revised 09/17/19 documents The purpose of the Fall Management Program is to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents.

Based on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This has the potential to affect all 70 residents living in the facility. Findings include: The Facility Nursing Schedule dated July 4th through July 18 was reviewed, and on July 14, 2023, the facility did not have a Registered Nurse (RN) for eight consecutive hours. On 7/20/23 at 3:30 PM, V2, Director of Nursing stated, that was an oversight, and it has been corrected. On 7/21/23 at 10:25 AM V1 Administrator stated, we use the state regulations for our policy for staffing. The facility's Resident Census and Conditions of Residents Form, CMS 672, dated 7/18/23 documents the facility has a census of 70 residents. The CMS 672 documents 5 residents have indwelling or external catheters, 1 resident is restrained, 5 residents have pressure ulcers, 33 residents have dementia, 7 residents are receiving Hospice, 2 residents are receiving dialysis, 2 residents are receiving intravenous therapy/IV nutrition, and or/ blood transfusions, and 10 are residents are receiving antibiotics.

Based on observation, interview, and record review, the Facility failed to store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 70 residents living in the Facility. Findings include: On 7/18/23 at 12:18 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R65's tray. V6 did not test the temperature of the soup before tray was passed to R65. On 7/18/23 at 12:37 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R30's tray. V6 did not test the temperature of the soup before the tray was passed to R30. On 7/18/23 at 12:47 PM, V6, Cook, removed a pan of hash brown casserole from the oven and placed it on the steamtable. V6 did not test the temperature of the casserole and plated the casserole on both R45's and R57's trays. The trays were then passed to R45 and R57. On 7/19/23 at 9:54 AM, the Nourishment room freezer had a half empty container of ice cream from a fast-food restaurant that was not labeled or dated. In the Nourishment refrigerator, there was a sealed plastic bag of watermelon cubes that was not labeled or dated. There was a half empty jar of pickled jalapenos with no date and a half empty jug of lemonade with no date. On 7/18/23 at 1:00 PM, V5, Food Service Director, stated she expects her staff to check temperatures before serving. On 7/20/23 at 8:37 AM in the dining room refrigerator there was a container labeled Italian chicken that was not dated. There was a plastic bag with four pieces of an unknown breaded meat that was not labeled or dated. There was an opened jar of cherries and an opened jar of jelly that were not dated. There were two opened containers of snow cone syrup that were not dated. On 7/20/23 at 1:47 PM, V1, Administrator, stated she expects staff to follow the Facility's food service policies. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, undated, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Policy documents General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The Policy documents Keep potentially hazardous foods out of the temperature danger zone (41 F - 135 F, or per state specific regulations). The Facility's Monitoring Food Temperatures for Meal Service Policy, undated, documents, Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. The Policy documents If the serving/holding temperature of a hot food item is not at 135 F (Fahrenheit) or higher (check your state specific regulations: some states require 140 F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165 F for a minimum of 15 seconds. The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility.

A. Based on interview and record review, the facility failed to identify causative organisms to assist with identification of patterns to prevent infections. This has the potential to affect all 70 residents living in the facility. Findings include: 1. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated February 2023 documents Sections for infection site, symptoms, date of culture/x-ray and organism/results. The Line Listing documented on 02/27/23: R55 had symptoms of dysuria and was started on Keflex with no causative organism/results listed. 2. The facility Infection Control Log for March 2023 documents 5 cultures with no organisms listed on the log. There was a total of 24 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated March 2023 documents on 03/20/23 R19 had symptoms dysuria. The Line Listing documented R19 was started on Bactrim DS with no organism/results listed. The Line Listing documented 03/05/23 R59 had symptoms of lethargy and was started on Keflex with no causative organism/results listed. The Line Listing documented on 3/6/23, R49 had symptoms of urinary symptoms and was started on Levaquin with no causative organism/results listed. 3. The facility Infection Control Log for April 2023 documents one culture with no organism listed on the log. There was a total of 11 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated 04/17/23 documents R4 had symptoms of dysuria. The Line Listing documented she had no growth but was started on Keflex for UTI. 4. The facility Infection Control Log for May 2023 documents 4 cultures with no organisms listed on the log. There was a total of 22 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated May 2023 documents on 05/03/23 R13 had symptoms of abnormal UA results. The Line Listing documents R13 was started on Macrobid with no causative organism/results listed. The Line Listing documents on 05/08/23 R13 had symptoms of lethargy and was started on Macrobid with no causative organism/results listed. The Line listing documents on 05/05/23 R32 had symptoms of lethargy and was started on Bactrim with no causative organism/results listed. 5. The facility Infection Control Log for June 2023 documents 3 cultures with no organisms listed on the log. There was a total of 9 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated June 23 documents on 06/08/23 R30 had dysuria and was started Bactrim DS with no causative organism/results listed. 6. The facility Infection Control Log for July 2023 documents 2 cultures with no organisms listed on the log. There was a total of 5 infections documented on the log. Facility's Line Listing, Monthly Infection Report for Individual Nursing Units dated July 23 documents on 07/12/23 R32 had symptoms of malodorous dysuria and was started Keflex with no organism/results listed. On 07/21/23 at 10:47 AM, V2, Director of Nursing (DON), stated that the infection control log is missing organisms because sometime hospice will not order antibiotic but will not do a culture and sometimes the doctor will order antibiotics before the culture comes back. Facility's Infection Prevention and Control Program Manual Surveillance dated 2019 documents Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. The Resident Census and Condition of Residents Form, CMS 672 dated 7/18/23 documents there are 70 residents living in the Facility. B. Based on observation and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 3 of 11 residents (R11, R47, R58) reviewed for infection control in the sample of 44. Findings include: 1.R11's Minimum Data Set, dated dated dated [DATE] documents R11 requires extensive assistance of two plus persons for toilet use and is always incontinent of urine. R11's Physician Order, dated 6/5/23, documented R11 was receiving Cefuroxime Axetil for a Urinary Tract Infection (UTI) On 07/20/23 at 1:58 PM, V20, CNA, assisted R11 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves and removed blanket from R11. V20 washed R11's peri-area and vagina with wet wash cloth. V20 dried R11's peri-area and vagina with a towel. V20 rolled R11 toward wall and washed R11's buttocks and gluteal cleft with a new wet washcloth and dried with a towel. V20 placed a new bed pad under R11. R11 was rolled toward V20. Bed pad was straightened out and R11 was rolled onto back. V20 doffed gloves and covered resident with blanket. V20 donned new gloves without hand hygiene and cleaned up supplies. 2. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. On 07/20/23 at 1:43 PM, V20, CNA assisted R47 with incontinent care. V20 washed hands with soap and water in bathroom. V20 donned gloves, pulled down covers, and open trash bags. V20 doffed gloves and donned new gloves without hand hygiene. V20 washed R47's peri-area and vagina with wet wash cloth. V20 then dried R47's peri-area and vagina with a towel. V20 doffed and donned new gloves without hand hygiene. V20 washed R47's buttocks and gluteal cleft with wet wash cloth, dried R47's buttocks with a towel and rolled a bed pad under R47. V20 doffed and donned new gloves without hand hygiene. Bed pad was straightened out and R47 was covered up. V20 doffed gloves and lowered bed. V20 donned new gloves without hand hygiene and clean up trash bags and supplies. 3.R58's MDS dated [DATE] documents a BIMS score of 4 out of 15. Resident is total dependence of two plus persons for toilet use. Resident is always incontinent of urine. R58's Physician's Order, dated 7/15/23, documented he was receiving Ciprofloxacin HCL for a UTI. On 07/20/23 1:12 PM, V4, CNA and V13, CNA assisted R58's with incontinent care. Both CNAs washed their hands with soap and water in the bathroom prior to starting. V4 washed R58's buttocks and gluteal cleft with wash cloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 then washed R58's peri-area and penis with a washcloth. V4 doffed gloves and donned new gloves without any hand hygiene. V4 dried R58's peri-area with a towel. V4 doffed gloves and donned new gloves without hand hygiene. V13 rolled R58's toward her. V4 placed incontinent brief under R58. R58 was then rolled toward V4. R58 was rolled on his back and incontinent was pulled up in front and secured. R58 covered up. V4 doffed gloves and donned new gloves without hand hygiene. The Facility's Infection Prevention and Control Program, dated 2019, documents that written standards, policies and procedures for the program will include f. The hand hygiene procedures to be followed by staff involved in direct resident contact. The Program documents that the facility will develop and implement written policies and procedures for infection control that, at a minimum Require staff to follow hand hygiene practices consistent with accepted standards of practice.

Based on interview, and record review the facility failed to ensure that residents who require antibiotics are prescribed the appropriate antibiotics to treat infections for 4 of 4 residents (R11, R41, R47, R58) reviewed for antibiotic stewardship in a sample of 44. Finding include: The Facility's Infection Prevention and Control Manual Antibiotic Stewardship and MDROs dated 2019 documents It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. 1. R11's Urinalysis report, dated 5/29/23, documents R11 had 2+ blood, 1+ protein, 3+ leukocytes and greater than 50 white blood cells. There was no culture and sensitivity attached to these results. R11's Health Status Note dated 05/29/23 at 3:40 PM documents Partial UA (urinalysis) rec'd (received) and reported to (V22, Physician), on call for (V21, Physician). (V22) would like to order Bactrim DS but this nurse informed him that resident's POA refuses Bactrim as it upsets her stomach. New order rec'd for Macrobid 100 mg (milligrams) PO (by mouth) BID (twice daily) for 5 days. POA (Power of Attorney) notified. At this time, there was no Culture and Sensitivity (C&S) results to ensure that Macrobid was sensitive to the organism causing R11's UTI. R11's Physician Order dated 05/31/23 documents Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohydrate Macro); Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 11 Administrations 7 days total. R11's C&S report, dated 6/2/23, documented Bactrim had intermediate sensitivity to the urinary bacteria. R11's Health Status Note dated 06/05/23 at 9:59 AM documents Final urine culture rec'd with intermediate sensitivity noted to Macrobid, (V21) notified, awaiting any new orders. R11's Physician Order dated 06/05/23 documents Cefuroxime Axetil Oral Tablet 500 MG (Cefuroxime Axetil); Give 1 tablet by mouth two times a day for UTI for 5 Days. 2. R41's Health Status Note dated 03/04/23 at 11:04 AM documents UA (urinalysis) from 03/01/23 rec'd, cx (culture) pending, (V16) notified, awaiting any new orders. R41's Health Status Note dated 03/04/23 at 2:10 PM documents (V23), NP (Nurse Practitioner) here, new order rec'd for Keflex 500 mg PO TID (three times daily) x 5 days. Resident aware and agrees with plan. This was ordered prior to identifying if the organism causing R41's UTI was sensitive to Keflex. R41's Physician Order dated 04/12/23 documents Amoxicillin-Pot Clavulanate Tablet 875-125 MG; Give 1 tablet by mouth two times a day for UTI for 7 Days to start 04/12/23 after UA collection. This antibiotic was started prior to getting a UA or C&S. R41's Health Status Order dated 05/29/23 at 11:43 AM documents Partial UA result rec'd and reported to (V16), cx (culture) pending, awaiting any new orders. R41's Health Status Note dated 05/29/23 at 1:18 PM documents New order rec'd per (V16) for Keflex 500mg PO TID for 7 days. Resident aware and agrees with plan. R41's Physician Order dated 05/29/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for UTI for 7 Day. This antibiotic was started prior to getting C&S results to determine if the antibiotic used was sensitive to the organism causing R41's UTI. 3. R47's Nursing Note dated 05/03/23 at 9:50 AM documents UA WAS OBTAINED LAST NIGHT AND SENT TO LAB. AWAITING RESULTS. R47's Physician Order dated 05/06/23 documents Cephalexin Capsule 500 MG; Give 1 capsule by mouth three times a day for infection for 7 Days. R47's Nursing Note dated 05/06/23 at 2:49 PM documents UA results. E. Coli detected. New order for Keflex 500mg 1 po BID x7 days. Resident and POA aware and voices understanding. R47's Urine Culture dated 05/06/23 documents Escherichia Coli. No sensitivity report noted. Unknown if E. Coli is susceptible to Keflex antibiotic. 4. R58's Health Status Note dated 07/10/23 at 6:07 PM documents R58's UA results were received and a new order from Bactrim DS 800/160, 1 tablet po twice daily for 7 days for UTI. R58's Urinalysis dated 07/10/23 documents Culture, urine microbiology tests to follow on separate report. R58 was started on Bactrim prior to receiving the C&S report to determine if the antibiotic given was sensitive to the organism causing R58's UTI. R58's Physician Order dated 07/15/23 documents Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl); Give 1 tablet by mouth two times a day for UTI for 10 Days. On 07/21/23 at 10:47 AM, V2, Director of Nursing, DON, stated that the facility's medical director, V16, is old school. V2 stated that V16 does not wait for the culture and sensitivity prior to ordering antibiotics. V2 stated V16 orders antibiotics for symptoms.

Based on interview and record review, the facility failed to provide residents and/or resident's representatives education on the risks and benefits of influenza and pneumococcal immunizations, and document education and refusals in the residents' medical records for 4 of 5 residents (R31, R35, R61 and R70) reviewed for influenza and pneumococcal immunization in the sample of 44. Findings include: 1. R31's Face Sheet documents R31 was admitted to the facility on [DATE] with diagnosis of Pneumonia, unspecified organism, abnormal sputum, Shortness of Breath, Cardiomyopathy and Chronic Kidney Disease. R31's Minimum Data Set, MDS, dated [DATE] documents R31 has severe cognitive impairment. The MDS documents R31 received the Influenza immunization 10/24/22. R31's MDS documented the pneumococcal vaccine was offered and declined. R31's medical records do not document R31 received education of the risks or benefits of the pneumococcal vaccination and there was no documentation R31 and/or R31's representative signed a refusal or declination form. 2. R35's Face Sheet undated documents was admitted to the facility on [DATE] with a diagnosis of Hemiplegia, Cerebral Infarction, Mild Cognitive Impairment of Uncertain or Unknown etiology and COVID-19. R35's MDS, dated [DATE], documents R35 has severe cognitive impairment. R35's MDS documents R35 received the Influenza vaccine on 10/24/22 and that R35 received the Pneumococcal immunization. R35's medical records do not document that R35 received education of the risks or benefits of the pneumococcal vaccination. 3. R61 Face Sheet undated documents R61's was admitted to the facility 5/2/22 with medical diagnosis of Atrioventricular Block, First degree, Type 2 Diabetes, Nondisplaced comminuted fracture of right patella, Initial encounter for closed fracture and Unilateral Primary Osteoarthritis left knee. R61's MDS, dated [DATE], documents R61 is cognitively intact. The MDS documents R61 received the Influenza immunization 10/25/22 the pneumococcal immunization was offered and declined. There was no documentation in R61's medical records that R61 and/or R61's responsible party received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/20/23 3:00 PM R61 stated she R61 did not know anything about a pneumonia shot. 4. R70's Face Sheet documents R70 was admitted to the facility on [DATE] and discharged [DATE]. R70's diagnosis was documented as Chronic Kidney Disease, Unspecified B-Cell Lymphoma, and fracture of Unspecified part of neck of right Femur, Subsequent encounter for closed Fracture. R70's MDS dated [DATE] documents R70 is cognitively intact. The MDS documents R70 received the Influenza immunization 10/25/22, the pneumococcal immunization was offered and declined. R70 medical records did not document he received any immunizations during his stay in the facility. R70's medical record did not document that R70 received education of the risks or benefits of the pneumococcal vaccination and did not sign a refusal or declination form. On 7/19/23 at 3:05 PM V2 Director of Nursing (DON) stated she had only been in the job a couple of months and was uncertain what procedure the previous DON had in place. But she (V2) did not have any refusal forms signed. On 7/20/23 at 1:35 PM V1, Administrator, stated, We have something we need to get straighten out and hence forth we will have documentation of refusals. The facility Policy Pneumococcal Vaccine revised August 2008 documents Residents/representatives have the right to refuse vaccination. Refusal will be documented on the Pneumococcal Immunization Informed Consent form and will include the date, reason for refusal and signature.

Based on interview and record review, the Facility failed to ensure residents were free from verbal abuse for 1 of 3 residents (R45) reviewed for abuse in the sample of 44. Findings include: R45's Minimum Data Set (MDS), dated [DATE], documents R45 is cognitively intact and requires extensive to total assistance with most Activities of Daily Living. R45's Progress Note by V1, Administrator, on 5/14/23 at 11:22 AM documents, Resident reported an agency CNA had been rude with her and threw a grabber on her bed and it landed on the resident's legs. This writer assessed bilateral lower legs and saw (no) injuries or discolored areas. The Facility's Initial Report sent to the Illinois Department of Public Health by V1 on 5/14/23 documents, At 10:30 AM on 5/14/2023, I was notified by (V12, CNA, Certified Nurse Aide), and (V13, CNA) that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went and immediately spoke with (R45) about allegation. (R45) states she was in bed and (V14, CNA) responded to call light and when asked to apply lotion to residents back she stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber at which point (V14) left room for 20 minutes. When (V14), CNA, returned to room she threw the grabber on the bed, and it landed on (R45)'s lower legs. (R45) states (V14) CNA was rude with her both times she came in room telling her she could do things herself. Roommate (R57) interviewed, and states (V14) was rude to (R45) but not her. (R45) states (V14) did not return to room after that. This writer examined legs and found no injuries or discoloration, (R45) states legs did not hurt when it (hit) by grabber. The Facility's Final Report sent to Illinois Department of Public Health by V1on 5/19/23 documents, At 10:30am on 5/14/23 I was notified by (V12), CNA and (V13), CNA that resident (R45) had told them a night shift CNA had thrown a grabber at her. Administrator went immediately to speak to (R45) about allegation. Resident states she was in bed at approximately 1830 (6:30 PM) on 5/13/23and (V14), CNA, responded to call light and when (R45) asked her to apply lotion to her back (V14) stated she couldn't reach the lotion and needed a grabber, (R45) handed (V14) her grabber to use and (V14) then left room returning 20 minutes later. Upon re-entering resident's room (V14) threw the grabber on the bed and it landed on (R45)'s lower legs and told (R45) to apply the lotion herself. (R45) states she only had those 2 encounters with the CNA (V14) then another (another) CNA took over her care. (R45) denies telling any staff about the episode until the next morning when she spoke to CNAs (V12) and (V13). Roommate (R57) was interviewed and states that she heard (V14) being rude to (R45) but she wasn't rude to her. (V14) is an agency and did not return calls for interview about episode. (V14) has been marked as a do not return on the agency portal. (R45) during interview stated she found the way care was refused and the way she was spoken to by (V14) was abusive. On 7/20/23 at 9:50 AM, V13 stated, (R45) told me that (V14) came in and was rude and nasty to her and got upset with her because she wanted things, then (V14) took the grabber and threw it at (R45). (R45) was upset, but said her leg wasn't hurt. On 7/20/23 at 11:28 AM, R57, R45's roommate, stated, (V14) was not very nice to (R45). She was very ugly to her. (R45) told (V14) she was going to turn her in, then (V14) made a remark that was not very nice. Then (V14) threw her hands up and broke my little flower (decoration). It was a gift from my old roommate who passed away. (V14) is in the wrong profession. R57's MDS, dated [DATE], documented R57 was cognitively intact. On 7/20/23 at 1:47 PM, V1 stated she would not expect staff to throw items on resident beds. The Facility's Abuse, Prevention and Prohibition Policy revised 10/2022 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy documents This facility prohibits mistreatment, neglect or abuse of residents. The Policy documents The residents must not be subjected to abuse by anyone.

Based on record reviews and interviews the facility failed to complete physician and family and/or representative notification of change in condition regarding a fall in a timely manner for 1 of 3 residents (R2) reviewed for falls in a sample of 11 residents. Findings include: 1. R2's Incident Report entitled, Falls/Incident Report Checklist documents (R2) had an unwitnessed fall on 6/21/2021 at 8:05 AM. Physician Notification was on 6/29/2021 at 14:35 (2:35pm), and Power of Attorney (POA) (V3) was notified on 6/29/2021 at 14:45 (2:45pm). R2's Progress notes dated 6/23/2021 at 18:30 (6:30 pm) document, Called down to room [ROOM NUMBER] due to daughter finding bruised area to residents temple area (3x2 centimeter irregular shaped lt purple discoloration); No recent falls per record; Resident has been staying in bed; Denies pain; Moves all ext's without complaint of pain. R2's progress notes dated 6/29/2021 at 14:38 (2:38pm)document, Late entry: 6/21/2021 0805 AM. Certified Nursing Assistant (CNA) called this nurse to residents room, resident was found on her left side on the floor beside her bed on blanket. Denies pain or discomfort, no sign/symptoms of distress, range of motion within normal limits for resident, no apparent injury noted. Resident lifted by staff back into bed. Assistant Director of Nursing (ADON-V5) notified of fall. R2's Progress notes dated on 6/29/2021 at 14:38 (2:38pm) document, (Doctor) notified at this time of fall, No new orders. R2's Progress Notes dated on 6/29/2021 at 14:53 (2:53 pm) document, POA (V3) notified of fall. On 7/15/2021 at 8:30 AM, V3 stated, On 6/23/21 during her visit she found a bruise on (R2's) forehead and reported it to the on-duty nurse. The nurse on duty said she did not know of any recent falls or injury's and notified the doctor and (V1Administrator ). On 6/29/2021 she was called by nurse (V4) who apologized because she had dropped the ball and failed to report a fall for (R2). On 6/21/2021 she found (R2) on the floor in her room and did not document or report it to the doctor. They did change (R2's) mattress because they thought it was the reason she may have rolled out of bed. On 7/15/2021 at 11:15 AM, V1 Administrator stated, about 3 weeks ago (V3) was visiting and reported a bruise on (R2's) forehead. There was no knowledge of any recent accident or injury to explain the cause for the bruising, so an abuse investigation was initiated. After the investigation was done and the final report was sent to Illinois Department of Public Health (IDPH), (V4) Registered Nurse (RN) reported (R2) had been found on the floor in her room a few days before the bruise. The fall was not documented and there was apparently a miscommunication between (V4) and (V5- Assistant Director of Nursing-ADON) regarding if it was a fall or not a fall. (V4) understood (V5) to instruct her to just monitor (R2). An addendum report was submitted to IDPH reporting the fall. The appropriate procedure was not followed by staff in this case, and there was a nursing in service done regarding the proper procedures for notification of residents change of condition, and review of reporting and investigation procedures. On 7/15/2021 at 11:30 AM, V5 ADON stated, (V4) should have initiated a fall protocol if (R2) was found on the floor. (V4) should have done a full nursing assessment, called the doctor and family, document in the nurses notes, on an incident report. They monitor the residents for injury after any falls each shift for 3 days. Nursing is expected to do a fall assessment and update the care plan with every fall at the time of incident. On 7/16/2021 at 1:25 PM, V2 Director of Nursing (DON) stated, (V4) should have initiated the facility fall protocol if (R2) was found on the floor and documented. The documentation would include an incident report, a fall risk assessment, and notify the doctor and family immediately. The nurses know this protocol and it would not be expected to get direction from nursing administration as to whether or not they should call the doctor or family. Nursing is only expected to report to the administrative nurse if a fall had occurred. On 7/16/2021 at 1:50 PM, V4 RN stated, on 6/21/2021 she was called to (R2's) room where (R2) was found lying on the floor by her bed. She was assessed (R2) with no injuries and assisted her with help back to bed. V4 also stated, she reported the fall incident to (V5) ADON on 6/21/2021 and she instructed her not to write it up and to just monitor (R2). Then on 6/29/2021 (V5) asked her to write a witness statement regarding the bruise investigation and that is when she reported the fall, documented the incident, and called the doctor and (V3). V4 also stated, she was aware of the facility protocol for falls and should have documented the assessment and made the notifications to the doctor and the family immediately at the time of the fall. Facility undated Policy entitled, Significant Condition Change and Notification documents in part, Purpose- To ensure that the resident's family and or representative and medical practitioner are notified of resident changes such as those listed below: An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention. A significant change in the resident's physical, mental, or psychosocial status. Procedure When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner.

Based on Interview and Record Review the facility failed to document a resident fall and appropriately follow up to ensure the environment was free of hazards in a timely manner for 1 of 3 residents (R2) reviewed for falls in a sample of 11 residents. findings include: 1. R2's Minimum Data Set (MDS) dated [DATE] documents, a Brief Interview for Mental Status (BIMS) assessment score of 4 which indicates resident has severe cognitive impairment and resident requires extensive assist of 2 staff to complete activities of daily living (ADL's). R2's Care Plan dated 5/28/2021, and revised 6/29/2021 documents in part, (R2) is at risk for falls related to limited mobility and dementia. (R2) will be free of falls through the review date. 5/28/2021-Be sure (R2's) call light is within reach and encourage the resident to use it for assistance as needed. 5/28/2021-Body pillow to promote safe bed positioning. 5/28/2021-Low bed 5/28/2021-Reclining back wheelchair for positioning aide for forward slumping. 6/29/2021 Scoop mattress (canoe mattress with defined borders at the head and foot of the bed. R2's Facility Incident Report entitled, Falls/Incident Report Checklist, dated 6/23/2021 at 1900 (7:00pm) documents, On 6/23/2021 at 6:30 PM (R2) had unwitnessed head injury, bruise. Called down to room 301, due to daughter finding bruise area to left temple area, no recent falls per record. Resident has been staying in bed; Denies pain, moves extremities without complaint of pain. A 3 by 2 centimeter irregular light purple discoloration. Physician notified on 6/23/2021 18:50 (6:50 pm). (V3) Power of Attorney notified on 6/23/2021 1830 (6:30pm). R2's Facility Incident Report entitled, Falls/Incident Report Checklist dated 6/29/2021 at 14:45 (2:45pm) documents, On 6/21/2021 at 8:05 AM. (R2) had Unwitnessed Fall. Certified Nursing Assistant (CNA) called this nurse to residents room. Resident found lying on left side on the floor on her blanket. Denied pain or discomfort. No sign or symptom of distress. Range of motion (ROM) within normal limit for resident. No apparent injury noted. Resident lifted back into bed. Physician notified on 6/29/2021 at 14:35 (2:35pm). (V3) Power of Attorney notified on 6/29/2021 at 14:45 (2:45pm). R2's Progress notes dated 6/23/2021 at 18:30 (6:30pm) document, Called down to room 301 due to daughter finding bruised area to residents temple area (3x2 centimeter irregular shaped light purple discoloration); No recent falls per record; Resident has been staying in bed; Denies pain; Moves all extremities without complaint of pain. R2's progress notes dated 6/29/2021 at 14:38 document, Late entry: 6/21/2021 0805 AM. CNA called this nurse to residents room, resident was found on her left side on the floor beside her bed on blanket. Denies pain or discomfort, no sign/symptoms of distress, range of motion (ROM) within normal limits for resident, no apparent injury noted. Resident lifted by staff back into bed. ADON (V5) notified of fall. R2's Progress notes dated 6/29/2021 at 14:38 (2:38pm) document, (Doctor) notified at this time of fall, No new orders. R2's Progress Notes dated 6/29/2021 14:53 (2:53pm) documents, POA (V3) notified of fall. Facility document attached to (R2)'s abuse report of 6/23/2021, entitled addendum letter To: Illinois Department of Public Health (IDPH); date 6/29/2021; From: (V1); Regarding: Update regarding (R2) investigation documents, emailed on 6/29/2021 at 4:52 PM documents, Please allow this to serve as an update/addendum to the final report sent on 6/28/2021 regarding a bruise of unknown origin on (R2). Upon further investigation it was determined that (R2) did sustain a fall on 6/21/2021. Power of Attorney (POA) and Physician have been made aware of the fall. (R2)'s care plan has been revised with an appropriate intervention, and staff re-education is underway. On 7/15/2021 at 8:30 AM, V3 stated, On 6/23/21 during her visit she found a bruise on (R2's) forehead and reported it to the on duty nurse. The nurse on duty said she did not know of any recent falls or injury's and notified the doctor and (V1). On 6/29/2021 she was called by nurse (V4) who apologized because she had dropped the ball and failed to report a fall for (R2). On 6/21/2021 she found (R2) on the floor in her room and did not document or report it to the doctor. They did change (R2's) mattress because they thought it was the reason she may have rolled out of bed. On 7/15/2021 at 11:15 AM, V1 Administrator stated, about 3 weeks ago (V3) was visiting and reported a bruise on (R2's) forehead. There was no knowledge of any recent accident or injury to explain the cause for the bruising, so an abuse investigation was initiated. After the investigation was done and the final report was sent to Illinois Department of Public Health (IDPH), (V4) Registered Nurse (RN) reported (R2) had been found on the floor in her room a few days before the bruise. The fall was not documented and there was apparently a miscommunication between (V4) and (V5- Assistant Director of Nursing-ADON) regarding if it was a fall or not a fall. (V4) understood (V5) to instruct her to just monitor (R2). An addendum report was submitted to IDPH reporting the fall. The appropriate procedure was not followed by staff in this case, and there was a nursing in service done regarding the proper procedures for notification of residents change of condition, and review of reporting and investigation procedures. On 7/15/2021 at 11:30 AM V5 ADON stated, (V4) should have initiated a fall protocol if (R2) was found on the floor. (V4) should have done a full nursing assessment, called the doctor and family, document in the nurse's notes, on an incident report. They monitor the residents for injury after any falls each shift for 3 days. Nursing is expected to do a fall assessment and update the care plan with every fall at the time of incident. On 7/16/2021 at 1:50 PM V4 RN stated, on 6/21/2021 she was called to (R2's) room where (R2) was found lying on the floor by her bed. She was assessed (R2) with no injuries and assisted her with help back to bed. V4 also stated, she reported the fall incident to (V5) ADON on 6/21/2021 and she instructed her not to write it up and to just monitor (R2). Then on 6/29/2021 (V5) asked her to write a witness statement regarding the bruise investigation and that is when she reported the fall, documented the incident, and called the doctor and (V3). V4 also stated, she was aware of the facility protocol for falls and should have documented the assessment and made the notifications to the doctor and the family immediately at the time of the fall. Facility undated Policy entitled, Significant Condition Change and Notification documents in part, Purpose- To ensure that the resident's family and or representative and medical practitioner are notified of resident changes such as those listed below: An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention. A significant change in the resident's physical, mental, or psychosocial status. Procedure When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner.

Based on interview, observation, and record review, staff failed to follow the facility policy for appropriate hand hygiene for 1 of 30 residents (R30) reviewed for infection control in the sample of 30. Findings include: 1. On 05/05/21 01:30 PM, V4 Licensed Practical Nurse (LPN) set up the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 was not observed to perform hand hygiene before she put on gloves. V4 removed the old gauze wrap, and discarded it in the trash. V4 then picked up a wound cleanser bottle with the same gloved hands, and sprayed it on the dried dressing material stuck to the outer ankle and used her gloved fingers to pull the dried material from the wound. V4 discarded the material in the trash, removed her gloves and put new gloves on without performing hand hygiene. V4 applied a new dressing, and with same gloved hands assisted residents bed to the low position. V4 removed the gloves and discarded them, and did not perform hand hygiene after the dressing. Surveyor then asked V4 if she had any alcohol based hand sanitizer available on the treatment cart, and V4 stated no she did not and she planned to wash her hands before she goes to the next patient. V4 then pushed her treatment cart out of R30's room, and used the hand sanitizer on the wall. 2. On 05/06/21 at 7:45 AM, V6 Certified Nursing Assistant (CNA) was feeding R8 breakfast with her gloves on. In the same room V5 CNA was feeding R30 his breakfast with her gloves on. After both residents finished their breakfast, V5 CNA left the room to get a mechanical lift for R30's transfer to bed. When V5 returned to the room with the lift, V6 came from R8's bedside area, over to R30's bedside to assist with R30's transfer wearing the same gloves. After R30 was in bed, V6 then assisted R30 with removal of his pants, removal of his incontinent brief, and cleansing his buttocks with wipes without changing gloves. V6 discarded the used incontinent brief in the bathroom trash, removed her gloves, and washed her hands in the bathroom with soap and water before application of the new brief. On 5/7/2021 at 12:50 PM, V9 Registered Nurse (RN) stated she would expects all staff to practice good hand hygiene with use of either hand sanitizer, or soap and water between each resident close contact. And before putting on, and after taking their gloves off. Facility's Policy entitled, Infection Prevention and Control Manual Dated 2019 documents in part, Standard Precautions. Hand Hygiene. Purpose: To cleanse hands to prevent the spread of potentially deadly infections. To provide a clean and healthy environment for residents, staff, and visitors. Procedure: Perform hand hygiene: (Soap, water, Alcohol-based hand rub- ABHR), and sink should be readily available in appropriate locations including but not limited to resident care areas and food and medication preparation areas. Antimicrobal gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a feed service setting. Staff must perform hand hygiene even if gloves are utilized. Gloves or the use of baby wipes are not a substitute for hand hygiene.

Based on observation, interview and record review the facility failed to ensure catheter care was provided every shift as ordered for 1 of 1 (R45) residents reviewed for catheter care in the sample of 30. Findings Include: R45's admission record dated 5/7/2021 documents R45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's MDS (Minimum Data Set) dated 3/29/2021 documents a BIMS (Brief Interview for Mental Status) score of 10 which indicates R45 has a moderate cognitive deficit. R45's current care plan (not dated) documents a focus area of urinary catheter related to BPH with obstructive [CONDITION(S)] with an initiation date of 3/22/2021. This focus area's interventions include urinary catheter care every shift and as needed. R45's order summary report dated 5/7/21 documents a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/06/21 at 9:10 AM, V13 (Certified Nursing Assistant/CNA) was observed providing urinary catheter care to R45. R45's penis and groin were red and inflamed with an area that appeared to be a blister that had burst near the area where the foreskin meets the head of the penis. V13 stated she didn't realize it was red and irritated and would report it to the nurse so a treatment could be started. When asked how often catheter care is provided V13 stated, it was supposed to be done every shift. R45 stated, they have never done catheter care like this before. R45's progress notes document on 5/6/21, patient had a blister on his penis under his foreskin. blister has now popped. no drainage, no bleeding from area. patient denies pain. MD (physician) .notified. R45's treatment sheets dated 4/1- 4/30/21 and 5/1- 5/31/2021 documents R45 received catheter care every shift. These treatments were signed by nursing staff including V4 (Licensed Practical Nurse/LPN-Wound nurse). On 05/06/21 at 10:40 AM, V4 (Licensed Practical Nurse/LPN- Wound nurse) stated she did not see the blister area on R45's penis but did see that the area was red and irritated. When asked who normally provided catheter care for R45 V4 stated, she wasn't sure how to answer that question. V4 stated she is not the one doing it and she would have to check with the floor nurse. V4 checked with V3 (Registered Nurse) who stated they all did, when asked who was performing catheter care. V3 stated, R45 is confused and does get catheter care as ordered. On 05/06/21 at 3:36 PM, V14 (Certified Nursing Assistant/CNA) stated, R45's penis had appeared red and irritated when she provided care within the past week. When asked if she had reported to anyone the area was red and irritated V14 stated she had reported it to a nurse but was unable to recall which nurse. On 05/07/21 at 9:20 AM, V4 (LPN/Wound nurse) stated she was not aware of the irritation on R45's penis until this surveyors observation on 5/6/21. V4 stated if she had been aware of it she would have called the physician and implemented a treatment because she doesn't want anyone to be in pain. On 05/07/21 at 11:40 AM, V16 (Nursing Assistant) stated, midnight shift usually got R45 up and ready and she has not provided catheter care to R45. ON 05/07/21 at 11:52 AM, V15 (CNA) stated, R45 is up and dressed a lot of the time when she comes in to work. V15 stated she considers catheter care as part of his am care so she doesn't do it unless there is obvious soiling or some other reason he needs cleaned. On 05/07/21 at 12:15 PM, V2 (Interim Director of Nurses/RN) stated she would expect each shift to provide catheter care and if an area of irritation is reported she would expect it to be followed up on and treatment orders obtained and initiated.

Based on observation, interview and record review the facility failed to ensure pressure areas were identified and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R16's facility admission record documents R16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's MDS (Minimum Data Set) dated 3/24/21 documents R16 has a modified independence in cognitive skills and is dependent on staff for transfers and locomotion and extensive assistance of staff for dressing, toilet use, personal hygiene, and bed mobility. R16's Braden Scale for Predicting Pressure Sore Risk dated 4/16/21 documents a score of 15 which indicates R16 is at risk for skin breakdown. On 5/6/21 at 10:19 AM, V3 (Registered Nurse) was observed providing treatments to R16's right leg. When R16 turned onto her right side this surveyor observed an area on R16's left heel that was covered with eschar. V3 assessed the area and stated the surrounding tissue on one side was mushy and it appears to be a blister that has popped. V3 stated she was going to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R16's weekly skin check dated 4/30/21 does not document a pressure area to R16's left heel. R16's skin and wound evaluation dated 5/7/21 documents the area to R16's left heel identified on 5/6/2021 as an unstageable pressure area that was acquired in house. The area is documented as measuring 1.6 cm (centimeters) x 1.4 cm. R16's progress notes document on 5/6/21, An unstageable pressure injury was found to R16's left heel measuring 1.66 cm x 1.6 cm. Area cleansed and has skin prep applied to it. R16 is wearing heel protector to left foot and staff is offloading pressure while in bed. R16 developed this injury due to using the trapeze bar and left heel to move herself in bed. Notified MD (physician) of pressure injury and awaiting any new orders. R16 is aware of the injury and the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/07/21 at 09:20 AM, V4 (Licensed Practical Nurse/Wound nurse) stated, when there is a new area identified between weekly skin checks the CNA's (certified nursing assistants) report it to the floor nurse. V4 stated she was not aware of the area to R16's left heel until it was observed by this surveyor on 5/6/21. V4 stated, if it had been there for awhile she must have just missed it. CNA's are supposed to be reporting any areas to the nurse who then should be letting her know or implementing treatments. On 05/07/21 at 11:13 AM, V6 (CNA) stated she did not see the area on R16's heel while providing care to her this week. V6 stated R16 gets her shower on evening shift so she would not be assessing the skin for open areas. On 05/07/21 at 11:56 AM, V9 (Registered Nurse) stated she would expect new areas of skin breakdown to be identified by staff while they are providing care so treatments can be implemented. The facility pressure ulcer/pressure injury prevention policy dated 4/2018 documents under planning, An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. The goal is for the resident to be free of preventable pressure ulcer/pressure injury.

Based on observation, interview, and record review the facility failed to provide assistance with ambulation to prevent a decline and/or ensure maintenance of ambulation abilities for 1 of 3 (R9) residents reviewed for activities of daily living in the sample of 30. Findings Include: R9's facility admission record dated 5/7/21 documents R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS (Minimum Data Set) dated 2/6/21 documents R9 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates R9 is cognitively intact. On 05/04/21 at 11:27 AM, R9 was sitting in her wheelchair in her room. R9 stated, she had received therapy services through sometime in April 2021 and hadn't received any services since then. R9 stated, she had been walking with her walker with therapy and they told her the certified nursing assistants (CNA) would continue to walk her since skilled therapy services were ending. When asked if the CNA's were walking her; R9 stated, no one has walked with her since then. R9's current care plan (not dated) documents a focus area with an initiation date of 5/18/2020, of ADL (activities of daily living) self care performance deficit, with an intervention to ambulate with the assist of one staff member as far as the oxygen concentrator would allow. R9's restorative program reviewed from 4/7/2021 through 5/6/2021 documents R9 is to ambulate with the assist of one staff member for as far as the oxygen concentrator will allow. R9 was not ambulated on 4/11, 4/15, 4/21, 4/22, 4/25, 4/26, 4/28, 5/5, and 5/6/21. On 5/6/21 at 11:18 AM, V6 (Certified Nursing Assistant/CNA) stated R9 uses her wheelchair to ambulate in her room and in the hallway. V6 stated R9 gets up in the morning and takes her wheelchair to the bathroom where she requires assistance to transfer out of the wheelchair and to the commode. V6 stated after that R9 is able to transfer herself. V6 checked R9's electronic health record and stated she could see where R9 is to be walked with staff assistance. On 05/06/21 at 1:23 PM, V12 (CNA/ restorative aid) stated she is working as a CNA on another unit today and when she works as a CNA on the floor she does the restorative programs she can for the residents on the unit she is working on but is unable to provide the restorative programs for the residents on the other units. V12 stated when the program says NA it means the program was not completed for the resident on that day. V12 stated the CNA's working on each unit should be completing the restoratives. On 5/6/21 at 1:23 PM V2 (Interim Director of Nurses/Registered Nurse) reviewed the documentation and confirmed R9's restorative program for ambulation was not being done every day as it should have been.

Based on Interview and Record Review, the facility failed to provide current information, and offer the administration of the recommended pneumonia vaccine (PPSV23) in accordance with national standards, for 4 of 5 residents (R1, R3, R4, and R5) reviewed for immunizations this survey. The Findings Include: On 12/16/2020 at 12:27 PM, V3 (Licensed Practical Nurse/LPN) stated he is in charge of immunization tracking for the facility. The reason the Pneumonia 23 vaccine is not referenced on their immunization records are since the PCV13 vaccine came out I don't offer the Pneumonia 23 anymore. R1, R3, R4, and R5's immunization records were reviewed, and there was no reference to the 23-valent [MEDICATION NAME] vaccine (PPSV23) being offered, declined, or administered. The facility policy entitled, Pneumococcal Vaccine, dated 2008 documents, Prior to or upon admission, residents will be assessed for eligibility to receive the [MEDICATION NAME]® (pneumococcal vaccine), and when indicated, will be offered the vaccination at the time of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The Center for Disease Control (CDC) documents, Pneumococcal Vaccination: What Everyone Should Know PPSV23 states, [MEDICATION NAME]®external icon?: Doctors give a single shot of this vaccine to people who need it. CDC recommends 1 or 2 additional shots for people with certain chronic medical conditions. This vaccine helps protect against serious infections caused by 23 types of pneumococcal bacteria. The Center for Disease Control article, dated, November 22, 2019 entitled, Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal [MEDICATION NAME] Vaccine Among Adults Aged =[AGE] years: Updated Recommendations of the Advisory Committee on Immunization Practices; Summary, In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent [MEDICATION NAME] vaccine (PPSV23) for all adults aged =[AGE] years. The Pneumococcal [MEDICATION NAME] Vaccine Information Statement (VIS) dated, 10/30/2019 documents, PPSV23 protects against 23 types of bacteria that cause pneumococcal disease. PPSV23 is recommended for: All adults [AGE] years or older, Anyone 2 years or older with certain medical conditions that can lead to an increased risk for pneumococcal disease. Most people need only one dose of PPSV23. A second dose of PPSV23, and another type of pneumococcal vaccine called PCV13, are recommended for certain high-risk groups. Your health care provider can give you more information. People [AGE] years or older should get a dose of PPSV23 even if they have already gotten one or more doses of the vaccine before they turned 65.