Every finding on record at Effingham Healthcare & Senior Living

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was available 7 days a week for 8 consecutive hours a day. This failure has the potential to affect all 36 residents living in the facility.The Findings Include: On 08/27/2026 at 10:00 A.M., V2 (Director of Nursing) stated she is aware that every other weekend there is no RN coverage. V2 stated they are in the process of hiring staff to work to cover the shifts that are needed. V2 stated she clocks in and out and knows her hours count towards RN coverage.On 08/27/2026 at 10:28 A.M., V8 (Licensed Practical Nurse / Assistant Director of Nursing) stated she is responsible for the nurse schedule. V8 stated every other weekend there is no RN coverage. V8 stated they are trying to hire an RN to help cover every other weekend that there is no RN coverage. V8 stated there is only one full-time Registered Nurse at the facility besides V2.On 08/27/2026 at 11:28 A.M., V1 (Administrator) stated she is aware that the facility is not meeting the RN coverage of 8 hours a day for 7 days a week. V1 stated there are ads out to hire RN's and the facility just hired a PRN (as needed) RN to help cover.On 08/27/2026 at 1:08 P.M., V1 stated the facility does not have a policy for Registered Nurse hours and they follow the regulations for the required hours.The facility's working schedules for June 2026, July 2026, and August 2026 documented the following dates were lacking RN hours: 06/1/2026, 06/02/2026, 06/03/2026, 06/06/2026, 06/07/2026, 06/18/2026, 06/20/2026, 06/21/2026, 06/22/2026, 07/06/2026, 07/07/2026, 07/09/2026, 07/10/2026, 07/11/2026, 07/12/2026, 07/13/2026, 07/16/2026, 07/17/2026, 07/21/2026, 07/24/2026, 07/25/2026, 07/26/2026, 07/31/2026, 08/01/2026, 08/02/2026, 08/06/2026, 08/07/2026, 08/08/2026, 08/09/2026, 08/11/2026, 08/15/2026, 08/16/2026, 08/18/2026, 08/22/2026, 08/23/2026, and 08/24/2026.The Minimum Data Set Resident Matrix with a print date of 08/25/2026, documents that 36 residents are currently residing in the facility.

Based on observation, interview and record review the facility failed to implement enhanced barrier precautions for 2 (R1 and R7) of 4 residents reviewed for infection control in the sample of 9.The Findings Include:1. R1's admission Record documented an admission to the facility of 01/20/2026. Diagnoses listed include unspecified atrial fibrillation, atherosclerotic heart disease of native coronary artery, chronic kidney disease, spinal stenosis, and morbid obesity.R1's Order Summary dated 08/27/2026 documented an order for site: Umbilical: cleanse wound with normal saline or sterile water, apply Xeroform to wound bed, cover with clean dry dressing daily and PRN as needed for soiled or loose dressing.R1's Care Plan with an initiated date of 05/21/2026, documents a focus area of R1 has actual impairment to skin integrity of the umbilical r/t (related to) abscess. There was no intervention listed for the use of enhanced barrier precautions.2. R7's admission Record documented an admission date to the facility of 06/11/2026. Diagnoses listed include type 2 diabetes mellitus, hyperlipidemia, essential hypertension, unspecified atrial fibrillation, and chronic kidney disease.R7's Order Summary dated 08/27/2026 documented an active order for right lower extremity (posterior): Cleanse area and pat dry, apply collagen Ag (silver) to wound bed, then apply nonadherent gauze, then wrap with kerlix (cotton gauze bandage) daily and as needed for soiled or loose dressing, right lower extremity (posterior): Cleanse area and pat dry, apply triad to periwound, then apply collagen ag to wound bed, then apply non-adherent gauze, then wrap with kerlix daily and as needed for soiled or loose dressing, and right shin, cleanse with normal saline or wound cleanser, apply Xeroform (non-adheren petroleum gauze) to wound bed, cover with bordered gauze dressing daily and as needed for soiled or loose dressing.R7's Care Plan documented a focus area of Implementation of Enhanced Barrier Precaution due to R7 having a wound and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with an initiated date of 08/27/2026.On initial tour of the facility on 08/25/2026 at 9:15 A.M., R1 and R7 did not have isolation precautions in place. There were no signs posted outside R1 and R7's room nor any personal protective equipment available outside of their rooms.On 08/25/2026 a Resident Matrix was provided. R1 and R7 were not marked to be on Transmission Based Precautions.On 08/25/2026 at 1:00 P.M., V8 (Licensed Practical Nurse) and V16 (Doctor of Nursing Practice) were observed entering R1's room and close the door. On 08/25/2026 at 1:11 P.M., V8 and V16 were observed exiting the room. V8 nor V16 donned or doffed personal protective equipment during this time. There was no personal protective equipment station available outside of R1's room.On 08/25/2026 at 1:49 P.M., V8 and V16 were observed entering R7's room and close the door. On 08/25/2026 at 2:01 P.M., V8 and V16 were observed exiting the room. V8 nor V16 donned or doffed personal protective equipment during this time. There was no personal protective equipment station available outside of R7's room.On 08/27/2026 at 10:00 A.M., V2 (Director of Nursing) stated she will have to look at the list of residents who are on isolation and make sure everyone who is on isolation should be. V2 stated she will review the policy and make sure all residents who have open wounds are in the appropriate precautions. V2 stated she is not sure if R1 and R7 have to be on enhanced barrier precautions.On 08/27/2026 at 10:28 A.M., V8 (Licensed Practical Nurse / Assistant Director of Nursing) stated that only pressure ulcers and deep wounds had to be on enhanced barrier precautions. V8 stated she did not think every open area had to be on precautions. V8 stated she is not sure if R1 and R7 should be on enhanced barrier precautions or not. V8 stated she will review policy and verify with regional nurse about it.On 08/27/2026 at 1:16 P.M., V8 stated R1 and R7 have both been placed on enhanced barrier precautions.The facility policy titled Enhanced Barrier Precautions with a revision date of December 2024, documented Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms to residents.3. Contact precautions apply when . b. a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device.

Based on interview and record review the facility failed to safely transport a resident and thoroughly investigate an accident for 1 (R4) of 4 residents reviewed for accidents in the sample of 9.The Findings Include: R4's admission Record documents that R4 was admitted to the facility on [DATE]. The diagnoses listed include chronic obstructive pulmonary disease, dependence on renal dialysis, type 2 diabetes mellitus, chronic combined systolic and diastolic heart failure, pneumonia, and end stage renal disease. The same admission Record documents that R4 was discharged to home on 7/12/26.R4's MDS (Minimum Data Set) dated 0/20/2026 documented that R4 had a BIMS (Brief Interview for Mental Status) 09, indicating R4 had moderate cognitive impairment. Section GG of the same MDS documented under GG0170 Mobility, Q3. Does the resident use a wheelchair and/or scooter? 1. Yes, is coded.R4's Care Plan documented a focus area of the resident has limited physical mobility related to weakness with an initiated date of 04/26/2026. Interventions listed include wheel 50 feet with two turns: 1 assist. A focus area of resident review shows R4 is a moderate risk for falls. Interventions listed include medication review, clip alarm, call don't fall sign placed by bathroom, resident to be in recliner after supper, and resident's call light in reach.R4's Progress Note dated 07/02/2026 documented while resident was in wheelchair in transport van, R4 bumped his head on the lift gate. Resident assessed and for injury and no visible injury noted at this time. Neuro checks initiated and are within normal limits.R4's incident report dated 07/02/2026 documented this nurse was notified by transport driver that while resident was in wheelchair in transport van R4 bumped his head on the lift gate. Under section titled Notes documents 07/03/2026 R4 noted to bump head on lift gate during outpatient transfer. Dialysis bag not to be on the back of the resident's wheelchair during transfers. Transportation staff and resident educated, voiced understanding. On 08/26/2026 at 11:25 A.M., V11 (Transport Driver) stated she was transporting R4 back from dialysis. V11 stated she had strapped R4's wheelchair down, and his dialysis bag was left on the back of his wheelchair. V11 stated the bag must have made R4's wheelchair top heavy because when she slowed down to make a turn, R4's wheelchair tipped over backwards. V11 stated R4's back was on the floor of the van. V11 stated she immediately stopped and put the wheelchair in the upright position. V11 stated she was about two minutes from the facility, so she continued to drive back to the facility. V11 stated she is not sure why the wheelchair tipped over because she had all the proper straps in place at the time of the incident. V11 stated as soon as she got back to the facility, she immediately told the administrator. V11 stated R4 was immediately assessed for injuries. V11 stated R4 had no visible injuries.On 08/26/2026 at 11:39 A.M., V12 (Certified Nurse Assistant) stated she only heard about the incident from other staff members from the facility. V12 stated she heard that a strap or a buckle was not fastened correctly and that caused the wheelchair to tip over.On 08/26/2026 at 12:32 P.M., V13 (Registered Nurse) stated she was R4's nurse the day of the van incident. V13 stated she was coming up the hallway and heard the staff talking that R4 hit his head in the van. V13 stated she was not told the specifics of the incident, so she does not know what he hit his head on. V13 stated she is not exactly sure what is on the incident report. V13 stated she initiated the report and neuros, but management finished the incident report. V13 stated that R4 refused to go to the hospital and wanted to go the next day. R4's progress note dated 07/03/2026 documented that R4 complained of headache and soreness pain to chest and right shoulder. After lunch resident stated that pain is unrelieved and is requesting to go to local emergency department.R4's local hospital after summary dated 07/03/2026 documents a fall is the reason for the visit. Diagnoses listed include headache, fall, and head injury.R4's records from a separate Emergency Department visit dated 7/5/26 documents under findings of a CT (Computed Tomography) of the head of No CT evidence of an acute intracranial abnormality.On 08/26/2026 at 12:42 P.M., V8 (Licensed Practical Nurse / ADON) stated she asked V11 (Transport Driver) what occurred, and V11 told V8 that R4 hit his head on the lift gate. V8 stated V11 never said she had to stop and pick his chair up or that the wheelchair flipped all the way over. V8 stated V11 made it sound like he bumped his head on the lift gate, but the chair never turned over. V8 stated the IDT (Interdisciplinary Team) discussed the incident and decided the intervention was to remove the bag from the wheelchair during transport. V8 stated she was never told that R4's wheelchair had turned over completely and V11 had to stop and sit R4 back upright.On 08/26/2026 at 1:14 P.M., V8 stated she is not sure what was in the bag that R4 took to dialysis. V8 stated she knows there was a blanket and a head pillow but unsure if there was anything else in it.On 08/26/2026 at 2:52 P.M. attempted to call V14 (Former Administrator) without success. The phone number provided by the facility for V14 was no longer in service.On 08/27/2026 at 9:21 A.M., V11 stated on the day that R4's wheelchair tipped over he did not have foot pedals on. V11 stated R4 was in a high back wheelchair, and the dialysis bag was on the handles. V11 stated she is not sure what exactly was in the bag, but she thinks it was a blanket and a pillow. V11 was asked to secure a wheelchair in the van as if she was transporting a resident. This surveyor asked V11 to place the wheelchair where it was in the van when the incident occurred. While the wheelchair was secured with the straps, V11 was unable to move the wheelchair to the position it was in during the incident. V11 had to remove the straps to place the wheelchair with the back on the floor as it was when the incident occurred. V11 stated that R4 did lean to the right in his wheelchair. V11 stated she knows she had all the straps fixed appropriately. V11 stated when she returned to the facility she told V14 (Former Administrator) that the chair had tipped over and when the chair was tipping over R4 hit his head on the liftgate.On 08/27/2026 at 10:00 A.M., V2 (Director of Nursing) stated V14 handled the entire situation when R4 hit his head on the lift gate of the van. V2 stated that V14 got very defensive and angry when staff would ask questions about the incident. V2 stated she felt like something more happened but was told she was wrong and to leave it alone. V2 stated when she asked V11 (Transport Driver) about the incident, V11 responded that she told V14 everything. V2 stated she was never told that R4's wheelchair had tipped completely over.On 08/27/2026 at 11:28 A.M. V1 (Administrator) stated the incident with R4, and the van happened before she was employed at the facility. V1 stated she is looking into the incident but there is no investigation that she has found. V1 stated she had no idea what occurred or what was reported to V14 at the time of the incident.The facility policy titled Accidents and Incidents - Investigating and Reporting with a revision date of July 2017, documented All accidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.The facility policy titled Van Usage Policy and Procedure with no date documented Purpose: the purpose of this policy is to establish procedures by which employees formally acknowledge and accept responsibilities of operating a facility owned van. Further it establishes requirements for enforcement of operating procedures and safe driving practices. Policy: When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and the resident, obey all state and local traffic laws, and abide by established driver operating procedures. Procedure step 3 c. documents Ensure all residents and wheelchairs are safely secured.

Based on observation, interview, and record review, the facility failed to provide alternative substitutes of similar nutritive value at mealtimes. This has the potential to affect all 36 residents residing in the facility. The Findings Include: On 4/26/26 at 12:00 PM, the meal served was observed to be roasted turkey, glazed carrots and stuffing. On this date and time, V15 (Cook) stated there was not a planned meal alternative for the residents. V15 stated that they have a planned menu signed off by the Dietitian. V15 said that if a resident does not like what is served, they will make them a cold cut sandwich, an egg salad sandwich or peanut butter and jelly after they are finished with all meals being served out. During the lunch meal at 12:45 PM, R21 stated that she does not like the stuffing, and carrots are not her favorite. R21 stated she does not know if they have other items available to ask for. On 4/27/26 at 10:00 AM during Resident Council meeting, R5, R9, R21 and R29 all stated that they do not have a variety of foods to choose from for meals and would like to have an alternative option to choose from. R9 further stated they do not always post the menu up on the board and that is the only way they know what is being served at the next meal. R9 stated it would be nice to know ahead of time what they are eating and what the alternative would be to choose from. On 4/28/26 at 1:00 PM, V1 (Administrator) stated that they are working to incorporate an always available menu that would include a variety of protein and side options to choose if residents do not like the main selections. V1 confirmed at this time there are no planned meal alternatives, it is just what they have from leftovers from previous meals or the options that V15 mentioned above. V1 stated there is not a policy regarding alternative food selections. The Long-Term Care Facility Application For Medicare and Medicaid dated 4/26/26, documents 36 residents currently reside in the facility.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was available 7 days a week for 8 consecutive hours a day and failed to ensure a full time Director of Nursing (DON) was on staff. This failure has the potential to affect all 36 residents in the facility. The Findings Include:1. On 04/26/2026 at 10:40 AM, V1 (Administrator) stated the facility has not had a Director of Nursing (DON) since 3/13/26. V1 stated they are in the process of hiring a new one, but a start date has not yet been set. V1 stated in the interim, the facility staff have been doing the scheduling and if an issue arises, they contact a regional nurse with any questions or concerns. 2. On 4/26/2026 at 10:45 AM, V1 stated every other weekend, the facility does not have a Registered Nurse (RN) available to work the full 8-hour shift. V1 stated they are seeking to hire an RN who is able to work a full 8-hour shift on the weekends that lack coverage. The facility's working schedules for February 2026, March 2026 and April 2026 documented the following dates were lacking RN hours: 2/3/26, 2/4/26, 2/7/26, 2/8/26, 2/13/26, 2/17/26, 2/18/26, 2/21/26, 2/22/26, 2/26/26,3/2/26, 3/3/26, 3/8/26, 3/21/26, 3/22/26, 4/4/26, 4/5/26, 4/8/26, 4/14/26, 4/18/26, 4/19/26, 4/22/26 and 4/20/26.The Director of Nursing Services policy and procedure states that the nursing services department is under the direct supervision of a registered nurse .2. the director is employed full time and is responsible for, but is not necessarily limited to .h. ensuring sufficient and competent staffing levels to meet the needs of residents as indicated by the facility assessment and resident care plans; j. participating in the planning and budgeting of nursing services .The Long-Term Care Facility Application For Medicare and Medicaid application dated 4/26/26, documents that 36 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to protect the privacy of 2 (R1 and R7) of 4 residents reviewed for resident rights in the sample of 27.Findings Include:1. R1's admission Record documented R1 was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of sacral region. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating R1 has moderate cognitive impairment. R1's current Care Plan documents a Focus area of Skin Integrity: Resident may be predisposed to develop skin impairment caused by pressure. R/T (related to) Moderate Risk per Braden Scale- Risk factors . This Focus area includes interventions of Braden/Skin risk assessment quarterly, pressure relieving devices, and apply incontinent barrier cream. On 4/29/26 at 11:00 AM, V3 (Registered Nurse/RN), V2 (Wound Nurse), and V4 (Certified Nursing Assistant/CNA) provided wound care to R1 with this surveyor present. R1 was in bed with blankets pulled back, incontinence brief loosened, and lower body exposed when this surveyor entered room. R1's roommate was in their bed and appeared to be sleeping. V2, V3, and V4 removed R1's incontinence brief and administered treatment to the pressure ulcer located on R1's left hip. The privacy curtain was not pulled throughout the observation. During administration of the treatment, V2 and V3 left the room to obtain more supplies. The door to the hallway was left open as R1 was exposed. 2. R7's admission Record documented an admission date of 9/5/25 and included diagnoses of pressure ulcer of sacrum and osteomyelitis. R7's MDS assessment dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. R7's current Care Plan documents a Focus area of Skin Integrity: Resident has actual impairment to skin integrity of the sacrum r/t (related to) Surgical, Non-healing wound .Date Initiated: 09/05/2025. This Focus area includes interventions of administer treatment as ordered. On 4/29/26 at 11:19 AM, V2 (Wound Nurse), V3 (RN), and V4 (CNA) administered treatment to the pressure ulcer located on R7's sacrum with this surveyor present. There were two roommates present in R7's room with the privacy curtains pulled around their beds. The door to R7's room was left open throughout parts of R7's treatment when V3 exited the room to obtain supplies. However, R7's bed was located behind the door, so she wasn't exposed to the hallway. During the treatment, V17 (CNA) entered R7's room without knocking. V17 entered the pulled curtain around one of R7's roommates, assisted her to a wheelchair, and wheeled the roommate out of the room while R7's buttocks were exposed for the roommate to see. V17 then entered the room a second time without knocking. V17 entered the other roommates closed privacy curtain and assisted her up and out of the room. V17 took the roommate past R7, whose buttocks were exposed. Throughout this observation, R7's buttocks were exposed and V2, V3, and V4 were administering the treatment to the pressure ulcer located on R7's sacrum. On 4/29/26 at 1:59 PM, V1 (Administrator) stated she would expect privacy curtains to be pulled and doors to be closed during treatments to protect the privacy of the resident. On 4/29/26 at 2:27 PM, V2 (Wound Nurse) stated she would expect staff to knock before entering the room and wait until treatments were completed to provide non-emergent care to other residents in the room. V2 stated she would expect doors to be closed, and privacy curtains pulled to protect the privacy of the residents. The facility Dignity Policy dated February 2021 documents, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.7. Staff are expected to knock and request permission before entering residents' rooms.11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to report allegations of a missing item to the state agency (Illinois Department of Public Health) for 1 (R27) of 2 residents reviewed for abuse in the sample of 27. Findings included:R27's Care Plan Summary/ Participation Record dated 4/9/2026 documented a care plan meeting with V2 (Wound Nurse), V5 (Minimum Data Set/MDS Coordinator), V10 (Social Services Director/SSD) and V13 (Family) with topic of discussion of missing shoes. On 04/27/2026 at 9:33 AM, V13 (Family) stated she had come into the facility a few weeks ago and noticed R27 was missing a pair of her Skechers shoes. V13 stated she alerted staff of the missing shoes and then had a care plan meeting with the facility on 4/9/2026 to discuss the missing shoes. V13 stated she is still waiting to hear from the facility on how they are planning to resolve the missing shoes. On 4/28/2026 at 11:06 AM, V4 (Certified Nursing Assistant/CNA) stated R27 was moved to a different room not too long ago. V4 stated she had been made aware that R27 was missing 2 different pairs of shoes, and the facility found one pair but not the other. On 4/28/2026 at 11:13 AM, V10 (SSD) stated about a few weeks ago, R27 was moved from one room to another room and V13 (Family) notified V10 that R27 was missing 2 pair of shoes. V10 stated the facility found one pair of R27's shoes but not the other pair. V10 stated she did not file a grievance form or list it on the grievance log. V10 stated she had a care plan meeting with V13 where they discussed missing shoes on 4/9/2026. V10 stated she notified V9 (Housekeeping Supervisor) of the missing shoes so they could look for them but is not aware if V9 has done that yet or not. On 4/28/2026 at 11:21 AM, V1 (Administrator) stated she was made aware a few weeks ago that V13 notified the facility of R27 missing a pair of shoes. V1 stated V9 is in the process of looking for the shoes but she is not sure where she is in that process. V1 stated she does not have a grievance on file for the missing shoes and did not report it to the state department as abuse-theft. The facility policy Abuse, Neglect, Exploitation or Misappropriation, - Reporting and Investigating (revision date September 2022) documented under Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Policy Interpretation and Implementation 2. The administrator or the individual making the allegation immediately reports his or her suspicion on the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility

Based on interview and record review, the facility failed to ensure PASRR (Preadmission Screening and Resident Review) Level 2 screenings were completed for 1 (R4) of 5 residents reviewed for screenings in the sample of 27.Findings Include:R4's Transfer/Discharge Report dated 4/29/26 documented R4 was admitted to the facility on [DATE]. This same report includes diagnoses of bipolar disorder, cerebral infarction, dementia, brief psychosis episode, and major depressive disorder.R4's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 09, indicating R4 had moderate cognitive impairment.R4's current Care Plan documents a Focus area of, Anti-Psychotic: The resident uses anti-psychotic medications for brief psychotic disorder, paranoid delusions r/t (related to) MDD (major depressive disorder). Date Initiated: 09/25/2025. This Focus area includes the interventions to administer medications as ordered, consult with pharmacy as needed, and discuss with physician and family related to ongoing need for medications.R4's Notice of PASRR Level 1 Screen Outcome dated 8/8/22 documents No Level 2 required due to no serious mental illness.R4's Progress Note dated 7/8/25 documented, In house psychiatrist in to see resident on 7/3/25. New orders to start Quetiapine 25 mg (milligrams) PO (by mouth) q (every) HS (bedtime) and new diagnosis of brief psychotic disorder.R4's medical record did not document a new screening after the diagnosis of psychotic disorder on 7/8/25.On 4/28/26 at 9:45 AM, V1 (Administrator) stated they did not get a Level 2 screening after the new diagnosis of psychotic disorder on 7/8/2025.The admission Criteria policy dated 3/2019 documents, Our facility admits only residents whose medical and nursing care needs can be met .

Based on interview and record review the facility failed to ensure showers were provided as scheduled for 1 (R28) of 1 resident reviewed for ADLs (Activities of Daily Living) in the sample of 27.Findings Include:R28's admission Record documented an admission date of 10/31/25 and included diagnoses of complete lesion at C5 level and pressure ulcer of sacral region. R28's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R28 is cognitively intact. This same MDS documents R28 requires substantial/maximal assist with bathing. R28's current Care Plan includes a Focus area with a start date of 11/10/25 of, ADL: Resident is usually able to perform ADLs with setup to mod (moderate) assist r/t (related to) complete lesion at c5 level spinal cord, depression, orthostatic HTN (hypertension), and S3PU (Stage 3 Pressure Ulcer) to buttock. This Focus area includes an intervention of Shower/bathe self: max (maximum) assist x (times) 1. Date Initiated: 11/10/2025. On 4/26/26 at 10:50 AM, R28 stated he didn't get a shower for a long time because he requested a day shift shower, and it took them a long time to make the change. R28 stated he just started getting showers about three weeks ago. The facility Shower List documents R28 should receive assistance with bathing on Monday, Wednesday, Friday, and Saturday. R28's document titled GG ADL Documentation documents NA (indicating bathing was not completed) on the following dates 3/4, 3/6, 3/7, 3/9, 3/11, 3/20, 3/21, 3/23, 3/27, 3/28, 4/1, 4/3, 4/4, 4/6, and 4/8. This same report does not document any initials, indicating R28 did not receive assistance with bathing on 3/5, 3/8, 3/10, 3/19, 3/22, 3/24, 3/26, 3/29, 3/30, 3/31, 4/2, 4/5, and 4/9. This indicates R28 did not receive assistance with bathing from 3/4-3/11 (9 days), 3/19-3/24 (6 days), and from 3/26-4/9 (15 days). On 4/28/26 at 3:23 PM, V16 (Certified Nursing Assistant) stated she has not been employed here very long but has previously come in on her days off to assist R28 with showers. V16 stated R28's showers used to be on night shift. This surveyor reviewed R28's shower sheets with V16 and asked when she may have assisted R28 with showers and V16 was unable to recall the dates she may have assisted him. On 4/29/26 at 2:42 PM, V2 (Wound Nurse) stated she didn't see any documentation of R28 refusing assistance with bathing and didn't have a good answer for why R28 did not receive assistance with bathing as scheduled. On 4/29/26 at 3:00 PM, V1 (Administrator) stated she would expect residents to be assisted with bathing as scheduled. The facility Bath, Shower/Tub policy dated February 2018 documents, Purpose: /the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Documentation: 1. The date and time the shower/tub bath was performed.5. If the resident refused the shower/tub bath, the reason(s).

Based on interview, observation, and record review, the facility failed to ensure care plan fall interventions were implemented for 1 (R16) of 3 residents reviewed for falls in the sample of 27. Findings included:R16's admission Record documented an admission date of 10/07/2022 and included diagnoses of Alzheimer's disease, unspecified, transient cerebral ischemic attack, unspecified, major depressive disorder, recurrent, moderate, vitamin D deficiency, unspecified and anemia. R16's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. Under Functional Abilities and Goals, the MDS documents that R16 needed partial/moderate assistance (helper does less than half the effort-helper lifts or holds trunk or limbs and provides less than half the effort) for toilet transfer and documented R16 used a wheelchair. R16's Care Plan documented a focus area of Fall Risk: resident is at risk for falls related to does not ambulate at this time due to wound to the left heel. Corresponding interventions listed anti-slip strips placed on floor next to resident's bed dated 10/20/2025, anti-slip strips in front of resident's bathroom toilet dated 3/4/2026 and call don't fall sign placed in room. On 04/29/2026 at 11:38 AM, R16's room did not have non-skid strips located in front of his bed, the bathroom had no anti-slip strips in front of the toilet and there was no call don't fall sign hanging in the room. On 04/29/2026 at11:40 AM, V6 (Certified Nursing Assistant/CNA) stated all fall interventions are communicated through a communication book. V6 stated R16's fall interventions do not include non-skid strips in front of his bed, bathroom or call don't fall sign. On 04/29/2026 at 11:42 AM, V3 (Registered Nurse/RN) stated all fall interventions are located on the residents care plan. V3 stated R16's Care Plan documented fall interventions that included non-skid strips to be in place in front of his bed, toilet and call don't fall sign hanging in his room, and they should be in place. The facility's communication binder called Care Needs Notices had no documentation of R16's fall interventions of non-skid strips in front of his bed, bathroom or a call don't fall sign. On 04/29/2026 at 11:54 AM, V5 (MDS Coordinator) stated she does enter all interventions on resident care plans. V5 stated once they complete the fall investigation and review the root cause, the facility will implement appropriate interventions. V5 stated V2 (Wound Nurse) will put out communication to staff on new interventions in place. V5 stated R16's Care Plan documented fall interventions that included non-skid strips in front of his bed, toilet, and a call don't fall sign and should be in place. On 04/29/2026 at 12:00 PM, V2 (Wound Nurse) stated after the fall investigation is completed with root cause, the IDT (interdisciplinary team) will meet and implement new and appropriate interventions. V2 stated V5 will document new interventions on the resident's care plan, and V2 will document in the Care Needs Notices book for the CNA staff. V2 stated the nursing staff are to check the care plans daily for any updated information and should have implemented R16's fall interventions of non-skid strips in front of his bed, toilet, and call don't fall sign. On 04/29/2026 at 12:15 PM, V1 (Administrator) stated, it is her expectation that staff implement and follow fall risk interventions in place for residents. The facility's Fall-Clinical Protocol (revision date March 2018) documented under Monitoring and Follow-Up.2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.3. If interventions have been successful in fall prevention, the staff will continue approaches and will discuss periodically with the physician whether these measures are still needed.

Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were implemented during medication administration and resident care for 2 (R7 and R35) of 13 residents in the sample of 27. Findings included:1. R7's admission Record documented an admission date of 9/5/2025 and included diagnosis of chronic kidney disease, stage 3, unspecified, acute kidney failure, unspecified, sepsis, pressure ulcer of sacral region, unstageable, and weakness. R7's Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment. This MDS also documented under Special Treatment/Programs that R7 had been receiving intravenous medications. R7's Medication Administration Record (MAR) documented DAPTOmycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligrams)/50ML (milliliters)-% (Daptomycin Sodium Chloride) Use 500 mg intravenously one time a day for osteomyelitis for 4 Weeks with a -Start Date of 03/31/2026. On 04/27/2026 at 10:47 AM, V8 (Registered Nurse/RN) donned a gown, completed hand hygiene then donned gloves. V8 entered R7's room and placed IV (Intravenous) supplies on R7's bedside table without wiping the table down and with no barrier placed. V8 hung the IV medication on the IV pole, opened the tubing and spiked the bag. V8 then primed the tubing with the medication. The IV tubing blue cap was touching the floor during priming of the tube. Once tubing was finished priming, V8 placed the tubing on the IV pole while touching the blue cap that had been on the floor. V8 then grabbed a saline flush with an alcohol wipe from the bedside table, opening both items and turning to R7. V8 returned the saline flush and alcohol wipe to the bedside table so she could push R7's right shirt sleeve up enough to access her IV site. Using both hands with the same gloves she had donned prior to entering R7's room and spiking/priming the medication and tubing, V8 then struggled to get the IV tale port to come down out of R7's shirt sleeve. V8's gloved hands touched R7's arm, bed and shirt. V8 got the IV access positioned where she could access it, grabbed an new alcohol pad, cleaned the IV access site and then flushed the site with the saline flush that had been sitting on the bedside table with no barrier. V8 flushed the site then connected the IV tubing to the IV access without cleaning the IV access point where the cap had been, with alcohol. Upon initiation of the IV medication, an alarm sounded for air. V8 then stopped the IV pump, removed the tubing port from the access, pulled the tubing from the pump and started flicking the tubing to remove air with the same gloved fingers. During this time, V8 was holding the IV connection site with her hand without donning or duffing of gloves or completing hand hygiene. V8 finished getting the air out of the IV tubing and placed it back in the IV pump. V8 reached into her scrub pants pocket to pull out keys for her medication cart, pulled the IV pump with her while the IV connector port was still in her left hand, used her right hand to unlock the medication cart and grabbed an alcohol pad. V8 returned to R7, cleaned her IV access site with an alcohol pad, and reconnected the tubing. During this observation, V8 never performed hand hygiene or changed gloves. The facility's Administration Set/Tubing Changes (revision date October 2024) documented under Purpose: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV (intravenous) therapy equipment. Preparation:.2. Assemble equipment and supplies as needed. Assess equipment for sterile condition. Do not use if not sterile. General Guidelines:1. Adhere to Standard-ANTT (Aseptic Non-Touch Technique) when connecting, changing and accessing administration set injection ports. Steps in the Procedure: 1. Perform hand antisepsis. 4. Prime new administration set, including add-on devices and tubing: .b. Remove cap from tubing, open roller clamp to prime tubing, then hold the distal end of tubing over sink or trash can (keep tip sterile) and allow all of the air bubbles to leave tubing;.6. [NAME] clean non-sterile gloves. 7. Connecting new tubing:. 2. R35's admission Record documented an admission date of 5/22/2024 and included diagnosis of osteoarthritis of knee, unspecified, type 2 diabetes mellitus with unspecified complications, urinary tract infection (UTI), site not specified and muscle weakness (generalized). R35's MDS dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. R35's Care Plan documented a focus area of contact isolation related to urinary tract infection (start date of 4/18/2026) and resident has a urinary tract infection. Corresponding interventions included to educate resident and family on the need of isolation precaution. Educate family and staff regarding the transmission, pathophysiology, etiology and treatment of infection and give antibiotic therapy as ordered. R35's Physician Order Summary documented a discontinued date of 4/27/2026 of Zosyn Intravenous Solution 4-0.5 GM/100ML (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 4.5 gram intravenously every 8 hours for UTI for 7 Days. On 04/26/2026 at 11:11 AM, V11 (Licensed Practical Nurse/LPN) entered R35's room with a saline flush. V11 did not don gown or gloves and did not complete hand hygiene prior to disconnecting the intravenous (IV) tubing and flushing R35's IV port. On 4/26/2026 at 11:12 AM, a contact isolation sign was observed on the outside of R35's door with personal protective equipment (PPE) available. On 04/26/2026 at 11:19 AM, V11 (LPN) stated she should have donned a gown and gloves when disconnecting R35's antibiotic from his intravenous connection and flushing his port. On 04/27/2026 at 11:26 AM, R35 was self-propelling in his wheelchair down the hallway. V7 (LPN) called out to R35 and told him she needed to see him real quick. R35's midline IV catheter tip was hanging out of his left forearm with dried blood on it with a dressing over the access port. R35 was alert and oriented. R35 stated his midline catheter came out this morning before 8:00 AM medication time and is not sure how it happened. On 4/27/2026 at 11:28 AM, V7 (LPN) walked up to R35 and removed his dressing and midline catheter in the hallway without donning a gown or gloves. V7 stated she had gone into R35's room around 8:00 AM this morning and noticed his midline catheter was out and notified V8 (Registered Nurse/RN). R35's Progress Note dated 4/27/2026 at 11:37 AM by V7 (LPN) documented R35's mid-line located in the left arm was noted to be out this am, this nurse removed all excess remaining which was taped to the arm. On 04/27/2026 at 12:10 PM V8 (RN) stated she was made aware that R35's midline catheter had come out around 8:00 AM this morning. V8 stated V7 should have immediately removed the catheter and dressing and used standard infection control practices for removal. On 04/27/2026 at 12:17 PM, V7 (LPN) stated she had not gotten back down to R35's room to remove his midline catheter or dressing this morning but she was busy. V7 stated she should have used a glove when removing the catheter and dressing but thought she might as well get it done when she saw R35 in the hallway. On 4/27/2026 at 1:00 PM V1 (Administrator) stated her expectations are that staff maintain standard infection control practices and follow facility policy and procedures. The facility's Standard Precautions (revision date September 2022) documented under Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infection agents. Standard Precautions include the following practice:.2. Gloves: a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. b. Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. (For specific pathogens, refer to current CDC isolation precautions guidelines.)

Based on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 (R1) of 3 residents reviewed for accidents in the sample of 5. This failure resulted in R1 acquiring a laceration to her head on the top left side resulting in 2 sutures being placed.This past noncompliance occurred between 11/26/25 and 12/1/25. Findings include:R1's admission Record documented an admission date of 11/10/2025 and diagnoses including chronic systolic heart failure, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, and adult failure to thrive. R1's Minimum Data Set (MDS) dated [DATE], documented under section C- (cognitive patterns) a BIMS (Brief Interview for Mental Status) of 15, indicating R1 was cognitively intact. This same document under section GG- Mobility documented that R1 is dependent, which means helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for a chair/bed-to chair transfer. R1's Care Plan documented a focus area of R1 having limited physical mobility related to weakness, morbid obesity, osteoarthritis, restless leg syndrome, hypertension, spinal stenosis, gout, and left tibia fracture, pain, change in cognitive status, visual impairment, mood, incontinence with an intervention of chair/bed-to-chair transfer: The resident is dependent by 1-2 staff. On 12/23/2025 at 10:04 AM, R1 stated that on 11/26/2025, V3 (Licensed Practical Nurse/LPN) and V4 (Certified Nurse Assistant/CNA) had been in the process of transferring her from a shower chair to her bed via mechanical lift. R1 stated, during the transfer, V3 and V4 were having trouble getting the wheels to move on the mechanical lift. R1 stated, while being guided to her bed, elevated in the sling, she could see the mechanical lift starting to tip over. R1 stated, she landed on the floor beside her bed, hitting her bottom and heels on the floor, and the mechanical lift hit her in the head causing a laceration. R1 stated, she had been sent to the local emergency room where she received 2 staples to the top left side of her head. On 12/23/2025 at 10:29 AM, V3 (LPN) stated she had been assisting V4 (CNA) in the afternoon on 11/26/2025 transfer R1 from a shower chair to her bed via mechanical lift. V3 stated, she had been the operator of the mechanical lift while V4 was guiding R1. V3 stated, the mechanical lift had been hard to maneuver with R1 in the sling. V3 stated, during the transfer with R1 elevated in the sling, R1's weight became unbalanced when V4 repositioned R1 for the bed while lift was still in motion causing the mechanical lift to tip over. V3 stated, R1 landed on her buttock in the floor and the mechanical lift hitting R1 in the top left side of her head causing a laceration. On 12/23/2025 at 10:56 AM, V4 (CNA) stated, her and V3 (LPN) had been transferring R1 from a shower chair to her bed via mechanical lift on 11/26/2025 in the afternoon. V4 stated, during R1's transfer she had been guiding R1 while V3 operated the mechanical lift. V4 stated, R1 had been close to the weight limit for the mechanical lift of 450 pounds. V4 stated, while guiding R1 while elevated in the sling she turned R1 to position for the bed, R1's weight became unbalanced causing the mechanical lift to tip over. V4 stated, R1 fell to the floor, hitting her buttock and heels on the ground next to her bed and the mechanical lift hit R1 on the top left side of her head causing a laceration. On 12/24/2025 at 10:45 AM, V4 stated and further clarified that there was a lack of communication between her and V3 during R1's transfer. V4 stated, she had repositioned R1's legs too soon during the transfer while lift was still in motion, which caused the mechanical lift to tip over. On 12/23/2025 at 11:46 AM, V2 (Director of Nursing/DON) stated she had been working the day R1 had fallen with the mechanical lift. V2 stated, V3 and V4 notified her that in the process of transferring R1 from a shower chair to her bed via mechanical lift the lift had tipped over with R1 in the sling causing a laceration to the top left side of her head. V2 stated, the investigation determined that R1's weight became unbalanced during the transfer causing the mechanical lift to tip over. On 12/23/2025 at 11:50 AM, V1 (Administrator) stated she had been notified by V2 that V3 and V4 had been in the process of transferring R1 from a shower chair to her bed via mechanical lift and the lift had tipped over with R1 elevated in the sling causing the lift to hit the top left side of R1's head. V1 stated the investigation determined that R1's weight became unbalanced during the transfer during repositioning and motion of lift and caused the mechanical lift to tip over. On 12/23/2025 at 12:05 PM, V5 (Physical Therapy Assistant/PTA) stated, the mechanical lift could tip over if R1's weight had become unbalanced outside the base center of the mechanical lift during transfer. R1's Progress Note dated 11/26/2025 at 5:55 PM documented R1 was transferring with 2 staff members from shower chair to bed. Resident sustained a fall. Laceration noted to left top of head. Resident sent to ER (emergency room) for evaluation and treat. R1's Progress Note dated 11/26/2025 at 6:30 PM documented R1 returned to facility from local hospital in ambulance accompanied. R1 had new orders to remove staples from laceration in 7 days. R1's after visit hospital summary dated 11/26/2025 documented under history of present illness.mechanical lift flipped over, patient landed on her bottom, mechanical lift struck her in the left side of head, laceration to scalp and under physical exam weight of 437 pounds. This same document under laceration repair dated 11/26/2025 at 4:34 PM performed by V15 (emergency room Physician) to the left parietal scalp area, 2.5 centimeters (cm) in length, repair method of 2 staples. The facility's incident investigation report dated 11/26/2025 documented R1 had been in the process of being transferred via mechanical lift by V3 (LPN) and V4 (CNA). R1 had been being pushed toward the bed when the mechanical lift became unbalanced with resident still elevated in sling. R1 did experience a fall and sustained a laceration to the left top of head. Resident was sent to the local emergency room (ER) for evaluation and treatment. Resident returned from the ER with two staples and orders to remove in 7 days. The facility policy titled Lifting Machine, Using a Mechanical Lift (undated) documented under Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Steps in Procedure 16. Gently support the resident as he or she is moved, but do NOT support any weight. On 12/23/25 at 11:50 AM, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 12/1/25. In attendance - V1, V2, V3, V12 (Regional Director), and V13 (LPN/MDSC - Minimum Data Set Coordinator). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents that are transferred per mechanical lift. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V2 and V15 (ADON) provided in-service to nursing staff on mechanical lift/safe transfers and return demonstration on use of mechanical lift. Completed on 12/1/25. All beds checked and ensured they are locked. 4. Plan to monitor performance to ensure solutions are sustained: V2 (DON) will complete observations of 3 lift transfers weekly for 6 weeks. Should any concerns be identified, during transfer, V2 will immediately intervene and provide additional education with return demonstrations. The first complete facility audit was completed on 12/1/2025 by V2.

Based on observation, interview and record review, the facility failed to keep resident rooms clean for 1 (R5) of 3 residents reviewed for homelike environment out of the sample of 7. Findings Include:R5's admission Record documented an admission date of 11/21/2025. This same record documented diagnosis including cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, ST-elevation myocardial infarction of unspecified site, and presence of aortocoronary bypass graft. On 11/22/25 at 11:51 AM, an observation in R5's room revealed the following: 5 separate fecal matter smeared areas on the floor between bed 1 and bed 2.On 11/22/2025 at 12:00PM, an observation of 5 separate areas of fecal matter still smeared on the floor in R5' room between bed 1 and bed 2 after observing V3 (Housekeeping) clean R5's room including sweeping and mopping the floor.On 11/22/2025 at 12:10 PM, V3 (Housekeeping) stated she had swept and mopped R5's room.On 11/22/2025 at 12:18 PM, V1 (Administrator) stated her expectations would be for the housekeeping staff to clean resident rooms per the facility policy, including cleaning the fecal matter off the floor.On 11/24/2025 at 11:15 AM, R5 who was alert and oriented stated he had been in the facility for a few days. R5 stated, the facility does not clean very well and does not clean his room daily. On 11/24/2025 at 11:16 AM an observation in R5's room revealed fecal matter in the same area as noted on 11/22/2025 between bed 1 and bed 2 still smeared on the floor. The facility policy titled Homelike Environment (revised February 2021) documents under Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. This same document under Policy Interpretation and Implementation documents under step 2, the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: a. clean, sanitary and orderly environment.

Based on observation, interview and record review, the facility failed to maintain aseptic technique during bowel incontinence care and catheter care and apply Enhanced Barrier Precautions for 1(R1) of 3 residents reviewed for infection control in the sample of 7. Findings include:R1's admission Record documented an admission date of 9/5/2025 with diagnosis including urinary tract infection, acute kidney failure, unspecified, pressure ulcer of sacral region, unstageable, and malignant neoplasm of endocervix.R1's Minimum Data Set (MDS) dated on 9/11/2025 documented a Brief Interview for Mental Status (BIMS) summary score of 9 which indicates moderate cognitive impairment. This same MDS documents R1 is dependent with care for toileting which required the helper to do all the effort. Section H documented under appliances of an indwelling catheter present and documented R1 is frequently incontinent of bowel.R1's Care Plan documented a focus area of implementation of Enhanced Barrier Precaution due to wound, without secretions or excretions that are unable to be covered or contained in part with an interventions to ensure personnel protective equipment (PPE) and alcohol based hand rub are readily and accessible and use enhanced barrier protection during high contact care activities dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting device care or use central lines, urinary catheter, wound care with an initiation date of 9/8/25. The same Care Plan documents a focus area of Resident may be predisposed to develop skin impairment caused by pressure. R/T (related to) Moderate Risk per Braden Scale- Risk factors noted as: incontinent of bowel. Potential problem for friction and shear contributing factor includes bowel incontinence, limited mobility. Stage 4 pressure wound noted to sacrum with an initiation date of 9/5/25.On 11/24/2025 at 12:29 PM, enhanced barrier precautions signs were observed outside of R1's door with a bin of PPE readily available to be used for contact precautions.On 11/24/2025 at 12:30 PM, V11 (Certified Nurse Assistant/CNA) and V13 (CNA) provided bowel incontinence and indwelling catheter care for R1. V11 and V13 donned gloves. V11 and V13 gathered supplies that included 3 wash cloths and spray foam. V11 and V13 applied gloves then rolled R1 on to her right side. R1 was incontinent of bowel and bowel movement (BM) was observed to R1's sacral area, buttocks, legs and mechanical lift pad. V13 laid all 3 washcloths on R1's mechanical lift pad while wiping BM with one of the washcloths. V13 then folded the washcloth over to wipe again and continued to use the same washcloth for multiple passes not following the front to back method. V13 was observed rolling up the mechanical lift pad under R1 while placing the remaining 2 wash cloths on R1's bed pad. V13 then removed the saturated film covering to the sacral area wound and continued to push the foam back into the wound with her dirty gloves. V13 continued in the same manner of wiping the BM while folding over the washcloths. V13 then passed the dirty washcloth to V11 (CNA) to use. V11 (CNA) sprayed the dirty washcloth with foam spray to clean R1's indwelling catheter tube and perineal area and not following the front to back method. V11 then requested more washcloths. V13 doffed her gloves with no hand hygiene completed and left the room to get more washcloths. V11 returned to R1's room applied new gloves, without completing hand hygiene, and handed the washcloths to V13. V11 had then rolled R1 to her left side and started cleaning BM while using a spray foam cleaner and folding over the washcloths and continuing to use them. Once incontinence care had been completed, V11 and V13 dressed R1 in clean clothes from her closet, covered her with her blankets and set the head of her bed up without changing gloves and without performing and hand hygiene. V11 and V13 doffed their gloves prior to leaving R1's room prior to exiting R1's room without performing hand hygiene. V11 and V13 were not observed wearing a gown while providing catheter and incontinence care to R1.On 11/24/2025 at 12:47 PM, V11 and V13 both stated, the facility does have a policy for perineal care. V11 and V13 stated that they completed perineal care the way they were trained. V13 stated she should have applied the enhanced barrier precautions prior to starting R1's care.On 11/24/2025 at 2:10 PM, V2 (Director of Nursing/DON) stated her expectation for perineal and bowel incontinence care is all staff to follow policy and procedure.On 11/24/2025 at 2:30 PM, V1 (Administrator) stated her expectation is for all staff to follow policy and procedure for perineal and bowel incontinence care.The facility policy titled Perineal Care (revised February 2018) documents Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This same document under Equipment and Supplies documented, the following equipment and supplies will be necessary when performing this procedure: 1. Wash basin, 2. Towels, 3. Washcloth, 4. Soap (or other authorized cleaning agent) and 5. Personal protective equipment (e.g. gowns, gloves, mask, etc., as needed). Steps in the Procedure documented 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within reach.The Centers for Disease Control guidance for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated 4/2/24 found at www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html documents under Enhanced Barrier Precautions The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse for 8 consecutive hours per day, 7 days a week. This has the potential to affect all 32 residents living at this facility.The facility's Nursing schedule for August and September 2025 revealed the facility did not have 8 consecutive hours of RN (Registered Nurse) coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/9/2025 at 8:50am, V1 (Administrator) said the facility did not have the required 8 hours of continuous RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/8/2025 at 11:00am, V2 (Director of Nursing) said she realizes the facility does not have 8 continuous hours of RN coverage during the weekends. V2 said the facility is actively advertising to hire more Registered Nurses to meet the requirement. V2 said V8 (RN) was the only RN providing RN coverage on 9/6/25 and 9/7/25, but V8 only worked 4 hours each day. V2 agreed the facility did not have the required 8 consecutive hours or RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 and 8/9/25.On 9/8/2025 at 1:00pm, V8 (RN) said she worked on Saturday, 9/6/25 and Sunday, 9/7/25, due to the facility having residents with IV (intravenous) therapy going, but she only worked 4 hours per day. V8 said no other Registered Nurses worked over the weekend.The facility's matrix with print date of 9/8/25 documented 32 residents reside at this facility.Facility policy titled Staffing, Sufficient and Competent Nursing (dated 2001) documents the following in part: Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3.) A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

Based on interview and record review, the facility failed to provide 8 hours per day, 7 days per week Registered Nursing (RN) coverage for the facility. This failure has the potential to affect all 37 residents residing in the facility. The facility's June 2025 Nurse Schedule documents on 06/01/25, 06/14/25, 06/15/25, 06/28/25 and 06/29/25 the facility did not have a Registered Nurse (RN) scheduled. On 06/04/25, 06/06/25, 06/09/25, 06/12/25, 06/20/25, and 06/26/25, V2 (Director of Nursing/DON) was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on the dates of 06/04/25, 06/06/25, 06/09/25, 06/12/25, and 6/26/25, V2 worked 7.5 hours, and on 06/20/25, V2 worked 7 hours. The facility's July 2025 Nurse Schedule documents on 07/05/25, 07/06/25, 07/26/25 and 07/27/25, the facility did not have an RN scheduled for 8 hours. On 07/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 07/09/25, V2 worked 7.5 hours. The facility's August 2025 Nurse Schedule documents on 08/06/25 and 08/10/25, the facility did not have a RN scheduled. On 08/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 08/09/25, V2 worked 3 hours. On 08/15/2025 at 9:47 AM, V2 (DON) stated that she is aware there is not RN coverage every day on the schedule. V2 stated that there is a PRN (as needed) nurse who has recently started and is helping cover shifts. V2 stated the facility is advertising for a Registered Nurse position. V2 stated that this month is better than the last two with Registered Nurse coverage. On 08/15/2025 at 10:33 AM, V1 (Administrator) stated she is aware that they are short on RN coverage. V1 stated there is a RN job posted on Indeed for some time.The Minimum Data Set (MDS) Resident Matrix with a date of 08/12/25, documented 37 residents are residing at the facility.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (R1 and R6) of 3 residents reviewed for abuse in the sample of 9.1. R1's admission Record documented an initial admission date to the facility on [DATE] and included diagnoses of hemiplegia affecting left nondominant side, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, morbid obesity, osteoarthritis, obstructive sleep apnea, disorder of prostate, generalized anxiety disorder, major depressive disorder, calculus of ureter, and abdominal pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/01/2025, R1 reported that V4 (Licensed Practical Nurse/LPN) spoke inappropriately to him. V4 was sent home, and investigation immediately initiated.A typed letter dated 08/08/2025 documented it was the follow up to the initial report of a nurse speaking inappropriately to R1. R1 reported that V4 spoke inappropriately to him when he requested his as needed pain medication. V4 explained to R1 that it was not time for his pain medication. R1 reported that this frustrated him. During the investigation, the resident reported that he has a temper and was in pain. The nurse was educated about customer service and approach.The facility's investigation folder provided by V1 (Administrator in Training) included a handwritten letter from R1 that documented R1 turned on his call light at an unknown time. V6 (Certified Nurse Assistant/CNA) answered the call light and went to report (R1's) pain to V4 (LPN). R1 documented that V4 came into his room yelling at R1 saying very loud I guess you want an ambulance too. I was in pain, so I yelled back at him. There was no documentation of this incident in R1's electronic medical record. On 08/12/2025 at 1:02 PM, R1 stated that V4 (LPN) had come in sometime around 8:30 PM and brought R1 medications. R1 said that he fell asleep and woke up 4-5 hours later. R1 stated he turned on the call light and asked V6 (CNA) to ask V4 if it was time for pain medication. R1 stated that V4 said I guess you want a damn ambulance after telling him that it wasn't time for medications. R1 stated that when he woke up, he did not know what time it was. R1 stated that he understands that there is a time frame that has to pass for him to receive his medications. R1 stated that the nurse (V4) was out of line when he yelled at me. R1 stated that he (R1) shouldn't have raised his voice, but he was in severe pain. R1 stated that he had written down what happened on a piece of paper and given the facility a copy of it. On 08/12/202 at 1:19 PM, V1 (Administrator in Training) stated that she was on vacation when this incident occurred between R1 and V4. V1 stated that V11 (Regional Director) completed the investigation. On 08/12/2025 at 1:55 PM, V11 (Regional Director) stated she got a call from V2 (Director of Nursing/DON) regarding the incident that occurred with R1 and V4. V11 stated that she was informed that R1 had upset V4 over pain medication. V11 stated that she did not speak to any of the staff that gave statements. V11 reiterated that R1 stated he was upset and loud. V11 stated that V4 (LPN) has an intellectual issue and does not believe he would yell at anyone. V11 stated that if V4 raised his voice it was to talk over R1. On 08/12/2025 at 2:28 PM, V4 (LPN) stated that one of the CNA's told him that R1 was wanting a pain pill. V4 stated that he went into the room to tell R1 that it was too early. V4 stated that R1 accused him of yelling at R1. V4 stated I was not trying to yell at R1, I was trying to explain that he would have to wait one more hour because it was not time. V4 said he asked R1 if he needed an ambulance. V4 stated that V11 (Regional Director) nor V2 (DON) called V4 to speak about this incident. On 08/13/2025 at 11:30 AM, V10 (LPN) stated she was the on call nurse the night of this incident. V10 said she never took a statement from V4, he was crying so much she could not understand him.On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated that she only briefly spoke with V4, that she did not do an interview with him. V11 stated that she thought that V2 (DON) or V10 (LPN) spoke with V4.On 08/13/2025 at 1:35 PM, V2 (DON) stated that she did not do the investigation, that V11 completed the investigation because V1 was out of town. V2 stated that she spoke to V4 briefly, but he did not say much during the time she spoke to him. V2 stated she asked V4 what occurred but barely got any information out of him because he was still upset. On 08/15/2025 at 10:35 AM, V1 (Administrator in training) stated that she has no documentation of education for V4 for customer service and approach. V1 stated that she has reached out to V11 (Regional Director) to see if she has the education.2. R6's admission Record documented a facility admission date of 11/03/2016 and included diagnoses of Alzheimer's Disease, hyperlipidemia, dementia, type 2 diabetes mellitus, dysphagia, developmental disorder of speech and language, convulsions, and essential hypertension. R6's MDS assessment dated [DATE] documented a BIMS score of 06, indicating R6 has severe cognitive impairment. R6's Care Plan with a revision date of 06/03/2025, includes a focus area of R6 has a communication problem as evidenced by disruption in ability to speak. R6 is non-verbal but does nod yes and no with her head. The interventions listed are acknowledge resident at each greeting, allow extra time for resident to respond, allow resident to complete thought process before responding, do not finish sentences for resident and anticipate and meet needs.A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/13/2025, R1 reported that he has witnessed a staff member, V4, was yelling at a certain resident and other residents. R1's handwritten letter (referenced above) also documented that R1 has heard V4 yell at R6 and other residents. On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated she did not complete a separate investigation for the allegation of abuse to R6. V11 stated she just looked at it as one case. V11 stated that she did read the allegation on the handwritten letter that R1 gave to her that had the allegation on it. On 08/13/2025 at 2:37 PM, V13 (Regional) stated they are starting an investigation regarding the allegation pertaining to R6. Facility policy titled Abuse, Neglect, Exploitation or Misappropriation - reporting and investigating documented under policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The same policy documents under section Investigating Allegations 1. All allegations are thoroughly investigated.7. The individual conducting the investigation at a minimum: . E. interviews any witnesses to the incident. H. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. I. documents the investigation completely and thoroughly.

Based on interview and record review the facility failed to provide substantial evening snacks to residents. This failure has the potential to affect all 37 residents residing at the facility. Findings include:Facility matrix dated 7/7/25 documents there are currently 37 residents living in the facility. On 07/10/25 at 9:30 AM the sign posted on the snack cart documents: breakfast 8:00 AM, lunch 12:00 PM, and dinner 5:00 PM.On 07/10/25 at 10:20 AM, R6 Who is alert and oriented, stated, the staff do not come and ask between after dinner and before bedtime if he would like a snack or a substantial snack such as a half a sandwich or a yogurt. On 07/10/25 at 11:40 AM, R8 who is alert and oriented, stated the staff do not come and ask if she would like a snack in the evening, after dinner. On 07/10/25 at 12:46 PM, R27 who is alert and oriented, stated, they (the staff) do not ask if he would like a snack after dinner in the evening time, but it would be nice if they did. On 07/10/25 at 12:49 PM, R22 who is alert and oriented, stated, the staff do not ask if he would like a snack after dinner in the evening. On 07/10/25 at 12:54 PM, R19 who is alert and oriented, stated, they do not come around and ask if he would like a snack in the evening but if he asks earlier in the day they will bring him a [NAME] bar or something similar.On 07/10/25 at 1:05 PM, R4 who is alert and oriented, stated, she does not remember anyone asking her if she would like a snack in the evening. On 07/14/25 at 11:50 AM, V7 (Minimum Data Set Coordinator) stated, breakfast is at 8:00 AM, lunch is at 12:00 PM, and dinner is at 5:00 PM. On 07/14/25 at 11:13 AM, V9 (Certified Nurse Aide/CNA) stated, sometimes they have snacks for the evening, sometimes not very many. V9 stated the amount of snacks they have depends on how many snacks the kitchen leaves for them before they leave. The kitchen is locked after the kitchen staff leaves. Sometimes they do not have enough snacks for all the residents. The snacks are usually oatmeal cream pies or maybe a plastic bag of chips. V9 stated, very rarely do they have sandwiches or anything like that. On 07/14/25 at 12:08 PM, V13 (CNA) stated, they have some snacks in the evening, depending on how many snacks the kitchen leaves them. The usual snacks are chips, graham crackers, or sometimes yogurt. V13 stated, they do not always have enough snacks for all the residents.On 07/14/25 at 12:11 PM, V14 (CNA) stated, she works every other weekend in the evening. V14 stated, she usually has snacks for the evening, usually oatmeal cream pies or graham crackers and sporadically a half a sandwich. On 07/14/25 at 12:15 PM, V16 (Cook) stated, he will leave snacks for the evening before he leaves. He leaves whatever they have sometimes oatmeal pies, chips, or cookies. V16 stated, sometimes he will put out some sandwiches if they already have some made. The facility policy dated 07/2017 titled, Frequency of Meals documents 6. evening snacks will be offered routinely to all residents. Timing of the snack will consider relevant factors. 7. residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen (14) hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other.

Based on interview, observation, and record review the facility failed to maintain floors, sinks and shower rooms in a clean, safe and sanitary condition for 20 of 20 (R2, R4, R6, R7, R8, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R26, and R27) residents reviewed for environment in a sample of 27. Findings include:On 07/09/25 at 8:12 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad.On 07/09/25 at 9:15 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:30 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:45 AM the soiled/wet bed pad and soiled brief had been removed from R2's floor. On 07/09/25 at 12:45 PM, R6's floor was sticky, surveyor's shoes were sticking to the floor when walking over to the bed to speak with R6. On 07/09/25 at 1:40 PM, there was dried spilled liquid of the approximate size of 12 inches by approximately 6 inches on the floor of R4's room near the waste can. On 07/10/25 at 9:10 AM the south hall shower room contained a black substance along the bottom of the left wall and approximately four inches up the wall of the shower stall and up to approximately 24 inches up the wall in the grout. The back wall contained a black substance between the floor and the wall of the back wall up to approximately 20 inches in the grout between the tiles. The right side wall of the shower stall contained a black substance between the floor and the wall to approximately three inches up the wall. The wall also contained a black substance in the grout to approximately 16 inches up the wall in the grout. On 07/11/25 at 11:37 AM R8's bathroom sink contained a black substance covering an area of approximately 7.5 inches from the middle of the back of the sink to the top of the sink by approximately 6 inches wide. This area surrounded the overflow opening in the sink. The porcelain contained cracks under the black substance and extending over an inch past the black substance with the black substance being into and under the cracks.On 07/10/25 at 12:59 PM, V15 (Maintenance) stated R8's bathroom sink should not look like that, it should be replaced. He will send a picture of the sink to his supervisor to see if he can get it replaced. On 07/14/25 at 11:19 AM, V7 (Minimum Data Set Coordinator) stated, she does work the floor on occasion. V7 stated the residents listed under South Hall on the (facility name) Room List reside on the south hall and utilize the shower room on the south hall, V7 stated, the shower room should not contain the black substance on the walls of the shower stall and in the grout of the shower stall. On 07/14/25 at 12:52 PM V15 stated, the shower room on the south hall should not contain the black substance on the walls and in the grout of the shower stall. The undated facility document titled, (facility name) Room List documents R6, R7, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R27 reside on the south hall. The facility policy dated 07/2013 titled Cleaning and Disinfecting Residents' Rooms documents: General guidelines: 1. housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 6. 6. Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60- minute intervals.

Based on observation, interview and record review, the facility failed to notify the doctor and obtain treatment orders when a change to a pressure area was detected and failed to apply heel protectors to prevent further skin breakdown for 3 of 4 residents (R3, R4, R5) reviewed for pressure areas in the sample of 27.Findings include:1. R4's admission record documents an admission date of 11/25/2015 with the following diagnoses in part; multiple sclerosis, chronic pain syndrome and autonomic neuropathy in diseases not elsewhere classified. R4's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 7, indicating R4 is severely cognitively impaired. Section M-Skin Conditions documents that R4 has pressure ulcers.R4's Order Summary Report documents R4 has treatment orders to her left ischial tuberosity, Right heel, right medial lower leg, right calf and behind her left knee.R4's Treatment orders on for her right heel document; Right medical heel: Apply barrier wipe q (every) shift and PRN (as needed) everyday shift for DTPI (Deep Tissue Pressure Injury) with a start date of 7/4/25 and a discontinue date of 7/9/25.R4's Treatment Administration Record for July documents that R4 received this treatment every day from 7/4-7/9, 2025. On 7/9/25 at 1:05pm, wound care was observed on R4 and administered by V4 (Licensed Practical Nurse/LPN) and assisted by R3 (LPN). V4 went to apply the barrier wipe to R4's right medial heel, there was a boarder dressing on the right heel dated 7/7. Upon removal of the dressing on R4's heel by V4, the dressing was noted to have a dark bloody tinged drainage on it. R4's right heel was noted to have a small open area approximately 2cmx2cm that was draining. V4 checked the order to ensure she had read it correctly. V4 confirmed it was only the barrier wipe ordered and left the dressing intact. V4 went to notify the Nurse Practitioner and to receive new treatment orders.R4's progress notes document on 7/9/25 at 2:35pm, Floor nurse reported a decline in wound on right medial heel. (Name of wound care provider) NP (Nurse Practitioner contacted, new order received as follows: Cleanse wound with wound cleanser, apply collagen to wound bed, cover with bordered gauze dressing q2d (every 2 days) and PRN (as needed). Order Processed. On 7/9/25 at 1:23pm, V4 stated that the nurse practitioner should have been notified and new orders received when the area was noticed and before any new treatment was applied. 2. R3's admission record documents an admission date of 4/28/25, with the following diagnoses listed in part; adult failure to thrive and muscle weakness.R3's Current Care Plan documents R3 has severe impaired cognitive function or impaired thought processes as evidenced by a BIMS score of 3 related to Dementia, date initiated 5/12/25.R3's Order summary sheet documents an order with a start date of 5/29/25, Heel protectors to be worn in bed every shift for pressure injury.R3's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place every day from July 1-9, 2025.On 7/7/25 at 1:52pm R3 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R3 was observed lying in bed without heal protectors on and there were no heal protectors anywhere in her room.On 7/9/25 at 9:35am, R3 was observed lying in bed without heel protectors on, V5 did not even have heel protectors anywhere around her.On 7/9/25 at 1:39pm, V3 and V4 both stated they were not sure if R3 should have had heel protectors on while lying in bed. V3 and V4 stated if R3 had an order for them, they should be put on her while she is in bed.On 7/10/25 at 1:41pm, V5 (Certified Nursing Assistant/CNA) stated she was not sure where V3's heel protectors were, but she would locate a pair for her.3. R5's admission record documents an admission date of 3/10/22 with the following diagnoses in part; Type 2 diabetes Mellitus without complications, pressure ulcer of other site, stage 3, and other specified disorders of muscle.R5's Minimum Data Set (MDS) dated [DATE] documents no brief interview for mental status was conducted due to resident is rarely/never understood.R5's Order Summary Report documents the following order, Heel protectors while in bed-Monitor wearing q (every) shift. Ensure heel protectors are on while in bed. With a start date of 5/31/25.R5's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place everyday from July 1-9, 2025.On 7/7/25 at 1:52pm R5 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R5 was observed lying in bed with her heal protectors laying on her bedside table.On 7/9/25 at 9:35am, R5 were observed lying in bed without heel protectors on.On 7/9/25 at 1:38pm, R5 was observed in bed, and did not have heel protectors in place, they were sitting on her bedside table. V# (LPN) grabbed them and put them on R5.On 7/9/25 at 1:39pm, V3 and V4 both stated that R5 should have had heel protectors on while lying in bed.On 7/9/25 at 2:15pm, V2 (Director of Nursing) stated all treatments performed must have an order, if a treatment is to be changed, the doctor would need to be contacted for further instruction.Facility Policy titled Wound Care with a revision date of October 2010 documents under the section titled, preparation; Verify that there is a physician's order for this procedure.

Based on observation, interview and record review, the facility failed to ensure assistance with hygiene care for 1 (R31) of 1 resident reviewed for dignity in the sample of 24. This failure resulted in R31 being left in urine-soaked clothing with urine dripping under his chair during mealtime, which would cause a reasonable person to feel discomfort, humiliation and frustration. The Findings Include: R31's Face Sheet documents an admission of 10/9/2023 and includes the following diagnosis: schizophrenia. R31's quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section H of this same MDS documents R31 is frequently incontinent for urine. Section GG - Functional Abilities and Goals documents R31 requires supervision or touching assistance for toileting hygiene and lower body dressing, meaning the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R31's Care Plan documents a problem area of Self Care Deficit - needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL's (Activities of Daily Living). Goals for this focus area are for R31 to participate in bathing/dressing during am/pm care for the next 90 days. Interventions for this problem area include: Assist with ADL's as necessary with staff assist of supervision/limited. Set up. Have necessary items in place. Offer supervision and verbal cues. Segment tasks as needed to allow Resident to complete tasks in efficient time, safe and quality manner. Observe for changes in Resident ADL ability and notify nurse for follow up w/ Restorative, therapy or Medical Doctor. Provide privacy and dignity. Remind Resident as necessary to pull curtains and keep closed during times of undress. Provide sufficient time to complete tasks. Avoid rushing Resident but keep on task to avoid dignity issues. Resident will make appropriate choices regarding ADL's preferences. On 9/18/24 at 11:40 AM, R31 was walking down the hall from his room to the dining room for lunch. R31's clothing was wet from under his armpit to the back of his knees. At 11:43 AM, R31 sat down in the dining room awaiting lunch and a puddle began forming under his chair leaking from his seat. Several staff passed R31 and assisted in placing a clothing protector on him during this time. At 12:05 PM, surveyor brought to the attention of V5 (Certified Nurse Assistant/CNA) that R31 was standing up in a puddle and his pants were falling down. V5 at this time took R31 back to his room to clean him up. The chair and floor remained wet during this time. At 12:20 PM, R31 re-entered the dining room in clean dry clothes and sat down in the wet seat with his feet in the puddle of urine under the table. At 12:25PM, V2 (Director of Nursing/DON) placed a paper towel on the floor and used her foot to soak up the puddle asking who spilled something. On 9/18/24 at 2:30 PM, V5 stated that R31 is generally incontinent of urine and bowel and wears an incontinent brief. V5 stated that she did not call housekeeping to clean up the chair or the floor, but she did not see the puddle under the chair. V5 stated that the weight of R31's saturated incontinent brief is what was causing his pants to fall down. On 9/18/24 at 4:30 PM, V10 (Guardian) stated that she visits her residents every quarter. V10 stated that she was last there in June 2024 and when she arrived, R31 was sitting in the common area and his clothing was wet from urine. V10 stated that once she arrived, R31 was taken to be cleaned up and changed. V10 stated that she expects that staff will keep R31 cleaned up, dry and not left sitting in urine-soaked clothing. V10 stated that while R31 is unable to tell us himself, R31 would be embarrassed to be sitting in urine-soaked clothing and a puddle of urine underneath him along with the two other residents sitting next to him at the dining room table. The Illinois Long Term Care Ombudsman Program Residents' Rights for people in Long Term Care Facilities booklet documents that 'Your rights to dignity and respect include: you have the right to make your own choices, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, and your facility must provide equal access to quality care regardless of diagnosis, condition or payment source.

Based on interview and record review, the facility failed to provide an acceptable reason for discharge and failed to allow a resident to return to the facility for 1 (R1) of 3 residents reviewed for transfer/discharge in the sample of 19. This failure resulted in R1 remaining in the emergency room without placement from 12/12/23 to 12/18/23 and being admitted to a hospice room at the hospital due to not having a facility to be discharged to. This failure resulted in R1 having feelings of embarrassment, devastation, abandonment and fear of not knowing what was going to happen to him. Findings Include: R1's Admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. R1's undated Care Plan documents a Focus area with an initiation date of 11/04/23, Dependent for ADLs- Unable to assist/Assists only minimally. Not a candidate for Restorative Programming. Further decline in ability/participation likely due to Quadriplegia. Resident is dependent on 2 assist via Hoyer lift for transfers/ADLs. The interventions documented for this Focus area include, Place in wheelchair for positioning while up and all transport Provide bathing, hygiene, dressing and grooming per Resident's preference as able Provide oral care with am and pm cares Scheduled repositioning program .Transfer Resident using mechanical device of Hoyer and 2 staff members . This same Care Plan documents a Focus area with an initiation date of 11/06/23 of, Resident (R1) is known to display/has history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations. Resident refuses care, then accuses staff of denying him care. Adjustment disorder w (with)/mixed disturbances of emotions and conduct. The interventions documented for this care area include, Administer psychotropic medications as ordered by physician . Allow resident time and opportunity to express feelings, anger, or frustration. Provide empathy and validation of feelings while orienting to reality. Ensure 2 staff members are present for care and services to minimize risk of false accusations Investigate any reality basis and share facts w/resident. Provide reality orientation as possible .Psychotherapy services as needed/desired/tolerated by resident . R1's Progress Notes dated 12/12/23 documents, Res (resident/R1) showing s/s (signs/symptoms) of AMS (altered mental status) with hallucinations and delusions. Res making statements that he fell out of bed. Res is paraplegic and unable to get himself in/out of bed. Res transported to (name of local hospital) via (name of local ambulance service). On 1/2/2024 at 2:16 PM, V3 (Hospital Case Manager) stated R1 was sent to the local hospital for evaluation on 12/12/23. V3 stated R1 was discharged from the hospital and cleared to return to the facility on that same day. V3 stated the facility refused to re-admit R1 to the facility. V3 stated the facility hand-delivered discharge papers to R1 while in the hospital emergency room . V3 stated R1 remained in the hospital emergency room from 12/12/23 to 12/18/23. V3 stated on 12/18/23 they were able to get R1 admitted to their in-house hospice and R1 remained in the hospital in a hospice room. V3 stated they have attempted to find placement for R1 and have been unable to find a facility that will accept him. The facility Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 12/12/23 documents under Federal Proceeding.This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facility .the reason for this proposed transfer or discharge is: your welfare and needs cannot be met in this facility, as documented in your clinical record by your physician .the safety of individuals in this facility is endangered .the health of individuals in the facility would otherwise be endangered, as documented by a physician in your clinical record . The notice documents R1 will be relocated to the local hospital and the effective date of the transfer is documented as 12/12/23. The untitled letter signed by V11 (Physician) and attached to the facility discharge date d 12/12/2023 documents, It is in my profession (sic) opinion with collaboration of my colleagues: (R1) is not suitable for residency in (name of facility). He has been non-compliant with his wounds treatment, medication, IV (intravenous) therapy, and physician orders. (R1) has exhibited psychosocial distress to other residents that reside within (name of facility). This included but is not limited to the following: verbal aggression, having to relocate his once roommate to a different room to ensure he was not subjected to this. It is of this facility's duties to protect the safety of all the residents while creating a calm living environment. Due to the sensitivity of the population of those we serve including those who have schizophrenia, developmental delays, trauma/PTSD (post-traumatic stress disorder), dementia/Alzheimer, and other mental health diagnosis where the presentation of his behaviors created adverse effects on these residents. Many interventions were utilized in attempts to resolve (R1) bio-psycho-social needs. An attempt to be assessed by (name of clinical social worker and psychiatric consultants) to aide in assisting him in his mental and emotional needs; however, this was met with refusal, thus unable to provide treatment. (Name of facility) also attempted to send many referrals for this resident to outside agencies, Long-Term Care Facilities, Behavioral Homes, and more; however, being met with denials. His refusal of care impacts his overall well-being, coupled with his underlying mental and behavioral changes impede the ability to provide continuity of care to address his medical needs. R1's regional hospital discharge papers dated 9/16/23, prior to R1's admission to the facility, document, R1 is a .male with a past medical history of quadriplegia due to recent spinal cord injury and glaucoma Had stage 4 decubitus ulcers .Pt (patient/R1) left the hospital AMA (against medical advice) .throughout hospitalization Pt (R1) refused IV, labs, and IVF (intravenous fluids) . This indicates the facility was aware of R1's behaviors of refusal of care prior to admission to the facility. R1's local hospital record with an admitted [DATE] documents the following progress notes. 12/12/23 9:02 AM, Patient (R1) is a .quadriplegic who was sent in from nursing home for shoulder pain. Patient was discharged from the nursing home while patient was in the ER (emergency room ) due to staff at the nursing home being unable to deal with him. Currently we are looking for placement for the patient . 12/12/23 1:41 PM, This RN (Registered Nurse) spoke with V2 (Director of Nurses) at (name of facility). Again, let V2 know that patient was up for discharge and clarified with her that they will not be allowing patient to return. Requested documentation of refusal to allow the patient to return be faxed to the ER (emergency room ), V2 stated they would be happy to fax written documentation of this refusal. 12/12/23 3:59 PM, This patient (R1) has requested to go elsewhere than his current NH (nursing home) facility . 12/12/23 5:13 PM, V1 (Administrator) and V2 (Director of Nurses) from (name of facility) dropped of PT (patient/R1) D/C (discharge) papers and took documenters name as recipient. 12/12/23 6:59 PM, Patient (R1) .male history of quadriplegia presenting from the nursing home for musculoskeletal pain. Patient was sent to the ER by the nursing home and then discharged from the nursing home 12/13/23 1:54 PM, Multiple referrals sent to various nursing homes today 12/13/23 7:32 PM, Briefly, (R1) .is being evaluated for placement. Patient (R1) is a quadriplegic and apparently difficult to manage at NH where he was discharged and will not be accepted back. Case management is working on placement. 12/14/23 3:36 AM, I assumed care of this patient (R1) .Patient has been in this emergency department for nearly 2 full days, awaiting placement. Case management has been seeing the patient. He was discharged from his nursing home. The patient is adamant that he would like to be DNR (do not resuscitate), on hospice, with comfort measures only. He clearly has an infected sacral wound, which I see he was admitted for earlier this month although he declines treatment for this. He continues to decline treatment for this here .The patient understands that refusal of treatment for his infections could lead to worsening condition and possible death . 12/16/2023, I again assumed care of this patient .at 7 PM on 12/14. Patient (R1) is refusing any medical treatment, is desiring to be on hospice, is no longer welcome at his living facility, so case management is working on placement at an alternative facility. 12/18/23 9:45 AM, Reviewed Hospice philosophy and desire for hospice care. Patient (R1) understands his choices and able to decipher benefit vs (versus) burden. He is requesting comfort care. Patient informed all long-term care referrals have been declined. Agreeable to plan for possible transfer to accepting hospice house. On 1/4/24 at 11:29 AM, R1 stated he was not aware he was being discharged from the facility when he went to the emergency roiagnom on [DATE]. R1 stated he didn't want to return to the facility because he felt like he would just get revenge care. When asked why he was discharged from the facility R1 stated he thought it was because he called the state agency on the facility. R1 stated when the director (no name given) delivered the discharge papers to the hospital she told him he should never have called the police. R1 stated the hospital is currently looking for other options for him. When asked if there was any harm related to his discharge R1 stated, Absolutely. R1 stated he knew it was revenge. R1 stated he told them (the facility) it was illegal to evict someone for no reason. At 3:03 PM on this same date, when asked how he felt about the involuntary discharge, R1 stated it was devastating and embarrassing. R1 stated he felt abandoned, afraid, and didn't know what was going to happen to him. On 1/4/24 at 1:58 PM, V8 (CNA) stated R1 was never really rude to her. V8 stated she had witnessed him being rude to other staff. V8 stated she never heard R1 yelling or cursing at other residents and didn't have any residents complain to her about R1's behaviors. On 1/4/24 at 2:03 PM, V9 (LPN) stated R1 was just an unhappy person. V9 stated he wouldn't let her, or several other staff provide care for him. V9 stated R1 called staff names and talked about their personal appearances. V9 stated R1 refused care such as dressing changes and turning and repositioning. When asked if any of R1's behaviors were ever directed at other residents? V9 stated, No. It was mostly towards staff. When asked if she had any other residents complain about R1's behaviors, V9 stated, Not really. On 1/4/24 at 1:33 PM, V5 (CNA) stated R1 preferred V5 to be his caregiver. V5 stated R1 was verbally aggressive with other staff but not with him. When asked if R1 was ever verbally aggressive with other residents V5 stated he didn't think so. When asked if any other residents reported being afraid of R1 or appeared afraid of R1, V5 stated, I wouldn't say so. V5 stated R1 usually got out of bed and came out of his room at least daily. When asked if R1 was verbally aggressive in front of other residents V5 stated, The majority of the time he wasn't. I would say he was just happy to be up and out of his room. On 1/4/24 at 1:40 PM, V6 (CNA) stated she and R1 got along pretty well. V6 stated R1 could be difficult and challenging but she didn't have any issues with R1. V6 stated she never witnessed R1 yelling, cursing, or harming other residents. V6 stated she did have residents complain about R1's screaming and cursing. V6 stated they appeared disgusted but not afraid. When asked what she did to mitigate R1's behaviors, V6 stated she would have conversation with R1 and meet R1's needs as much as possible and report to V1 (Administrator) if she needed assistance. V6 stated R1 never physically harmed anyone. On 1/4/24 at 1:50 PM, V7 (Restorative Aid/CNA) stated she got along with R1. V7 stated R1 didn't have a problem with her. V7 stated she remembered R1 having two roommates at different times. V7 stated one of them was masturbating and R1 yelled at him so they moved the roommate to a different room. V7 stated no other residents have voiced fears or concerns related to R1's behaviors. On 1/4/24 at 2:01 PM, R10 stated he doesn't remember being roommates with R1. R10 stated he was not scared of anyone at the facility and doesn't remember being afraid of or feeling threatened by any other resident. On 1/4/24 at 2:08 PM, R11 stated he had a roommate with R1's name. R11 stated he didn't have any problems with R1. R11 stated he is not afraid of any resident at the facility. R11 stated he has never been scared of another resident since he has lived at the facility and was not aware of any resident having a problem with a peer. On 1/4/24 at 12:20 PM, V4 (LPN) stated R1 was very angry, resisted care, and made false accusations against staff. V4 stated R1 didn't really come out of his room but when he did, he was more social. V4 stated R1 would get upset at night and start screaming at staff and the other residents on his hall would get upset. V4 stated R1's language offended a lot of people. When asked what the facility did to mitigate R1's behaviors, V4 stated she didn't really know. V4 stated she knew the social worker, nurse practitioner, and therapist spent a lot of time in R1's room. V4 stated R1 enjoyed having certain people to vent to. When asked what she did when R1 was having verbally aggressive behaviors, V4 stated she would let V2 (Director of Nurses) know and write a detailed progress note. V4 stated R1 didn't have many good days. V4 stated she would also utilize social services and the therapist. When asked about distraction, redirection, or activities as interventions, V4 stated R1 wasn't really up for staff redirection. V4 stated she knew R1 enjoyed getting up. V4 stated R1 would refuse to get up a lot but when he did get up you could tell R1 really enjoyed it. When asked if other residents reported or appeared being afraid of R1, V4 stated there was one night that he was screaming and yelling and R4 was upset and tearful. V4 stated R4 didn't say she was afraid, but she appeared afraid. R4's progress note dated 12/12/23 10:31 PM documents, This nurse went to administer res's (R4) 1000 medication. Res stated that she was tired due to being kept up all night by the man across the hall who yells awful things all day and night long. This nurse asked res what the man (R1) says. Res became tearful. Res stated He is always yelling the F word which really upsets me. The way he talks to staff is awful. I feel bad for you guys for having to listen to him talk like that. But it's scary for me too. Especially at night. I just lay here and have to listen to the awful things he screams. Res also stated, You guys (staff) are in there all the time, and that takes you guys away from helping other residents. Admin (V1/Administrator) and DON (V2/Director of Nurses) made aware of res's concerns and statements. R4 was discharged from the facility prior to this survey so was not available for interview. On 1/4/23 at 2:57 PM, V10 (Social Services Director) stated R1 was loud and could be very angry and other residents would hear him and be scared. When asked if other residents reported being scared to her, V10 stated she knew the information was in the resident records. This information was requested from the facility. The facility provided this surveyor with R4's progress note dated 12/12/23. They were unable to provide other reproducible evidence related to peers being afraid of R1. On 1/4/24 at 3:18 PM, V2 (Director of Nursing) stated R1 was sent to the local hospital because he was demanding to be sent. V2 stated they heard he was trying to press criminal charges against staff and staff were upset about how R1 had treated them the night before. V2 stated after talking with their corporate office and medical director they determined it was in everyone's best interest to discharge R1. V2 stated there were no charges that were brought against any staff and the allegations were investigated by the facility and the local police. V2 stated she was not aware of R1 targeting any other residents. V2 stated it was unsettling for residents to lay in bed at night and listen to R1 be so insulting. V2 stated she was only aware of R5 complaining regarding R1's behavior and that was because her room was close to R1's and she was alert and oriented. On 1/04/24 at 11:25 AM, R5 stated she is not scared of any other resident at the facility. R5 denied knowing any other resident that was scared of any resident. R5 stated she has a lot of friends that are residents here. R5 denied any concerns. On 1/4/23 at 3:37 PM, V1 (Administrator) stated on the morning of 12/12/23, R1 requested to be transferred to the local emergency room and to call the police. V1 stated she advised the staff to send R1 out per his request. V1 stated R1 reported to the local hospital he wanted to press charges on facility staff for battery. V1 stated the allegation of abuse was investigated by the facility and local law enforcement and there were no findings, and no charges were filed against any staff. V1 stated they had been reviewing a possible discharge for R1 since they couldn't meet R1's needs. V1 stated hospice had been in and R1 refused hospice services with four different providers. V1 stated they reviewed R1's refusal of care. V1 stated on night shift prior to R1 being transferred to the local hospital on 12/12/23, R1 had been shouting and it was bothering R4. V1 stated after reviewing the information with the interdisciplinary team they came to the conclusion it was better for the psychosocial care of our other residents to discharge R1 from the facility. V1 stated there were only three staff members R1 liked, so medical care was met with resistance from R1. V1 stated R1 told hospice and the local law enforcement on 12/12/23 at the hospital that he didn't want to return to the facility, so that helped make the decision in moving forward with the involuntary discharge. V1 stated R1 was not allowed to return to the facility from the hospital. V1 stated R1 was transferred to the hospital on 12/12/23 and was given the immediate involuntary discharge papers while at the hospital on 12/12/23. V1 stated she knew there were residents who complained about how R1 talked to the staff and him cursing. V1 stated R1 did not yell at other residents. R1 was just vocal and vulgar. When asked if R1 was capable of physically harming someone, V1 stated, No, R1 only had control of his left arm. The undated facility Transfer and Discharge Policy and Procedure documents, It is the policy of (name of corporation) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility .3. The safety of individuals in the facility is endangered In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the resident's welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Type of Transfer and Discharge: Less than 30-day notice. Transfers and discharges with less than 30 days' notice may occur in limited circumstances. 1. The health or safety of others in the facility is endangered; 2. The health of the resident has improved to allow more immediate transfer or discharge; 3. The residents urgent medical needs require more immediate transfer; 4. The resident has not resided in the facility for 30 days. Under Involuntary transfers or discharge the policy documents, Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record .In all other instances of involuntary transfer or discharge the mandated federal and state 30 day 'Notice Transfer or Discharge will be issued, and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance, and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Services Director shall counsel the resident and summarize the counseling session in the resident record.

Based on interview and record review the facility failed to ensure residents were safely transferred without injury for 1 (R3) of 3 residents reviewed for mechanical transfers in the sample of 12. The failure resulted in R3 suffering pain with left sided rib fractures, numbers 3 - 10 and a pneumothorax to the left lung. Findings Include: Review of R3's Admission Record documented R3's initial admitted to the facility as 08/23/21. R3's date of birth is listed as 3/24/53. The same document lists diagnoses for R3 including but not limited to: Aphasia following Cerebral Infarction; Major Depressive Disorder; Essential Hypertension; Unspecified Atrial Fibrillation, etc. Review of R3's current Plan of Care documented an undated notation on the first page of the plan that stated, Special Instructions to include, Hoyer lift for transfers. Review of R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The same MDS documented in section G, R3 requires total dependence of two plus persons physical assist for transfers. R3's Clinical Record documented a late entry Progress Note made by V4 (Licensed Practical Nurse, LPN), dated 10/24/23 at 4:03 PM which stated, This nurse was called to res's (resident's) room at 0700. Upon entering, this nurse observed res lying on the floor. CNA's (Certified Nurse Assistant, CNA) (name) V11 and name (V10) stated that they had been transferring res via hoyer lift when the left bottom strap of hoyer sling came unattached from hoyer lift. Res then fell to the floor, landing on his left side. Res did hit his head. This nurse assessed res for injuries. No injuries noted at the time. Res c/o (complains of) pain to lt (left) side. Staff then used hoyer lift to place res back in bed The same note goes on to state that all necessary notifications were made with R3 being sent to the Emergency Department (ED) for evaluation and treatment. Review of the local hospital Emergency Department (ED) Provider Notes documented, R3 presented to the ED on 10/23/24 with the chief complaint of a fall, which is noted to have occurred from the hoyer lift, with R3 falling 3-4 feet, landing on his left side on the floor. R3 is documented as expressing back pain, being worse on the left side as well as left posterior rib tenderness and bruising. R3 also reports pain throughout his left side, arm, and leg. The ED Course listed on this same document stated through imaging results, R3 was discovered to have left 3rd-10th rib fractures with tiny lung base pneumothorax. Given the extensive nature of multiple rib fractures with underlying pneumothorax, recommend transfer to trauma center. Review of the out of town trauma hospital Discharge Summary documented R3 was admitted to the hospital on 10/24/23 and discharged back to the facility on [DATE]. Discharge diagnoses are listed as: Fall against object; Trauma; Traumatic fracture of ribs with tiny pneumothorax, left (#3-10), closed, initial encounter. This document stated After observation, he (R3) was tolerating a diet, pain was controlled on oral medications only with stable vital signs and labs. Therefore, (name) R3 was discharged in improved/stable condition. On 12/8/23 at 1:42 PM, R3 was asked if he recalled falling from the lift previously in which he responded yes. When asked if he knew what had happened that caused him to fall, R3 stated no. When asked if he experienced pain when he fell , stated yes. No responses were made when asked to rate his pain on a 0-10 scale. R3 stated yes when asked if he is happy with his care at the facility. On 12/8/23 at 2:29 PM, V10 (CNA) stated that she was a staff member performing the mechanical lift transfer on R3 when he sustained a fall from the lift. V10 stated that R3's cognition level varies as his normal status. V10 stated herself and V11 (CNA) had placed the mechanical lift sling under R3 while he was in bed and connected the sling to the lift and ensured a secure connection. V10 stated once in the air, she is unsure what occurred as it happened so fast but R3 fell from the sling, landing on his left side on the floor over the leg of the mechanical lift. V10 stated after the fall a sling loop was noted to be disconnected from the lift, but she doesn't know how that occurred. V10 stated V4 (Licensed Practical Nurse/LPN) was notified immediately and came to assess R3. V10 stated R3 was expressing no concerns of discomfort at the time, just that he wanted up. V10 stated R3 was sent to the emergency room (ER) for evaluation. V10 stated the sling used with the mechanical lift was inspected with no imperfections noted, as well as the lift being inspected with no faulty equipment noted. V10 stated she had never experienced any problems with the lift or this type of occurrence before. V10 stated she was interviewed by V1 (Administrator) regarding the incident and has been re-trained on mechanical lift use. On 12/8/23 at 4:14 PM, V11 (CNA) confirmed she was the aide transferring R3 with V10 from bed to his chair when he sustained a fall from the mechanical lift. V11 stated she is familiar with R3 and frequently provides his care. V11 stated R3 has trouble expressing his thoughts, with cognition varying as his normal status. V11 stated R3 requires the mechanical lift for transfer. V11 stated she is unsure of the root cause of the fall or any errors that occurred as it happened so fast and connections to the lift were checked prior to transfer. V11 stated while R3 was in the air being moved from the bed to over his chair, somehow a loop of the sling became disconnected from the lift and R3 fell to the floor. V11 stated R3 landed on his left side and herself and V10 did not move R3, but called for V4, who was his nurse. V11 stated V4 immediately responded and R3 was sent to the ER for evaluation. V11 stated R3 was not complaining of any discomfort, just wanted off of the floor. V11 stated she was interviewed by V1 regarding the fall and even after investigating cannot say what the problem was that allowed R3 to fall. V11 stated she has been re-trained in mechanical lift use and there have been no further incidents or falls with mechanical lift transfers. On 12/12/23 at 8:10 AM, V4 (LPN) stated she was the nurse working when R3 sustained a fall from the mechanical lift. V4 stated she was called to R3's room where she observed R3 lying on his left side over the leg of mechanical lift. V4 stated that V10 and V11 were the CNA's present, getting him out of bed and were shocked and couldn't explain what had happened that a portion of the sling had come undone from the lift, in which R3 then fell forward out of the sling and onto the floor. V4 stated that R3 was not complaining of any discomfort at that time and just wanted off the floor. V4 stated R3 was placed back in bed, and she notified the MD who ordered for R3 to go to the ER for eval. V4 stated that the ER eval did detect injuries including rib fractures were sustained. V4 stated she does not know the root cause of the fall but was re-trained herself on mechanical lift use as a facility wide in service was conducted. On 12/12/23 at 11:28 AM, V2 (Director of Nursing) acknowledged that R3 sustained a fall with fractures from a mechanical lift. V2 stated although the facility was unable to determine the root cause of the fall it is noted that if correct transfer procedures were being implemented, a fall should not have occurred. V2 stated R3 has been receiving pain medication and follow up assessments as indicated following his fall. On 12/8/23 at 9:30 AM, V1 (Administrator) stated that she's had no complaints made to her regarding improper nursing care, RN staffing, or falls. V1 stated she does acknowledge that an error or malfunction of some sort occurred during a mechanical lift transfer of R3 resulting in a fall with injury. V1 stated an investigation was conducted and the root cause could not be determined, therefore all staff were in-serviced on mechanical lift transfers. Review of R3's current Medication Administration Record (MAR) documented at this time R3 remains receiving a Lidocaine HCl External Patch 4 %, Apply to ribs topically one time a day for traumatic fracture of ribs. Remove after 12 hours. This order has a start date of 10/27/23. An additional order with a start date of 10/26/23, upon R3's trauma hospital return is for, Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. The MAR documents multiple doses of this medication were given as needed for pain and was documented as effective for the management of R1's pain management. An undated facility policy titled, (Company Name) stated, (Company Name) wants to ensure that its residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes residents and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment.

Based on observation, interview, and record review, the facility failed to provide the level of supervision necessary to prevent falls and consistently implement fall interventions for a resident assessed as a high risk for falls for 1 of 3 residents (R1) reviewed for accidents and supervision in a sample of 3. This failure resulted in R1 falling out of her wheelchair on 3/8/23, sustaining a right hip fracture. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE], and listed diagnoses of Sequelae of Cerebral Infarction, Congestive Heart Failure, Bipolar Disorder, Schizoaffective Disorder, Chronic Atrial Fibrillation, Diabetes Type 2, Generalized Muscle Weakness, and Unsteadiness on Feet. This MDS documented that R1 requires extensive assistance from at least two staff members for transfers and toileting and is always incontinent of bowel and bladder. The same MDS documented a Brief Interview for Mental Status (BIMS) Score of 99, indicating R1 is severely cognitively impaired that R1 was unable to complete the interview. R1's Fall Risk assessment dated [DATE] documented a score of 20, indicating R1 is at high risk for falls. R1's Care Plan dated 2/9/23 documented a problem area, Falls: Resident has risk factors that require monitoring and intervention to reduce potential for self-injury, with corresponding interventions, 2/9/23: Pressure pad alarm implemented. 2/14/23: 15-minute checks for 48 hours. 3/8/23: Implementing (a) 2 hour toileting program. 3/9/23: Educate staff on (the) importance of pressure pad alarm placement. A Final Report faxed to IDPH (Illinois Department of Public Health) dated 3/16/23 stated, Summary: (R1) fell on [DATE], resulting in injury. DX (Diagnosis) from the ED (Emergency Department): Right hip fracture. Resident Interviews: R1: I was trying to walk to the bathroom. Investigation Conclusion: Prior to this fall, (R1) was in wheelchair in the tv/common room. Through further investigation, it appears that this resident was attempting to self-ambulate. When staff arrived to resident no obvious signs or symptoms of distress or injury were noted. Residents only complaint of pain was to her right shoulder, all other range of motion was within normal limits. When she was interviewed, she stated she was trying to use the restroom when she fell . Resident was sent to ER (emergency room ) for evaluation and admitted for right hip fracture. During the time of this fall, her BIMS (Brief Interview for Mental Status) score presented as a 99. Staff noted her orientation presented as x2 (Oriented to two spheres), she also has a dx of Dementia with Behavioral Disturbances, resulting in the conclusion that resident is unaware of her safety awareness. The IDT (Interdisciplinary Team) met to review this fall, as a result, this resident will continue to utilize a pressure pad (alarm) and staff have been re-educated on her need for one; as well as resident has now been placed on a restorative therapy program for toileting/bladder. R1's Hospital Discharge Summary dated 3/22/23 documented, admitted : 3/8/23. discharge date : 3/22/23 .(R1) is a [AGE] year old female .who presented from a local nursing home following a fall. She had been seen earlier in (the same) morning also following a fall. (Morning) work up was negative and she was discharged back to the nursing home where she reportedly (later) fell out of bed striking head. CT (Computed Tomography Scan) head imaging was negative for acute findings, and imaging of right hip showed a femoral neck fracture .Imaging Study, Xray right hip, two views, 3/9/23: Impression: Angulated right femoral neck fracture. On 04/20/23 at 7:50am, R1 was sitting in her wheelchair in the dining room, watching TV next to a peer. R1 was alert and oriented to self only. V4 and V5 (Certified Nursing Assistants/CNA's) were standing nearby, at that time this Surveyor requested they bring R1 to a standing position, which they did with the use of a gait belt. R1 did not have a pressure pad style alarm in place at this time. On 4/20/23 at 1:00pm, V4 stated R1's fall interventions include a low bed, and Almost constant supervision from staff, we check on her every hour to hour and a half, and a pressure pad alarm when up to the wheelchair. V4 stated when he came to work at 6:00am the morning of 4/20/23, R1 was already dressed and up to her wheelchair and V4 did not realize the alarm was not in place. V4 stated R1 can usually tell staff when she needs to go to the bathroom and additionally, they check her at least every two hours for toileting needs. V4 stated R1's bowel and bladder continence are improving. V4 stated R1 requires the assistance of two staff for transfers. V4 stated R1's cognition varies, but generally she is only alert to self. On 4/20/23 at 1:10pm, V5 stated R1's fall interventions are a low bed and a pressure pad alarm, for certain when up to the wheelchair, and possibly also when in bed. V5 stated R1 can usually tell them when she needs to use the bathroom, and they check her at least every two hours for toileting needs. V5 stated R1 was already up to her wheelchair when she arrived on 4/20/23 at 6:00am to start her shift, and V5 was not aware the pad alarm was not in place. As far as R1's cognition, V5 stated, She can usually tell us if she's hungry or has to go to the bathroom, but that's about it. V5 stated R1 has had falls, but none have occurred while V5 was on duty. V5 stated R1 requires the assistance of two staff and a gait belt for transfers. On 4/20/23 at 3:15pm, V1 (Administrator) stated R1 often gets restless at night and staff get R1 up to the wheelchair to sit in the TV lounge area, which is adjacent to and visible within the nurse's station. V1 stated R1 has diagnoses of chronic mental illness, and requires one or two staff for transfers, depending on her level of cognition that day. V1 stated R1's cognition is variable depending on the day. V1 stated the facility's Fall Investigations are Quality Assurance documents and cannot be shared during the survey process, so the Surveyor interviewed V1, with V1 reviewing the fall investigations. R1's fall history is as follows: 2/14/22 at 5:00am. Location: TV lounge. Staff heard R1's pressure pad alarm sounding, staff ran to the area in time for staff to observe R1 in a standing position, and R1 took two steps and fell before staff could reach her. R1 stated she was trying to go to the bathroom. R1 had no injuries but was sent to the ER (emergency room ) per facility protocol as R1 is on an anticoagulant (Eliquis). ER found no injuries to R1, and R1 returned to the facility with no new orders. Root Cause Analysis: Attempted self- ambulation, lack of safety awareness. Intervention added: Every 15-minute visual checks for a 48- hour period and continue the pressure pad alarm. 3/8/23 at 4:15am. Location: TV lounge. R1 was found sitting on the floor in front of her wheelchair. The pressure pad alarm was in place and was sounding. R1 stated she was trying to get up to go to the bathroom. R1 was sent to the ER per protocol, R1 was returned to the facility with no injuries found and no new orders. Root Cause Analysis: Self ambulation. Intervention Added: Start a toileting program every two hours. 3/8/23 at 9:45pm. Location: TV lounge. Staff were at the CNA desk when they heard R1 yell for help. A few seconds later as staff were running to the area, they heard the pressure pad alarm sounding. R1 was lying on her left side and stated she was trying to get up to go to the bathroom. R1 was sent to the ER where a fractured right hip was diagnosed . Root Cause Analysis: Self ambulation with loose placement of the pressure pad alarm. Intervention added: Retrain staff on proper pressure pad alarm placement and the importance of using the pad. During this interview, V1 provided documents titled Care Need Notice which she stated is an in-servicing document for re-educating staff, and staff signatures were located on the bottom of the documents, which are as follows: 2/14/23: Related condition: Fall. What to watch for: Resident trying to self-ambulate. What to do: Assist resident with current needs and wants. (Start) 15- minute checks for the next 48 hours starting on 2/14/23 at 11:00am. 3/8/23: Related condition: Fall. What to watch for: Toileting program every two hours. What to do: Assist resident to use the bathroom and any other needs at least every two hours. 3/9/23: Related condition: Fall. What to watch for. Pressure pad alarm placement. What to do: Ensure pressure pad alarms are in place correctly when ordered. On 4/21/23 at 7:45am R1 was sitting in the TV lounge, this time with the pressure pad alarm in place. R1 was alert to herself only. On 4/21/23 at 9:30am, V11 (Advanced Practice Nurse/R1's Medical Provider) stated the facility has notified her of all R1's falls, including the 3/8/23 fall, which resulted in a right hip fracture. V11 stated R1 has diagnoses of chronic mental illness and has a history of sustaining a CVA (Cerebrovascular Accident). V11 stated her mental status is variable, she is highly impulsive, and oftentimes R1 is alert only to herself. V11 stated R1 is at high risk for falls. V11 stated she does not recall ordering a pressure pad alarm as a fall intervention, but pressure pad alarms can be initiated as a nursing judgement and do not require a provider order. V11 stated she does not recall the facility staff asking for her input about fall interventions, but V11 stated it doesn't sound as though the pad alarm has been very effective in preventing the resident from falling. V11 stated she may discuss with staff the possibility of implementing a weighted lap cushion as a fall intervention for R1. On 4/21/23 at 11:30am, V7 (CNA) stated she worked 6pm to 6am on 3/8/23. V7 stated she can't remember anything unusual about R1's status that evening. V7 stated she remembered R1 being in her wheelchair in the TV lounge watching TV prior to the fall. V7 stated when R1 is restless staff will put her in her wheelchair in front of the TV by the nurse's station so they can keep an eye on her. V7 stated she did not recall if they had tried to put R1 in bed earlier in the evening or not. V7 stated she recalls R1 was wearing gripper socks. V7 stated around 9:00pm, she and other staff were at the CNA desk charting when they heard R1 yell from the TV lounge. V7 stated R1 was laying on the floor on her left side but was complaining of right hip pain. V7 stated R1 said she was trying to go to the bathroom. V7 stated she can't remember if the pad alarm was going off or not. V7 stated R1 wears adult diapers and is on a toileting program where staff check her every two hours to see if she needs to go, and if so, they transfer her onto the toilet. V7 stated she recalls checking R1 at some time prior to the fall, changing her, and the pressure pad alarm was under her. V7 stated after the fact, staff thought maybe the pad alarm slipped and R1 wasn't sitting on the pressure point. V7 stated after the 3/8/23 falls, staff were re-educated on making sure the pad alarm is placed properly. On 4/21/23 at 11:50am, V6 (Licensed Practical Nurse/LPN) stated R1 is at high risk for falls, and her fall interventions include a pad alarm in bed, wheelchair, and recliner, toileting every two hours, and wearing proper footwear. V6 stated R1 is usually incontinent and wears adult diapers. V6 stated R1 at times will get restless at night and try to get out of bed, and when that happens staff get her up to the wheelchair and put her by the nurse's station where they can keep a close eye on her. V6 stated he was working on 6:00pm to 6:00am on 3/7/23 and 3/8/23, so was present for both of R1's 3/8/23 falls. V6 stated the first fall occurred at about 4:00am. V6 stated another resident came to him and said R1 fell . V6 stated when he entered the TV lounge, R1 was sitting on the floor, and V6 thinks the pad alarm was sounding. V6 stated R1 had on gripper socks. V6 stated R1 said she was trying to walk to the bathroom. V6 stated he examined R1 and found no injuries, but R1 was sent to the ER per facility protocol. V6 stated the second fall happened about 9:00pm, one of the CNA staff came to get him and said R1 fell . V6 stated R1 was lying on the floor on her left side in the TV lounge, complaining of right shoulder pain. V6 stated R1 was wearing gripper socks, and R1 stated she had tried to go to the bathroom by herself. V6 stated the pad alarm was not sounding at that time but one of the CNAs might have turned it off by then. V6 stated R1 was sent to the emergency room and was diagnosed with a right hip fracture. V6 stated staff were later re-trained on placing the pad alarm properly as it was apparently determined in the investigation that the pad had slipped and R1 wasn't sitting on the pressure point. On 4/21/23 at 2:45pm, V1 stated that with regard to the 3/8/23 Care Plan Intervention, Remind staff of importance of pressure pad alarm, this intervention does not mean the pad was not in use at the time of the fall, it was in place and V1 wanted it reinforced to staff how important an intervention the pad is. V1 stated to the best of her knowledge, the pad was in place at the time of the fall. V1 stated the investigation showed perhaps the pad rode up while R1 was fidgeting and was up against R1's back. V1 stated another possibility might be that R1 began sliding down in the wheelchair, keeping pressure on the pad until R1 was almost onto the floor. V1 stated when CNA staff begin their shift, they are to first go to the Alarm Tracking Binder and check and then document that all clip and pad alarms are in place and working properly. A March 2023 Alarm Tracking Sheet documents the slot for 2:00pm to 10:00pm on 3/8/23 Resident Compliance is blank. An April 2023 Alarm Tracking Sheet for 6:00am to 2:00pm on 4/20/23 documents Yes in the slot for Alarm present and functioning. On 4/21/23 at 3:10pm, V1 stated she can't explain why the 3/8/23 Alarm Tracking Document 2:00pm to 10:00pm slot is blank, or why the 4/20/23 6:00am to 2:00pm slot was checked when the Surveyor observed the pad was not in place. On 4/21/23 at 6:45pm, V9 (CNA) stated she was present for both of R1's falls on 3/8/23. V9 stated R1 is a high fall risk whose mental status really depends on the day. V9 stated prior to the fall at around 4:00am, staff checked to see if R1 needed to use bathroom at about 2:00am, they changed R1, and the pad alarm was under her. V9 stated at about 4:00am, V9 was down the south hall and heard the pad alarm sounding from the TV room. V9 stated staff couldn't get to R1 fast enough and when they got there R1 was on the floor. V9 stated the second fall that day happened at about 9:00pm, V9 and other staff were at the CNA desk charting. Staff heard R1 yell from the TV room, and as they approached, the alarm sounded. V9 stated R1 was laying on the floor. V9 stated, We thought afterward that maybe the pad slid up her back, she is often restless and fidgety. V9 stated after these two falls, staff was re-educated about making sure R1 is toileted every two hours and that the pad is in the proper place. V9 stated alarms are to be checked at the beginning of the shift and when they transfer the resident for toileting. V9 stated she doesn't know why the alarm tracker was not filled out for the time of the 3/8/23, 9:00pm fall. V9 stated she was working 4/19/23 from 6:00pm to 6:00am, and when V9 left that morning, R1 had the pad alarm in place. V9 stated that R1 is able to remove the pad out from underneath her and maybe she took it off. V9 stated she is not sure of why the Alarm Tracker was filled out on 4/20/23 from 10:00pm to 6:00am stating the alarm was in place and working, when the Surveyor observed it was not in place. On 4/21/23 at 7:05pm, V8 (CNA) stated R1 gets restless a lot and tries to get out of bed so staff usually put her in the wheelchair in front of the TV in the TV lounge so she can be seen from the nurse's station. V8 stated sometimes R1 is resistive to laying down in bed. V8 stated he worked on 3/8/23 during both of R1's falls. V8 stated the first fall around 4:00am or so, V8 heard the alarm go off and he ran to TV lounge but R1 was already laying in floor, and R1 said she had to go to the bathroom. V8 stated the second fall occurred about 9:00pm. Some of the staff were charting at the CNA desk when they heard R1 yell, and as they were getting to her, they then heard the pad alarm sounding, and R1 was laying in the floor. V8 stated R1 is checked for toileting needs and/or changed at least every two hours. V8 stated R1 would have been checked for toileting needs shortly after starting the shift at 6:00pm. V8 stated he worked on 4/19/23 from 6:00pm to 6:00am, and when he left that morning, R1 had the pad alarm under her. V8 stated he has previously observed R1 take the pad alarm out from underneath her. On 4/24/23 at 8:55am, V13 (LPN/Care Plan Coordinator) stated new Care Plan interventions are added after each fall occurs. V13 stated for the 2/14/23 fall, staff added an intervention of 15-minute checks for a 48-hour period. V13 stated she does not recall why an ongoing intervention was not added. V13 stated after the evening 3/8/23 fall, staff thought perhaps R1's pad alarm was not properly positioned under her. V13 stated they checked the batteries, which were working. V13 stated she has never observed or heard anything about R1 being able to remove the pad by herself. V13 stated prior interventions are evaluated after each fall occurs. V13 stated V13 feels the pressure pad alarm is an effective intervention for R1. V13 stated staff often put R1 in the TV area so she can be monitored closely. On 4/24/23 at 10:10am, V12 (LPN/Resident Care Coordinator/CNA Supervisor) stated she has not observed or heard any of her staff report that R1 can remove the pad alarm. V12 stated R1's cognition is, In and out. V12 stated V12 believes the pad alarm is an effective fall intervention. V12 stated CNA staff are to check all alarms at the beginning of their shift and then every eight hours. V12 stated if the 3/8/23, 2:00am slot on the alarm tracker document was blank, it was probably a documentation error. V12 stated the level of supervision R1 needs depends on her cognition that day. V12 stated staff often place R1 in the TV room so staff can monitor her closely. V12 stated she had heard from staff that the Surveyor observed R1 without the pad alarm on the morning of 4/20/23, but she was not in the facility at the time and doesn't know why the pad was not in place. On 4/24/23 at 12:35pm, V1 stated she had spoken to CNA staff to ask why R1 did not have the pad alarm in place when the Surveyor observed R1 on the morning of 4/20/23, and V1 stated, No straight answer was given. V1 stated until after the Surveyor left on the evening of 4/21/23, she had never had staff report that R1 can remove the pad, and V1 stated she has never personally observed R1 do this. V1 stated when the Surveyor left on 4/21/23, staff met regarding R1's falls and decided R1 needs some new fall interventions, so they will be contacting V11 for her input. The Facility's Fall Policy dated 11/10/18 stated, Policy: To provide for resident safety and to minimize injury related to falls .All staff must observe residents for safety .All falls will be discussed in the morning Quality Assurance meeting and any new interventions will be added to the Care Plan.

Based on interview, record review, and observation, the facility failed to refer an acutely ill resident for evaluation and treatment and failed to provide wound care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R4 becoming hospitalized on [DATE] for being lethargic and having poor skin turgor. R4 was diagnosed with pneumonia and continued to remain hospitalized as of 7/22/22. Findings include: 1. On 07/19/22 at 10:07am, V8, Emergency Medical Technician, stated he responded to a call from the facility on 07/18/22 about R4. V8 stated R4 was very lethargic with poor skin turgor. V8 stated facility staff told him that R4 had not eaten or drank in about three days. V8 stated it was his professional opinion that R4 should have been sent to the hospital sooner than she was. On 07/20/22 at 08:20 am, V9, emergency room (ER) Registered Nurse, stated R4 was brought into theER on [DATE], lethargic and dehydrated. V9 stated when she called the facility to get report, V10, Licensed Practical Nurse (LPN) stated that, (V1, Administrator) wanted (R4) sent out a couple of days ago, but for whatever reason, I guess it didn't happen. V9 stated it was her professional opinion R4 should have been sent to the hospital sooner than she was. An Emergency Department Hospital Admission Form dated 07/18/22 documented,(R4) is an [AGE] year old female with a history of Asthma, Dementia, Diabetes, [CONDITION(S)], Disease of the [CONDITION(S)], [CONDITION(S)], and (a history of) Pneumonia (on 03/09/20). The nursing home states the patient has not ate or drank for four days .(patient) Endorses being thirsty .When offered water, she drank with no coughing or difficulty. Physical Exam: .Oropharynx is VERY(caps, bold) dry with peeling skin on the lips. Assessment: Pneumonia: (Patient (diagnosed ) with Covid on 07/03/22), (and) Acute Kidney Injury on Chronic Kidney Disease Stage 3. On 07/20/22 at 10:20am,V10 LPN stated she worked with R4 on 07/18/22 from 8am to 6pm. V10 stated R4 was recovering from Covid and was refusing to eat or drink, and V10 was told in report she had been that way for a couple of days, and that she had stopped having urine output. V10 stated she felt R4 needed to be sent to the ER, and discussed it with V1, who agreed and stated, She thought the resident had needed to go out a couple of days ago but for whatever reason, she didn't. V10 stated she sent R4 to the ER around 7:15pm, but she probably should have sent her out earlier in the shift. On 7/20/22 at 1:59pm, V11 LPN, stated she worked with R4 on the 6am to 6pm shift on 07/17/22, the day before she was sent to ER.V11 stated she was told in report that morning that R4 had been refusing food and fluids. V11 stated when the evening shift Certified Nursing Assistants (CNAs) came in at 2pm, they reported when they worked the previous evening, R4 had no urine output.V11 stated this was not relayed during morning report. V11 stated she confirmed with the day shift CNAs she had not had output during the shift, and they had not reported it to V11. V11 stated she immediately assessed R4, and her vital signs were within normal limits, her lungs were clear, but she did have a slight non-productive cough. V11 stated her skin turgor was good. V11 said she did not contact the physician about R4 as she did not feel it was necessary. V11 stated she was however concerned about the lack of output and had decided to send R4 out when the CNAs reported R4 had soaked her adult brief. V11 stated she conferred with V1, who advised for R4 not to be sent out but to be closely monitored during the night. V11 stated she passed this along in shift change report. On 07/21/22 at 12:26pm, V1 stated she was called on 07/17/22 between 5pm and 6pm by V11, who stated R4 was not eating or drinking and had no urine output. V1 stated she told V11 to send R4 to the hospital. V1 stated V11 then called right back and stated R4 had a soaked adult brief. V1 stated she told V11 to call the doctor, encourage fluids and to monitor R4 closely. V1 stated she worked on 07/18/22, she saw R4 around noon and she looked sick, and staff stated she was no better. V1 stated she told V10 to send R4 to the hospital. V1 stated she worked late into the afternoon that day, and around 7 pm she noticed that R4 was still in her room. V1 stated she instructed V11 to immediately send R4 out. A July 2022 Food and Fluid Intake Sheet documented the following daily totals: 07/14/22: Food intake for the day was 25% of her lunch. Fluids: 100 cc (cubic centimeters). 07/15/22: No food intake, 260cc of fluid. 7/16/22:Food-25% of supper, 440cc of fluid. 07/17/22: 25% of lunch, 565cc of fluid. 07/18/22: No food or fluid intake. July 2022 Nursing Progress Notes contained no documentation indicating R4 was not eating or drinking, until the following entry on 07/18/22 at 7:18pm, authored by V10 (LPN), Resident is being sent to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission Nutritional assessment dated [DATE] documented that R4 required 1423 calories per day to maintain her admission weight of 111.8 pounds, and a daily total of 1524 cc of fluids. R4's Weight Record documented the following: May 2022: 94.6 pounds, June 2022: 98 pounds, July 2022: 99 pounds. On 07/21/22 at 10:40 AM, V16, Hospital Registered Nurse, stated R4's was still in the hospital and status was about the same as when she was admitted , but her daughter is now at the bedside, and she had perked up a bit and had started to eat a little. On 07/21/22 at 1:45pm, V7 (Physician/Medical Director) stated the facility called her on the evening of 07/18/22 to report R4 had not been eating or drinking and had no urine output and she told them to send her out. V7 stated that was the first time she was made aware that R4 had been in this condition for several days. V7 stated she has reiterated to the nursing staff previously that fluid intake is crucial in supportive care for resident recovering from Covid and they should have called her much sooner. V7 stated the facility should have notified her when R4 began refusing food and fluids and had no urine output. V7 stated, I have standing orders that any of my residents can be sent to ER at any time if they can't get hold of me. 2. On 07/19/22 at 9:53am, R133 was alert and oriented to person, place, time, and purpose. R133 was observed to have a bandaged right foot. R133 stated she had to be admitted to the hospital on 07/12/22 due to complications of Covid. R133 stated she is diabetic and has an arterial ulcer on the top of her foot. R133 stated the wound was debrided during the hospital stay. R133 stated the facility is supposed to be treating the wound daily, 'but they aren't consistently. R133 stated in spite of this, the wound has improved and is healing. On 07/19/22 at 3:04pm, V6, Registered Nurse, was observed providing wound care for R133. V6 stated to R133, The current order says to use Dakin's Solution, but I know before you went to the hospital, we had been using [MEDICATION(S)]. Which one do you want me to use now? R133 replied she preferred the [MEDICATION(S)], so V6 proceeded with the wound care using this treatment. A Physicians Order Sheet for July 2022 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily. On the July 2022 Treatment Administration Record and in the Nursing Progress Notes, there was no documentation to indicate the treatment was done on 07/16/22, 07/17/22, and 07/18/22. On 07/21/22 at 8:38am, V1, Administrator, acknowledged she had been made aware that the wound was not being treated as ordered. V1 stated she had had to write up some of the nursing staff for this. On 07/21/22 at 1:35pm, V7, Physician/Medical Director, stated the current July 2022 wound care treatment orders should be followed. V7 stated staff asking the resident how they want the wound to be treated is not acceptable practice. V7 stated the wound is healing adequately.

Based on observation, record review, and interview, the facility failed to assess a resident after two falls and failed to report and investigate these falls for 1 resident of 3 residents (R17) reviewed for falls in the sample of 24. This failure resulted in R17 not being promptly transferred to the hospital for evaluation where R17 was diagnosed with a fractured right humerus. Findings include: On 07/19/22 at 10:04am, R17 was observed in his room. R17 was sitting in a high backed wheelchair wearing a safety helmet and a sling to the right arm. R17 was alert but did not answer the surveyors' questions. R17 would occasionally grunt or squeal. R17's Minimum Data Set, dated dated dated [DATE] documented that R17 requires limited assistance from at least one staff member for transfers. R17's Care Plan with a revision date of 07/06/22 documented a problem area, Falls-Resident has risk factors that require monitoring and intervention to reduce potential for self injury. A Final Report submitted to the Illinois Department of Public Health dated 05/11/22 documented, (On 05/05/22) Resident (R17) was being assisted in ADL (Activities of Daily Living) when a staff member noted redness under the arm along with swelling, alerting her to follow up with the nurse on duty. The nurse then collected the residents' vital signs, and his temperature was elevated to 101.8 (degrees Fahrenheit) and (she) assessed the area where she noted redness and swelling of the right shoulder area. This occurred at 1930(7:30pm). This change of condition alerted the nurse to contact the physician at 1945 (7:45pm). The physician then informed the nurse to send this resident out (to the emergency room ) for further evaluation, based off the assessment and vitals stating it may be a possible infection. The resident returned with (diagnoses) of fever and right humerus fracture. At the time of the alleged incident the following was completed: The Administrator was notified, the DON (Director of Nurses) was notified, the Physician was notified, (staff) statements were obtained, the family was notified, IDPH was notified, and an investigation was initiated. Report further documents, Staff Interviews: (V12): Certified Nursing Assistant (CNA) (On 05/05/22 at 11:45am) I was serving lunch trays and when I walked out of the kitchen with food trays, I saw (R17) begin to lose his balance. As he began to fall, I caught him .catching his right arm to ease him to the floor with (V13, CNA) who came to assist. (V13): (On 05/05/22 at 11:45am), When I was serving dining room trays, (R17) was walking toward the kitchen. I was holding a tray .and I was helping guide (R17) back to his seat to begin eating his meal. When (R17) turned around to go toward his seat, he lost his balance and started to fall. (V12) was coming out of the kitchen and helped me lower him to the floor. (V6), Registered Nurse: (On 05/05/22) Two CNAs came to me and said (R17) 'almost fell '. After this set of interviews, this writer (V1) then interviewed staff members on the (5/5/22) evening (shift). The following was noted: (V14) CNA: I was walking down the hallway (on 05/05/22 on the 2pm to 10pm shift) checking on residents when I found (R17) on the floor next to his bed, laying on his fall mat. I had (V15, CNA) help me get him up. No abnormal reactions were had by this resident. (V150: V14 asked for help in assisting (R17) up from his fall mat where he was laying. His head was toward the wall (nearest the bathroom) laying on his right side. We rolled him onto his back .together we assisted in standing him up. We then walked (R17) until he was steady. The report further documents, Conclusion of Investigation: In conclusion, the facility has determined that the causation could have been either occurrence from the day and/or a combination of both, and/or anytime the resident was crawling (on his fall mat.) It is important to note that the resident has a diagnosis of intellectual disabilities, and his Care Plan states, He has the mentality of a three year old .Based on this incident, the QAC (Quality Assessment Committee) team has put in place that anytime (R17) is found crawling on the floor, nursing staff have to alert a nurse and they are to do a full assessment on him to ensure he has not obtained any injury. All staff have been educated that even if a fall was assisted to what they believe his safety, we will do best practice and ensure no injury took place in the assisting of the fall by having the on duty nurse fully assess the resident before standing him back up . There was no documentation in the nursing progress notes about staff assisting R17 to the floor nor of staff finding R17 on his fall mat. R17's Hospital emergency room Summary dated 05/05/22 documented, Exam: Right shoulder X-Ray. Trauma to the shoulder, and pain. Findings: There is a displaced fracture of the proximal humerus. On 07/20/22 at 1:05pm, V1 (Administrator) stated the facility's Fall Investigations represent Quality Assurance documentation and are only available to facility staff. V1 confirmed the above documented incidents as stated in the report. V1 confirmed the CNAs who found R17 on his fall mat did not report it to nursing staff. V1 confirmed R17 did not receive nursing assessment after either of the above referenced incidents, and neither were immediately investigated. V1 stated she had to re-educate staff that both of these incidents represented falls and should be reported and investigated as such. On 07/21/22 at 1:30pm, V7, (Physician/Medical Director), stated she was contacted by facility staff at 7:45pm on 05/05/22 stating they thought perhaps R17 had [CONDITION(S)] of the shoulder. V7 stated staff forwarded her a photo of the shoulder, which showed an obvious bone deformity. V7 stated she instructed staff to immediately send R17 to the emergency room . V7 stated controlled falls where a resident is lowered to the ground and unwitnessed falls wherein a resident is found lying on a fall mat should both be reported to a physician and investigated as falls. A Fall Prevention Policy dated 11/10/18 documented, Immediately after any resident fall, the unit nurse will assess the resident and provide any care or treatment needed .The unit nurse will place documentation of the circumstances of the fall in the nurses' notes.

Based on interview, record review, and observation, the facility failed to notify a resident's physician of a change in condition for 2 residents of 24 residents (R4, R17) reviewed for physician notification in the sample of 24. This failure resulted in R4 becoming hospitalized on [DATE] for being lethargic, having poor skin turgor. R4 was diagnosed with pneumonia and continued to remain hospitalized as of 7/22/22. This failure also resulted in R17 not being promptly transferred to the hospital for evaluation where R17 was diagnosed with a fractured right humerus. Findings include: 1. On 07/19/22 at 10:07am, V8, Emergency Medical Technician, stated he responded to a call from the facility on 07/18/22 about R4. V8 stated R4 was very lethargic with poor skin turgor. V8 stated facility staff told him that R4 had not eaten or drank in about three days. V8 stated it was his professional opinion that R4 should have been sent to the hospital sooner than she was. On 07/20/22 at 08:20 am,V9, emergency room (ER) Registered Nurse, stated R4 was brought into theER on [DATE], lethargic and dehydrated. V9 stated when she called the facility to get report, V10, Licensed Practical Nurse (LPN) stated that, (V1, Administrator) wanted (R4) sent out a couple of days ago, but for whatever reason, I guess it didn't happen. V9 stated it was her professional opinion R4 should have been sent to the hospital sooner than she was. An Emergency Department Hospital Admission report dated 07/18/22 documented,(R4) is an [AGE] year old female with a history of Asthma, Dementia, Diabetes, [CONDITION(S)], Disease of the [CONDITION(S)], [CONDITION(S)], and (a history of) Pneumonia (on 03/09/20). The nursing home states the patient has not ate or drank for four days (patient) Endorses being thirsty. When offered water, she drank with no coughing or difficulty. Physical Exam: Oropharynx is VERY (caps, bold) dry with peeling skin on the lips. Assessment: Pneumonia: (Patient (diagnosed ) with Covid on 07/03/22), (and) Acute Kidney Injury on Chronic Kidney Disease Stage 3. On 07/20/22 at 10:20am,V10 stated she worked with R4 on 07/18/22 from 8am to 6pm. V10 stated R4 was recovering from Covid and was refusing to eat or drink, and V10 was told in report she had been that way for a couple of days, and that she had stopped having urine output. V10 stated she felt R4 needed to be sent to the ER, and discussed it with V1, who agreed and stated, She thought the resident had needed to go out a couple of days ago but for whatever reason, she didn't. V10 stated she sent R4 to the ER around 7:15pm, but she probably should have sent her out earlier in the shift. On 7/20/22 at 1:59pm, V11 LPN, stated she worked with R4 on the 6am to 6pm shift on 07/17/22, the day before she was sent to ER. V11 stated she was told in report that morning that R4 had been refusing food and fluids. V11 stated when the evening shift Certified Nursing Assistants (CNAs) came in at 2pm, they reported when they worked the previous evening, R4 had no urine output. V11 stated this was not relayed during morning report. V11 stated she confirmed with the day shift CNAs she had not had output during the shift, and they had not reported it to V11. V11 stated she immediately assessed R4, and her vital signs were within normal limits, her lungs were clear, but she did have a slight non-productive cough. V11 stated her skin turgor was good. V11 said she did not contact the physician about R4 as she did not feel it was necessary. V11 stated she was however concerned about the lack of output and had decided to send R4 out when the CNAs reported R4 had soaked her adult brief. V11 stated she conferred with V1, who advised for R4 not to be sent out but to be closely monitored during the night. V11 stated she passed this along in shift change report. On 07/21/22 at 12:26 pm, V1 stated she was called on 07/17/22 between 5 and 6pm by V11, who stated R4 was not eating or drinking and had no urine output. V1 stated she told V11 to send R4 to the hospital. V1 stated V11 then called right back and stated R4 had a soaked adult brief. V1 stated she told V11 to call the doctor, encourage fluids and to monitor R4 closely. V1 stated she worked on 07/18/22, she saw R4 around noon and she looked sick, and staff stated she was no better. V1 stated she told V10 to send R4 to the hospital. V1 stated she worked late into the afternoon that day, and around 7 pm she noticed that R4 was still in her room. V1 stated she instructed V11 to immediately send R4 out. A July 2022 Food and Fluid Intake Sheet documented the following daily totals: 07/14/22: Food intake for the day was 25% of her lunch. Fluids: 100 cc(cubic centimeters). 07/15/22: No food intake, 260cc of fluid. 7/16/22: Food-25% of supper, 440cc of fluid. 07/17/22: 25% of lunch, 565cc of fluid. 07/18/22: No food or fluid intake. R4's July 2022 Nurses Notes contained no documentation about R4's lack of food and fluid intake nor lack of urine output. An Admission Nutritional assessment dated [DATE] documented that R4 required 1423 calories per day to maintain her admission weight of 111.8 pounds, and a daily total of 1524 cc of fluids. On 07/21/22 at 10:40 AM, V16, Hospital Registered Nurse, stated R4's was still in the hospital and status was about the same as when she was admitted , but her daughter is now at the bedside, and she had perked up a bit and had started to eat a little. On 07/21/22 at 1:45pm, V7 (Physician/Medical Director) stated the facility called her on the evening of 07/18/22 to report R4 had not been eating or drinking and had no urine output and she told them to send her out. V7 stated that was the first time she was made aware that R4 had been in this condition for several days. V7 stated she has reiterated to the nursing staff previously that fluid intake is crucial in supportive care for resident recovering from Covid and they should have called her much sooner. V7 stated the facility should have notified her when R4 began refusing food and fluids and had no urine output. V7 stated, I have standing orders that any of my residents can be sent to ER at any time if they can't get hold of me. 2. On 07/19/22 at 10:04am, R17 was observed in his room. R17 was sitting in a high backed wheelchair wearing a safety helmet and a sling to the right arm. R17 was alert but did not answer the surveyors' questions. R17 would occasionally grunt or squeal. R17's Minimum Data Set, dated dated dated [DATE] documented that R17 requires limited assistance from at least one staff member for transfers. R17's Care Plan with a revision date of 07/06/22 documented a problem area, Falls-Resident has risk factors that require monitoring and intervention to reduce potential for self injury. A Final Report submitted to the Illinois Department of Public Health dated 05/11/22 documented, (On 05/05/22) Resident (R17) was being assisted in ADL (Activities of Daily Living) when a staff member noted redness under the arm along with swelling, alerting her to follow up with the nurse on duty. The nurse then collected the residents' vital signs, and his temperature was elevated to 101.8 (degrees Fahrenheit) and (she) assessed the area where she noted redness and swelling of the right shoulder area. This occurred at 1930(7:30pm). This change of condition alerted the nurse to contact the physician at 1945 (7:45pm). The physician then informed the nurse to send this resident out (to the emergency room ) for further evaluation, based off the assessment and vitals stating it may be a possible infection. The resident returned with (diagnoses) of fever and right humerus fracture. At the time of the alleged incident the following was completed: The Administrator was notified, the DON (Director of Nurses) was notified, the Physician was notified, (staff) statements were obtained, the family was notified, IDPH was notified, and an investigation was initiated. Report further documents, Staff Interviews: (V12): Certified Nursing Assistant (CNA) (On 05/05/22 at 11:45am) I was serving lunch trays and when I walked out of the kitchen with food trays, I saw (R17) begin to lose his balance. As he began to fall, I caught him .catching his right arm to ease him to the floor with (V13, CNA) who came to assist. (V13):(On 05/05/22 at 11:45am), When I was serving dining room trays, (R17) was walking toward the kitchen. I was holding a tray and I was helping guide (R17) back to his seat to begin eating his meal. When (R17) turned around to go toward his seat, he lost his balance and started to fall. (V12) was coming out of the kitchen and helped me lower him to the floor. (V6), Registered Nurse: (On 05/05/22)Two CNAs came to me and said (R17) 'almost fell '. After this set of interviews, this writer (V1) then interviewed staff members on the (5/5/22) evening (shift). The following was noted: (V14) CNA: 'I was walking down the hallway (on 05/05/22 on the 2pm to 10pm shift) checking on residents when I found (R17) on the floor next to his bed, laying on his fall mat. I had (V15, CNA) help me get him up. No abnormal reactions were had by this resident. V15: V14 asked for help in assisting (R17) up from his fall mat where he was laying. His head was toward the wall (nearest the bathroom) laying on his right side. We rolled him onto his back .together we assisted in standing him up. We then walked (R17) until he was steady. The report further documents, Conclusion of Investigation: In conclusion, the facility has determined that the causation could have been either occurrence from the day and/or a combination of both, and/or anytime the resident was crawling (on his fall mat.) It is important to note that the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Based on this incident, the QAC (Quality Assessment Committee) team has put in place that anytime (R17) is found crawling on the floor, nursing staff have to alert a nurse and they are to do a full assessment on him to ensure he has not obtained any injury. All staff have been educated that even if a fall was assisted to what they believe his safety, we will do best practice and ensure no injury took place in the assisting of the fall by having the on duty nurse fully assess the resident before standing him back up . There was no documentation in the nursing progress notes about staff assisting R17 to the floor nor of staff finding R17 on his fall mat. A Hospital emergency room Summary dated 05/05/22 documented, Exam: Right shoulder X-Ray. Trauma to the shoulder, and pain. Findings: There is a displaced fracture of the proximal humerus. On 07/20/22 at 1:05pm, V1 (Administrator) stated the facility's Fall Investigations represent Quality Assurance documentation and are only available to facility staff. V1 confirmed the above documented incidents as stated in the report. V1 confirmed R17 did not receive nursing assessment after either of the above referenced incidents, and neither were immediately investigated. V1 stated she had to re-educate staff that both of these incidents represented falls and should be reported and investigated as such. On 07/21/22 at 1:30pm, V7, R17's (Physician/Medical Director), stated she was contacted by facility staff at 7:45pm on 05/05/22 stating they thought perhaps R17 had [CONDITION(S)] of the shoulder. V7 stated staff forwarded her a photo of the shoulder, which showed an obvious bone deformity. V7 stated she instructed staff to immediately send R17 to the emergency room . V7 stated controlled falls where a resident is lowered to the ground and unwitnessed falls wherein a resident is found lying on a fall mat should both be reported to a physician and investigated as falls. V7 confirmed the facility did not notify her immediately after the resident was lowered to the ground nor after the resident was observed on his fall mat. A Notification for Change in Resident Condition or Status Policy dated 12/7/17 documented, The nurse supervisor/charge nurse will notify the residents attending physician or on call physician when there has been an accident or incident involving the resident.

Based on interview and record review the facility failed to safely transfer 1 of 3 (R6) residents reviewed for transfers in the sample of 7. This failure resulted in a displaced proximal humerus to R6's left arm requiring emergency room (ER) evaluation and treatment on 1/20/21 along with pain management therapy. Findings Include: A Minimum Data Set ((MDS) dated [DATE] documents R6's admitted to the facility as 9/20/16. R6's Brief Interview for Mental Status Score is documented as 99, indicating she is not cognitively intact. R6's Transfer Status as well as Bed Mobility is documented as requiring Total Dependence of Two + persons physical assist. The Functional Status of Walk in Room and/or Walk in Corridor is documented as Activity did not occur. R6's Plan of Care with a Start Date of 5/3/19 documents, R6 uses a hoyer (mechanical) lift, wheelchair, and assist of 2 for transfers. Nurse's Notes made by V16 (Licensed Practical Nurse, LPN) dated 1/20/21 at 7:15 AM document, R6 was noted to have red/purple bruising near existing blue/purple bruising from previous skin tear. New onset bruising is documented as extending to top R6's left shoulder to lower forearm with swelling noted. V21 (Physician) notified and awaiting return call. Nurse's Notes made by V16 dated 1/20/21 at 11:30 AM document a new order for a venous doppler study of R6's left upper extremity and x-ray of her left elbow and shoulder. R6's left shoulder x-ray report dated 1/20/21 documents the findings of, A complete fracture through the proximal humerus is identified just beneath the humeral head. The fracture does not involve the articular surface. Superior medical displacement of the distal fracture fragment is noted. The glenohumeral and acromioclavicular articulations appear intact. Diffuse osteopenia is noted. Soft tissue swelling is present. A local emergency room (ER) After Visit Summary dated 1/20/21 documents R6 presented to ER with the reason for visit being an arm injury. R6 was diagnosed with [REDACTED]. Musculoskeletal assessment documents, There is marked tenderness over the proximal left humerus and severe pain with passive movement of the left shoulder. There is moderate tenderness diffusely over the distal half of the humerus, elbow, forearm, and wrist. Treatment documented as being completed is a left arm sling applied, along with [MEDICATION NAME] and ordansetron medications administered. An office visit note dated 1/22/21 by V22 (Physician) documents R6 was seen for evaluation of a left arm injury. V22 documents imaging studies show a [MEDICAL CONDITION] humerus with 100% displacement of the head in relation to the shaft. V22 documents a treatment plan as, Nonoperative treatment. For comfort we will get a shoulder immobilizer for her to use. Follow-up will be in 4-weeks. Medication Administration Records documents on 1/21/21 at 8:00 PM R6 was administered Tylenol 1000 milligrams (mg) by mouth for the reason listed as arm pain. Another entry made on 1/22/21 at 11:30 AM documents R6 was administered [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 mg by mouth with the reason listed as arm pain. On 1/27/21 at 12:11 PM, V21 (Physician) states he would expect the facility to follow R6's plan of care for all aspects of care including transfer status. On 1/22/21 at 11:05 AM, V12, Certified Nurse Assistant (CNA) states that R6 was in bed when she arrived to work on 1/20/21. V12 states that R6 was her normal status and she did not notice anything abnormal. V12 states that R6 was in a gown and had some previous bruising to a skin tear area on her left arm from earlier in the month. V12 states that herself and V13 got R6 out of bed and into her wheelchair that morning by lifting her under her arms. V12 states later in the morning herself and V14 then again transferred R6 from her wheelchair into a shower chair by lifting her under her arms. V12 states she left the shower room and V14 was going to bathe R6. V12 states she has worked at the facility since May 2020 and was not aware R6 was to be transferred with a hoyer lift. V12 states she reported to V1 she had not in fact used a lift and V1 instructed her one was to be used due to R6's brittle bones. V12 states in the past she has used a lift to transfer R6 maybe a total of 4 times in her employment during times when R6 was positioned awkwardly to lift. V12 states she was notified by V1 on 1/20/21 that she was suspended pending investigation outcome. V12 states she has been trained in abuse and if she observes an injury of unknown origin or abuse of any sort she would report it to the nurse and Director of Nursing immediately. On 1/26/21 at 1:33 PM V13, CNA states that she was working 1st shift on 1/20/21. V13 states she went to R6 room to get her out of bed. V13 states R6 was in a gown and was acting her normal self, with no abnormal or new onset bruising noted. V13 states herself and V12 transferred R6 out of bed in put her into her wheelchair by lifting her under her arms. V13 states a gait belt was not used. V13 states she had no further interaction with R6 the rest of the day. V13 states she was notified by V1 via phone that evening that she was suspending pending investigation related to R6 sustaining a fracture. V13 states she has since learned that R6 was to be transferred via hoyer lift by education that has been provided by V1. V13 states she just wasn't aware. R6 states the resident transfer status can be found in their chart. On 1/26/20 at 2:23 PM, V14, CNA states she was working on 1/20/21 when R6's fractured arm was discovered. V14 states herself and V12 transferred R6 from her wheelchair to the showerchair in R6's room by lifting her under her arms, not using a gait belt. V14 States R6 was wheeled to the shower room and once undressed purple bruising was observed to R6's left shoulder, arm and part of her chest. V14 states V16 Licensed Practical Nurse was notified and examined R6. V14 states R6 seemed to be her normal self pretty much, and guarded the extremity slightly more than usual, maybe, but has very low cognitive function. V14 states V16 stated she would notify the physician and to be careful with the extremity during her shower. V14 states the shower was completed without incident and herself and V17 transferred R6 back into her wheelchair by picking her up under her arms again. V14 states she was contacted by V1 later that evening and notified she was suspended pending investigation. V14 states a 2 person physical transfer is her normal method of transferring R6, although she states she knows some staff use the hoyer for her though. V14 states you can find out a resident transfer status by checking their chart. V14 states she since has had to complete transfer training prior to returning to work. On 1/22/21 at 2:14 PM, V16 Licensed Practical Nurse states she was working the morning R6 fracture was discovered. V16 states around 7:15 AM she was notified that V14 needed her in the shower room. V16 states she entered the shower room and witnessed R6 sitting in the shower chair. V16 states R6 left elbow was swollen and ruddy red with her left shoulder and there was purple bruising spreading onto her chest. V16 states R6 was guarding her arm and V14 reported no incident to cause injury had occurred that she was aware of and that the arm was bruised when she undressed her to be bathed. V16 states R6 has a history of [MEDICAL CONDITIONS] and her thought was that with her skin tear she had possibly developed a [MEDICAL CONDITION]. V16 states she instructed V14 to be very careful with R6's extremity getting her dressed and she was going to call V21 (Physician). V16 states she called V21 and a venous doppler and X-ray was ordered. V16 states outpatient x-ray services came to the facility and performed the studies. V16 states she assisted the x-ray technician with the studies and after x-raying the shoulder the technician asked if R6 had a history of [REDACTED]. V16 said not to her knowledge., but was shown the x-ray which looked to show a fracture. V16 states V21 was notified along with V1 and R6's family with orders to sent to the ER for eval. On 1/22/21 at 10:10 AM, V1, Director of Nursing (DON) states upon her arrival to work on 1/20/21 around 9AM she was notified by staff that R6 had bruising to her left arm. V1 states she went to R6's room where she observed purple bruising to R6's arm. V1 states R6 did not appear to be in any discomfort or distress at that time. V1 states staff reported they did not know what had happened, they just noticed the bruising when they undressed her to shower her this morning. V1 states an investigation of unknown injury was initiated. V1 states that R6 is confused and dependent on staff for all care. V1 states that R6 utilizes a hoyer lift for all transfers. V1 states that night shift staff interviews note R6 was her normal self with no bruising or abnormalities noted. V1 states that V13 is the staff member who reported dressing R6 on 1/20 in the am with no concerns noted. V13 and V12 reported transferring R6 from her bed to her wheelchair on 1/20 with no incident or concerns noted. V12 and V14 reported transferring R6 from her wheelchair to her shower chair on 1/20 with no incident. V14 reported bruising to V16 while undressing R6 for her shower. V1 states V12, V13, and V14 were all suspended pending the investigation. V1 states that R6 does have a roommate, but the roommate is confused and unable to give detail on any occurrence that happened. In a letter dated 1/25/21 directed to the Illinois Department of Public Health, states that the letter is to serve as a follow up to an incident that occurred on 1/20/21 involving R6. Following facility investigation their conclusion documents R6 sustained injury as a result of being improperly transferred approximately three times via two person axillary lift. The report documents all parties were suspended during the investigation, and completed the Limited Resident Lift Program prior to return of duty. A summary of care provided post incident documents R6 was transferred to the local emergency room for evaluation and treatment where she later returned to the facility that day and was seen by V22 (Physician-Orthopedic) on 1/22/21 where it was determined surgical repair of the fracture would be contraindicated and a supportive sling was prescribed. The letter documents the facility has taken measures to prevent further incidents as such by providing staff education and also updated R6's plan of care. Review of the not dated Limited Resident Lift Program documents the purpose for the program as, This policy describes ways to ensure that employees use safe resident handling and movement techniques at (Company) facilities for tasks that are designated as high-risk for safe resident handling and movement injuries. The same policy goes on to list one of the goals of the program as, Reduce the injury potential for both the resident and caregiver.

Based on observation, interview and record review the facility failed to: 1. Immediately separate [DIAGNOSES REDACTED] CoV-2 (Covid-19) positive residents rooming with Covid negative residents. 2. Move a resident who tested negative for Covid out of the designated COVID unit where 18 other Covid positive residents reside. 3. Prevent cross contamination between Covid-19 negative and Covid-19 positive residents in the same room and potentially on the Covid-19 unit. 4. Perform the recommended frequency for disinfecting/cleaning high touch areas. 5. Provide adequate resident supervision to ensure Covid-19 positive residents remain within the designated Covid-19 isolation areas and away from Covid negative residents. 6. Ensure staff wear masks correctly and perform hand hygiene in accordance with recommendations for staff and residents. These systemic failures have resulted in 27 residents testing positive for Covid-19, with death being the result for five residents R7, R22, R23, R27 and R29. These failures have the potential to affect all 31 residents residing in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ was identified to have begun on [DATE], when the facility continued to allow R3, R4, R5, and R7, who tested negative for Covid-19, to reside in the same rooms with R2, R16, R17, and R8 respectively, who tested positive for Covid-19. The facility also allowed R6, who tested negative, to remain in a private room on the Covid positive unit. The facility failed to implement recommended disinfection practices to prevent cross contamination between negative and positive residents and failed to follow recommended practices for hand sanitization and proper usage of PPE. The facility was notified of the Immediate Jeopardy on [DATE] at 10:38 AM. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. On [DATE] at 10:30 AM, V1 (Administrator) stated the facility census was 31, and they have 25 Covid positive residents in the building. V1 further stated the residents that have still tested negative for Covid-19 on [DATE] (R3, R4, R5, R6 and R7) are residing on the Covid-19 unit because they are presumed positive due to their roommate testing positive and showing symptoms. V1 said they do not have anywhere else to move these residents. Review of the facility's Room List for the date of [DATE] notes four empty rooms on the 200 hall. The four rooms contain twelve open beds total. 1. The Room List provided by V1 on [DATE], documents R7 and R8 are roommates. On [DATE] at 10:55 AM, V1 (Administrator) stated R7 and R8 are currently roommates and have roomed together since prior to [DATE]. Lab test results dated [DATE] document R8 was tested for Covid-19 on [DATE], with positive results returning on [DATE]. R7 was also tested on [DATE] with negative results returning on [DATE]. R7 was re-tested on [DATE] with negative results again returning on [DATE]. R7's follow-up testing on [DATE] returned with positive results on [DATE]. On [DATE] at 2:40 PM, R7 and R8 were observed residing in the same room. On [DATE] at 11:10 AM, V1 (Administrator) again stated R7 and R8 were still roommates. The facility's Covid assessment dated [DATE] documents R7 developed a nonproductive cough, lethargy, muscle pain and oxygen saturation levels of 89%, and noted R7's lung sounds were diminished. The [DATE] Covid Assessment documents R7's lung sounds were diminished however no oxygen saturation levels are documented. R7 had a productive cough, increased lethargy and a poor appetite. No documentation of regular monitoring of vital signs (temperature and oxygen saturation) from [DATE] to [DATE] could be found in R7's medical record. Nurse's notes for R7 do not document any symptoms for Covid-19 from [DATE] - [DATE]. Nurse's Notes from [DATE] document R7 expired at the facility. During an interview on [DATE] at 11:10 AM, V1 confirmed R7 and R8 were roommates until R7 expired on [DATE]. A Review of R7's Medical Record documents a positive Covid -19 test on [DATE]. R7's Medical Record does not indicate R7 was being treated for [REDACTED]. R7's Medical Record documents he was treated for [REDACTED]. R7's Covid Assessment Sheets dated [DATE] at 1:00 AM document he experienced lethargy, body aches, and cough. R7's Covid Assessment sheets document he required continued Oxygen therapy prior to R7's passing in the facility on [DATE] at 12:20 AM. On [DATE] at 12:16 PM, V31 (Medical Director) said R7 is her patient. V31 said she saw him in the facility last month and he was his normal self. V31 said the facility called her and said R7 tested positive for COVID. V31 said they called again and said his O2 sat dropped. V31 then stated, We put him on oxygen (O2), he stopped eating. The next call I got they said he died . He was not end of life. V31 stated before the Covid positive diagnosis, R7 was in his usual state of health and not expected to expire. 2. The Room List provided by V1 on [DATE] documents R3 and R2 are roommates. On [DATE] at 10:55 AM, V1 (Administrator) verified R2 and R3 are currently roommates and have roomed together since prior to [DATE]. R2 was tested for Covid-19 on [DATE] with positive results returning on [DATE]. R3 was also tested on [DATE] with negative results returning on [DATE]. R3 was re-tested on [DATE] with negative results again returning on [DATE]. R3's follow-up testing on [DATE] returned with positive results [DATE]. On [DATE] at 2:40 PM, R2 and R3 were observed residing in the same room. On [DATE] at 11:10 AM, V1 (Administrator) stated R7 and R8 were still roommates. 3. The Room List Provided by V1 on [DATE] documents R4 and R16 were roommates. On [DATE] at 10:55 AM, V1 (Administrator) stated R4 and R16 are currently roommates and have roomed together since prior to [DATE]. R16 was tested for Covid-19 on [DATE] with positive results returning on [DATE]. On [DATE] at 11:10 AM, V1 confirmed that R4 continued to occupy the same room as R16 until [DATE]. The Resident Notification of Room/Roommate change form documents R4 was moved from the Covid-19 unit on [DATE]. Nurse's notes for R4 do not document any symptoms for Covid-19 from [DATE] - [DATE]. On [DATE] at 10:00AM, V1 stated R4 remains Covid negative. 4. The Room List Provided by V1 on [DATE] documents R5 and R17 are roommates. On [DATE] at 10:55 AM, V1 (Administrator) stated R5 and R17 are currently roommates and have roomed together since prior to [DATE]. R17 was tested on [DATE], with positive results returning on [DATE]. R5 was also tested on [DATE], with negative results returning on [DATE]. R5 was re-tested on [DATE], with positive results returning on [DATE]. Nurse's notes for R5 do not document any symptoms for Covid-19 from [DATE] - [DATE]. On [DATE] at 2:15 PM, R5 and R17 were observed residing in the same room. Resident Notification of room/ Roommate change documents R5 was moved from the room on [DATE]. On[DATE] at 11:12:AM, V1 said R5 and R17 continued to occupy the same room until R5 was moved to another room this morning. 5. The Room List provided by V1 on [DATE] documents R6 was in a private room on the Covid-19 unit. While residing on the Covid-19 unit, R6 was tested on [DATE] with a negative result returning on [DATE], on [DATE] with a negative result returning on [DATE], on [DATE] with a negative result returning on [DATE] and again on [DATE] returning a negative result returning on [DATE]. R6 was re-tested again on [DATE] with a positive test result on [DATE]. R6's Significant Change Minimum (MDS) data set [DATE] documents under Functional Status that R6 is totally dependent on two staff to move in bed, does not get out of bed or walk in the hallway. On [DATE] beginning at 11:35 AM, V11 (Certified Nurse Aide/CNA) delivered lunch to R1 (placing it on his dresser), R2, R3, R4 and R14, with no observation of hand hygiene or PPE change. Then on [DATE] at 11:45 AM, V11 (Certified Nurse Aide) entered R6's room without changing PPE. On [DATE] at 12:18 PM, V11 (CNA) stated there are no different precautions that are required between rooms on the Covid-19 unit, even with residents (R3, R4, R5 and R6) still testing negative, due to the fact they are presumed positive because they were exposed. On [DATE] at 12:17 PM, V16 (Social Service Director) was observed entering R6's room (R6's Covid test results were still pending at this time) after entering R8's (a Covid-19 positive resident) room with no PPE change. On [DATE] at 12:50 PM, V7 (CNA) stated there are no different precautions that are required between rooms on the Covid-19 unit, even with residents (R3, R4, R5 and R6) still testing negative, due to the fact they were exposed when their roommates tested positive. Policy titled COVID-19 Control Measures documents Purpose: To prevent transmission of the COVID-19 Virus and to control outbreaks. Monitoring and Surveillance - Residents Monitor all residents for new onset of fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell. 3. Initiate temperature, pulse respiration and pulse oximetry every 4 hours and B/P (blood pressure) every 8 hours if a resident test positive for COVID-19 or if residents have signs/symptoms of COVID-19. 4. Place symptomatic resident in a private room, if available, until test results are received and follow facility Cohorting Procedure. This policy has a revision date of [DATE]. Policy titled COVID-19 COHORTING OF RESIDENTS states Purpose: To minimize interaction of infectious individual(s) from non-infected individuals. Procedure: 1. Identify Space within the facility to be dedicated to monitor and care for residents with COVID-19. Ideally, this space should be physically separated from other rooms that house residents without confirmed COVID-19. (Separate floor, wing or cluster of rooms) 2. Identify HCP (Health Care Provider) who will be assigned to work only within the dedicated area, when in use. 3. Move residents who develop symptoms consistent with COVID-19 to a private room, if available. 4. Test any resident that develops symptoms consistent with Covid-19. 5. DO NOT move a resident to a COVID-19 designated area until test results are received. 6. Move resident to COVID-19 designated area if test results are positive for [DIAGNOSES REDACTED]-CoV-2. 7. If space allows, a resident with confirmed COVID-19 should be moved to a private room on the designated COVID area. If space is not available, residents that are confirmed to have COVID-19 may be permitted to share a room. 8. DO NOT move an exposed roommate in another room with an unexposed resident. 9. If space allows, the exposed resident should be placed in a private observation room. If space is not available, exposed residents may be permitted to room share with other exposed residents, within a designated area, for observation. 10. Counsel all residents to restrict themselves to their room, as much as possible. 11. Ensure that Infection Prevention and Control Interventions are in place to decrease the risk of cross-contamination. 6. On [DATE], at 10:07 AM, V1 (Administrator) said 4 residents (R7, R23, R27, and R29) have expired in the facility and one (R22) expired in the hospital due to Covid-19. V2 (Director of Nursing/DON) said prior to the Covid-19 diagnosis, none of the 5 residents were expected to expire. They were not receiving end of life services, hospice or comfort measures. On [DATE] at 11:45 AM, V1 (Administrator) said R10 and R12 were the first residents confirmed with Covid-19, on [DATE] after being tested in the facility on [DATE]. V1 said on [DATE], R13 was confirmed Covid -19 positive on at the local hospital. On [DATE], 18 more residents tested positive for Covid-19 at the facility, (R1, R2, R8, R9, R14, R15, R16, R18, R22, R23, R24, R26 R28, R29, R30, R31, R32, and R34.) V1 said on [DATE] R17, R27 and R33 tested positive for Covid -19. On [DATE], R3, R5, R6 and R17 tested positive for Covid -19 at the facility. Resident lab records dated [DATE] through [DATE] document two residents R10 and R12 tested positive on for [DIAGNOSES REDACTED] CoV-2 (Covid-19) on [DATE]. R13 tested positive in the hospital on [DATE]. On [DATE], 18 residents tested positive (R1, R2, R8, R9, R14, R15, R16, R18, R22, R23, R24, R26, R28, R29, R30, R31, R32 and R34). On [DATE], three residents tested positive (R17, R27 and R33). On [DATE] R3, R5, R6 and R7 tested positive. 7. A review of R22's Medical Record documents a positive Covid -19 test date of [DATE]. R22's clinical record does not indicate R22 was being treated for [REDACTED]. On [DATE] at 10:15 AM, V2 said when she arrived at work the morning of [DATE], R22 was breathing hard. V2 said she called the doctor and the ambulance. V2 said after R22 left the facility, R22 coded in the emergency room and was pronounced dead. R22's Certificate of Death dated [DATE] documents R22's immediate cause of death is; 1. [MEDICAL CONDITION] Pneumonia and 2. Novel [MEDICAL CONDITION]. 8. A review of R23's Medical Record documents a positive Covid-19 test dated [DATE]. R23's Medical Record does not indicate R23 was being treated for [REDACTED]. On [DATE] at 10:30 AM, V1 said R23 expired on [DATE]. R23's Certificate of Death worksheet confirms R23 expired on [DATE]. 9. A review of R27's Medical Record documents a positive Covid-19 test dated [DATE]. R27's Medical Record does not indicate that R27 was being treated for [REDACTED]. On [DATE] at 10:07 AM, V1 said R27 was transferred to the hospital over the weekend, and while in the hospital R27's family and doctor decided R27 should receive hospice care. V1 said R27 came back to the facility and expired on [DATE]. A Certificate of Death Worksheet confirms R27 expired on 12/ ,[DATE], with cause of death listed as Novel Corona Covid -19 Virus. 10. A review of R29's Medical Record documents a positive Covid-19 test dated [DATE]. R29's Medical Record does not indicate R27 was being treated for [REDACTED]. On [DATE] at 10:07 AM, V1 said R29 expired in the facility that morning. A Certificate of Death Worksheet confirms R29 expired on [DATE], with cause of death listed as Novel [MEDICAL CONDITION]. 11. On [DATE] between 11:05 AM and 12:10 PM during continuous observation, R15, a Covid-19 positive resident, was observed in his wheelchair going up and down the hall with no mask on and entering rooms that housed negative residents (R3 and R4). In addition, during this same time period, R14, a Covid-19 positive resident, was observed entering the room of R3 unmasked, who at the time was negative for Covid-19. V11 (CNA) redirected the residents back to their rooms after they had entered the Covid-19 negative resident rooms, with R15 returning to the hallway after being redirected back to his room. 12. On [DATE] at 2:00 PM, R11, a Covid-19 negative resident that leaves the facility for [MEDICAL TREATMENT] (Monday, Wednesday and Fridays), was observed on the 200 hall with no infection control supplies outside of his room, with R10, R12 and R13 being Covid-19 positive residents also residing on the 200 hall. On [DATE] at 11:31 AM, V5 (Activity Director) was observed delivering lunches and entering R11's room, with no gloves, with a tray stacked with boxed lunches. She set R11's lunch down and exited the room, then entered R12's room and sat her lunch down and exited her room. She then handed R13's lunch to V11 (CNA) and entered R10's room and delivered her lunch with no hand hygiene observed. The policy Revised [DATE], titled Entering an Isolation Room states, 1.prior to entering the room [ROOM NUMBER]. Wash your hands or apply waterless antimicrobial agent. 6. Follow facility policy and procedure for removal of protective apparel. The policy undated, titled Removing PPE states, .Hand Hygiene. Perform hand hygiene immediately after removing all PPE! On [DATE] at 12:40 PM, V14 (Housekeeping) stated there is nothing different she needs to do between any rooms on the Covid-19 unit, no changing PPE or anything. V14 stated bleach water is used to clean the floors and the high touch surfaces, the high touch surfaces are to be cleaned every two hours, and she believes it needs to stay wet for a couple of minutes. The bleach water is made as per manufacture directions, she believes. The bleach that she uses is kept in the utility closet at the end of the hall on the Covid unit for the Covid unit. V1 (Administrator) provided her with training for infection control approximately one week ago. On [DATE] between 11:05 AM to 2:15 PM, (during continuous observation on the Covid-19 unit), no cleaning of high touch surfaces was observed as being done. On [DATE] at 2:30 PM, two bleach containers were observed in the utility closet on the Covid-19 unit with EPA # ,[DATE] and ,[DATE], with contact times of 5 minutes and 10 minutes noted respectively, from the United States Environmental Protection Agency Pesticide Registration, Disinfectants for Coronavirus (Covid-19). On [DATE] at 11:17 AM, V3 (Housekeeping Supervisor/ Laundry/ Cook) stated everything is supposed to be disinfected with bleach water with a one to ten dilution, there is a measuring cup in the utility room for the housekeeping staff to use to measure the bleach and the mop bucket is marked to know how much water is to be put in. The housekeeping staff is supposed to clean all high touch surfaces every two hours; she would like it every hour however they do not always have time. When on the Covid-19 unit, even prior to [DATE] when there were both negative and positive residents on the unit, there were no requirements to change PPE or mop water between rooms, besides the normal changing after every three rooms. V3 stated she has trained the staff to spray the high touch surfaces and to leave it for 5 to 10 minutes. V3 stated when cleaning other surfaces with the bleach rags, she's trained staff to wipe the surface and leave for 5 to 10 minutes. V3 stated she has not checked to ensure any surface stays wet for the contact time that it should and did not know there were different contact times for different bleaches. She provides the housekeeping staff with training every week. On [DATE] at 1:10 PM, V2 (DON) stated she had not educated anyone on contact times of disinfectants and did not realize different bleaches would have different contact times. On [DATE] at 11:34 AM, V14 (Housekeeping) was observed mopping the floor at 11:42 AM. The floor was observed to be dry at 11:45 AM, after 3 minutes. At 11:47 V14 stated this is the bleach I used. The bottle observed had the EPA registration number (,[DATE]), which has a contact time of 5 minutes. V14 stated she has not really paid attention to how long it takes for anything to dry, or how long any surface remains wet. On [DATE] at 12:16 PM, V31 (Medical Director) stated she had not spoken with the facility about cleaning procedures. The facility utilizes the corporation's cleaning procedures. Policy titled Covid-19 Control Measures revised [DATE] states, Environmental 1. Increase frequency of cleaning and disinfecting of high touch areas, with an EPA, hospital grade disinfectant that is effective against COVID-19. 2. Clean all resident rooms daily. 3. Follow facility procedure for Cleaning of Isolation rooms. The facility policy titled Routine and Terminal Cleaning of Isolation Rooms documents the following: Policy: To ensure all resident isolation rooms are clean and to prevent the spread of microorganisms. Note: In accordance with CDC guidelines, microorganisms are normal contaminant of walls, floor, and other surfaces; these environmental surfaces rarely are associated with transmission of infections to residents or personnel. Therefore, extraordinary attempts to disinfect or sterilize these environmental surfaces are rarely indicated. However, routine cleaning and removal of soil are recommended. Procedure: 1. All personnel are to use the same precautions during routine and terminal cleaning of isolation rooms as nursing personnel. 2. Remove all non-disposable resident care items by the double bagging method and take to the soiled utility room for cleaning and disinfecting. 3. Discard all disposable items in the appropriate trash container in the room. Remove all trash by the double bagging method and take to the appropriate biohazard waste container. 4. Any remining equipment is to be cleaned with the appropriate disinfectant-detergent used by your facility. 5. All horizontal surfaces in resident rooms are to be cleaned on a regular basis with the appropriate disinfectant-detergent as used by your facility and when soiling or spills occur, or when the resident is discharged . Horizontal surfaces include over bed table, dressers, non-carpeted flooring, mattresses, etc. 6. Cleaning of walls, blinds, and curtains is recommended only if they are visibly soiled. 7. Carpeted areas should be cleaned if there is heavy soiling or spillage. 8. No disinfectant fogging should ever be performed. 9. Upon termination of isolation: a. Remove any signs posted on the door. B. Clean and remove any cabinet placed outside the room to store supplies. C. Clean and remove large waste and linen containers from the room. D. Remove isolation Precautions from the resident's Care Plan/Kardex 10. Wash your hands. Dated ,[DATE] Revised [DATE]. An article from the Center for Disease Control and Prevention, (https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/services.html) dated 2003; Infection Control, Section E. Environmental Services: Guidelines for Environmental Infection Control in Health Care Facilities 1. Principles of Cleaning and Disinfecting Environmental Surfaces states, Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients. The transferal of microorganisms from environmental surfaces to patients is largely via hand contact with the surface. Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces as appropriate is fundamental in reducing their potential contribution to the incidence of healthcare-associated infections. Cleaning is the necessary first step of any sterilization of disinfection process. Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation. The physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces. If the surface is not cleaned before the terminal reprocessing procedures are started, the success of the sterilization or disinfection process is compromised. According to https://www.cdc.gov/hai/prevent/environment/surfaces.html, the Centers for Disease Control and Prevention guidance dated [DATE] states, Healthcare-associated Infections: Reduce Risk from Surfaces, Surfaces-A key Component of Environmental Cleaning states, the healthcare environment contains a diverse population of microorganisms. Surfaces contaminated with microorganisms can serve as reservoirs of potential pathogens. Many of these microorganisms are continuously shed or spread by direct skin contact onto surrounding environment surfaces. Contamination of surfaces, including high-tough surfaces in the room (e.g., bedrails, over-bed tables, and call-buttons) and reusable patient care equipment that is moved between rooms, can lead to: (1) transmission to the next patient who occupies the room or uses the same equipment, or (2) contamination of the hands or clothing of healthcare personnel with transmission to other patients. Therefore, cleaning and disinfection of environmental surfaces is fundamental to reduce potential contribution to healthcare-associated infections. Inadvertent exposures to environmental opportunistic pathogens may result in infections with significant morbidity and/or mortality. On [DATE] at 2:15 PM, when asked about the facility's procedure for routine cleaning of isolation rooms, V2 was holding the policy titled Routine and Terminal Cleaning of Isolation Rooms stating that is the policy they use. When asked if all non-disposable resident care items are removed by the double bagging method, taken to the soiled utility room, cleaned and disinfected, and all disposable items were placed in the appropriate trash container on a daily basis, V2 stated it is not like we bag and remove their hairbrush, so no. V2 confirmed there was no other policy to differentiate a routine cleaning from a terminal cleaning of an isolation room, stating this is the policy given to us by corporate. On [DATE] at 11:55 AM, V2 (Director of Nursing) verified the facility had not changed any policies from what was provided to surveyors the previous day. On [DATE] at 12:40 PM, V14 (Housekeeping) was observed cleaning R3's room, who was on isolation precautions as noted with signage outside the room. At no time did V14 remove or bag any non-disposable resident care items and take them to the soiled utility room for cleaning and disinfecting as stated in the facility policy. A non-dated CDC article at Coronavirus.gov titled 6 steps for Safe & Effective Disinfectant Use documents Step 4: Follow the contact time - You can find the contact time in the directions. The surface should remain wet the whole time to ensure the product is effective. 15. On [DATE] at 10:15 AM, V3 (Housekeeping/Laundry/Dietary) was wearing her mask with both her nose and mouth exposed. At the same time V15 (Dietary) was noted wearing her mask with her nose exposed. Again on [DATE] at 10:30 AM, V3 was noted wearing her mask with both her nose and mouth exposed. On [DATE] at 11:15 AM, V3 (Housekeeping Supervisor/ Laundry/ Cook) was observed in the kitchen with her mask not covering her nose or her mouth. On [DATE] at 11:17 AM, V3 stated she wears her mask at all times in the facility. After V3 was told she was observed with her mask worn incorrectly, not covering her nose or mouth, worn down under her chin, V3 stated the facility does have a policy to wear a mask at all times when in the facility, however sometimes in the kitchen she is too hot and does not. The undated policy titled Sequence for Putting on Personal Protective Equipment (PPE) from the Center for Disease Control and Prevention (CDC) states .2. Mask or Respirator .and denotes a picture of a person with their nose and mouth covered with the mask .4. Gloves .Use Safe work Practices to Protect Yourself and Limit the Spread of Contamination Perform hand hygiene. The section titled How to safely Remove Personal Protective Equipment (PPE) Example 1: 5. Wash Hands or Use an Alcohol-Based Hand Sanitizer Immediately after Removing all PPE. The facility's Resident Census dated [DATE] documents 31 residents are living in the facility. The IJ was identified to have begun on [DATE], when the facility continued to allow R3, R4, R5, and R7, who tested negative for Covid-19, to reside in the same rooms with R2, R16, R17, and R8 respectively, who tested positive for Covid-19. The facility also allowed R6, who tested negative, to remain in a private room on the Covid positive unit. The facility failed to implement recommended disinfection practices to prevent cross contamination between negative and positive residents and failed to follow recommended practices for hand sanitization and proper usage of PPE. V1 was notified of the Immediate Jeopardy on [DATE] at 10:38 AM. On [DATE] the surveyors confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: -Cohort residents in the correct zones (red, yellow, green) as of [DATE], according to Local Health Department guidance. -Re-education of staff on policy and procedure of cohorting during Covid: Completed by Director of Nursing on [DATE]. -Re-education by Regional Administrator, of Administrator and Director of Nursing on [DATE], on policy and procedures during Covid, which included but not limited to: cohort protocol, infection control, hand hygiene, and protective equipment. -Re-education and in-service, on policy and procedures for proper hand hygiene, infection control, and proper protective equipment usage for droplet and contact precautions during Covid: Completed [DATE] by Director of Nursing. -Re- education of staff on cleaning frequency of high contact areas; Completed by Director of Nursing on [DATE] -Re-education of all staff on the importance of frequent supervision and redirection of residents to ensure cross contamination is not occurring: Completed by Director of Nursing on [DATE].

These requirements are not met as evidenced by: Based on observation, interview and record review the facility failed to provide medications timely and as ordered by the physician, for 1 of 5 residents (R19) reviewed for medication administration in the sample of 30. R19 did not receive eight doses each of two medications that facilitate breathing for four days, six doses of one pain medication for two days, four doses of an anti-anxiety medication and four doses of a narcotic pain medication for one and a half days. These failures resulted in R19 experiencing an increase in pain, anxiety, oxygen therapy use and nausea, and unable to leave his room for meals or activities. Findings include: The September, 2019 physician's orders [REDACTED]. R19's [DIAGNOSES REDACTED]. The POS includes in part, the following medications: [REDACTED] 1. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg (milligrams) 2ml(milliliters) per nebulizer two times a day x 14 days - a breathing treatment for [REDACTED].>2. Arfoemoterol 15 mcg (micrograms) 2 ml per nebulizer two times a day x 14 days - a [MEDICATION NAME][MEDICATION NAME] for breathing problems caused by [MEDICAL CONDITION] 3. Pregabalin (Lyrcia) 50 mg capsule one by mouth three times daily - treats nerve and muscle pain 4. [MEDICATION NAME] /[MEDICATION NAME] 5/325 mg, ([MEDICATION NAME]) one to two tablets by mouth every 6 hours as needed for pain 5. [MEDICATION NAME], ([MEDICATION NAME]) 0.5 mg one tablet by mouth three times a day as needed as needed for anxiety On 09/23/19 at 3:15 PM, R19 said he was admitted to the facility on [DATE] or 09/20/19; he couldn't remember which date because he was so upset about his medications. R19 said he takes [MEDICATION NAME] (Antianxiety Medication) and [MEDICATION NAME] (a pain-relieving medication), but since he arrived at the facility he has only had the medication that was sent with him from the hospital and it ran out. Now, they are only giving him Tylenol. R19 said he did not receive [MEDICATION NAME] (a nerve pain medication) when he came to the facility. He takes three different breathing treatments and still hasn't gotten two of them. He is too upset to eat. He does not leave his room for meals or activities because he is anxious and in pain. R19 said he requires continuous oxygen, was admitted on 2 Liters per minute, yet needed to increase the oxygen consumption to 4 Liters per minute, because his anxiety and discomfort had increased without his usual medications and due to all the added aggravation. R19 had rapid pressured speech and said he was upset and anxious. On 09/26/19 at 1:35pm, V61 (Family) said R19 has been very upset and nauseated without his pain and anxiety medications. He is calling V61 frequently and is extremely upset and anxious, saying he is in pain. V61 stated he is waiting to see a pain specialist due to his rotator cuff tears. All of this is adding to his anxiety and breathing difficulty. The facility is telling them they could not get these medications refilled because it was the weekend when he ran out and V49 (Physician/Medical Director) would not refill these without first evaluating him. The September, 2019 Medication Administration Record [REDACTED] 1. R19 did not receive [MEDICATION NAME] and [MEDICATION NAME] on 09/19 at 5:30am, 09/20 - 9/22 at 5:30am and 8:00pm and 9/23 at 5:30am. On 09/23/19 at 2:30pm, V2 (Director of Nurses) stated R19 refused to take the [MEDICATION NAME] and Aformorerol breathing treatments at 5:30am because he did not want to be awakened at that time. On 09/24/19 at 3:30pm, V7 (Licensed Practical Nurse) said the facility did not have the [MEDICATION NAME] or the [MEDICATION NAME] in the building to give to R19 from 09/19/19 through 09/23/19. When she came to work on 09/23/19, she noted these breathing treatments were not being given. V22 (Registered Nurse) informed her these medications did not come in. This is when she called the pharmacy and ordered both medications. The treatments were started on 09/23/19 at 8:00pm. 2. R19 did not receive Pregabalin ([MEDICATION NAME]) 50 milligrams three times a day (7:30am/3:30pm/8:00pm) on 09/19 at 8:00pm, 9/20 x 3 doses and 09/21 x 2 doses. On 09/24/19 at 3:30pm, V7 stated the hospital did not send the facility a prescription for the [MEDICATION NAME] when he was discharged on [DATE]. She sent a fax to V49 requesting this medication on 09/20/19. The [MEDICATION NAME] was not available for R19 until 09/21/19 at 8:00pm. *The September, 2019 Controlled Substance Proof of Use log documents the following: 1. [MEDICATION NAME] ([MEDICATION NAME]) 0.5mg, take one table by mouth three times daily as needed. R19 received the first tablet at 9:15pm on 09/19/19 and the last tablet at 8:00 PM on 09/21/19. A Controlled Substance Prescription dated 09/23/19 documents R49 ordered [MEDICATION NAME] ([MEDICATION NAME]) #30 tablets for R19. 2. [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg, take one-two tablets by mouth every six hours as needed for pain. (Amount Received #10) R19 received the first dose at 9:15pm on 09/19/19 and last dose at 2:00pm on 09/22/19. (The MAR indicated [REDACTED].) A Controlled Medication Prescription dated 09/23/19 documents R49 ordered [MEDICATION NAME]/[MEDICATION NAME] 5/325 ([MEDICATION NAME]) #30 tablets for R19. On 09/24/19 at 3:30pm, V7 stated R19 arrived at the facility on 09/19/19 with a limited supply of [MEDICATION NAME] (#10) and [MEDICATION NAME] (#6). She called V49's office and the pharmacy on Friday 9/20/19, regarding the need for medications. On Saturday 09/21/19 at 2:00pm, she faxed a refill request to the pharmacy and V49 for these medications. Even though this was a Saturday she was hoping V49 would go into his office and see it. They needed a hard copy to refill these medications and had no way to obtain it since it was the weekend. A Nurse's Note dated 9/19/19 at 7:40 PM states: (R19) assessed. Resident becomes agitated easily, short term patience, complains of back/shoulder pain. O2 (Oxygen) on at 4L/minute via NC (nasal canula), at this time due to drop in pulse ox (oxygen saturation), assist x 2 required for bed mobility and transfers. The 09/20/19 2:00am Nurse's Note documents that R19 is agitated easily with oxygen on at 4 Liters/minute. He is complaining of pain. Short of breath on exertion and receives nebulizer treatments for shortness of breath. The only other documentation regarding the need for the [MEDICATION NAME] or the [MEDICATION NAME] is on the Controlled Substances Proof of Use log and the PRN (as needed) Medication Information log which indicates when the medications were given. These documents are not completely filled out to identify R19's pain level, location and if there was any relief provided by the medications. The Nurse's Notes limited documentation states that R19 is agitated and short of breath frequently. No note details he is requesting his pain medications or that any of R19's medications did not arrive or could not be refilled. On 09/23/19 at 4:00pm, V1 (Administrator) stated the hospital did not send R19 with enough of his pain and anxiety medication. He ran out over the weekend and the facility could not get them refilled. These medications require a hard copy prescription and this could not be done over the weekend. V1 stated that V49 had said he would not refill either of these medications without first seeing the resident. Therefore, there was nothing else the facility could do. On 10/03/19 at 4:00pm, V49 said he received a call and a fax for [MEDICATION NAME] and [MEDICATION NAME] only on 09/20/19. These medications were approved that day. On 09/23/19 he received a refill request for the [MEDICATION NAME] and [MEDICATION NAME] and agreed to refill the medications. V49 said the facility can page him anytime a medication is needed. If he is not available, the on-call physician will help. In a controlled environment such as a long term care facility, he would not have denied R19 his pain medication or the [MEDICATION NAME]. Again, the facility never asked him to refill either of these medications before 09/23/19. He was not aware that R19 did not receive his [MEDICATION NAME] until this writer discussed this issue with him. He approved this medication on 09/20/19. V49 stated regarding the [MEDICATION NAME] and the [MEDICATION NAME], when I was asked I didn't piddle around, I said yes. The lag was not on my end. Additionally, he had no knowledge that the breathing treatments were not being given as ordered.

Based on interview, observation, and record review, the facility failed to use 2 staff members to properly transfer one of three residents (R1) in the sample of three reviewed for falls. This failure resulted in R1 being sent to the emergency room for treatment of [REDACTED]. Findings include: 1. On 04-25-13 at 2:30 AM, per E8's (Certified Nurse Aide) written statement, E8 was rolling R1 over in bed to put a pillow under his side. R1 rolled out of the bed. The facility's Final Investigation report dated May 02, 2013 indicates E8 failed to have another nursing staff member assisting her with R1's bed mobility, per R1's plan of care. R1's nurses notes and incident report dated 04-25-13 at 3:20 AM, indicate R1 was transferred to the local hospital's emergency room with skin tears to bilateral forearm, bridge of nose, and right eye brow. R1's Minimum (MDS) data set [DATE], indicates R1 is totally dependent for bed mobility and requires the physical assist of two plus persons. R1's Physical Restraint/Enabler Assessment (undated) indicates for transfers to use a mechanical lift with two assist, two assist for bed mobility and turning and repositioning. On 04-30-13 at 1:50 PM, R1 was asked what happened to his nose. R1 replied, "They threw me out of bed". R1 was observed to have steri strips across the bridge of his nose, a small scabbed area near his right eyebrow, light greenish with a small amount of light bluish discoloration mostly below both eyes. R1 was noted to have a dressing on top of each hand. On 05-01-13 at 11:10 AM, E1 (Administrator) stated R1 is a two person assist. E8 did not wait for E11 to help her.

Based on observation, interview and record review the facility failed to assess and address pain for one of seven residents (R3) reviewed for pain management in the sample of 12. This failure resulted in the resident exhibiting tearful behavior due to pain incurred when showered. Findings include: 1. The admission sheet in R3's medical record notes a [AGE] year old female admitted to this facility on 7-11-12. [DIAGNOSES REDACTED]. The Minimum Data Set, ((MDS) dated [DATE], indicates no cognitive impairment, non ambulatory, dependent for transfers, frequently incontinent and dependent for hygiene and bathing. Section JO600 for pain is scored as occasional at a level of 4 out of 10. The physician's orders [REDACTED]. R3 also has an order dated 7-11-12 for [MEDICATION NAME] Cream twice a day to rectal area. The only [MEDICATION NAME] ordered routinely is Aspirin 81mg daily. An as needed (PRN) pain medication order was noted for [MEDICATION NAME] 325mg, two pills every six hours At 10:15AM, on 8-28-12, R3's buttocks were observed red from excoriation with denuded areas. R3 complained of pain on the buttocks as well as joint pain when turned in bed for observation. At 10:20AM, R3 was observed on a hard shower chair in the hallway crying of pain. When asked where she hurt she indicated it was her "bottom". E8, (Shower Aide), told R3 at this time she would hurry. At 10:30AM, R3 was back in bed still crying/complaining of pain. R3 stated the shower really hurts her. R3 noted the shower chair caused her pain on her buttocks. R3 states she was not offered pain medication prior to showers. E8 noted R3 complains the shower hurts her really bad and therefore wants only one a week instead of two as scheduled. E9, (Registered Nurse), stated at 10:40AM, on 8-28-12, she is unaware of R3's complaints of pain during showers. The PRN Medication Sheet indicates R3 was given two 325mg of Tylenol on 7-12-21, 7-14-12, 7-19-12, 7-23-12, and 8-15-12 all for general discomfort and 8-19-12 for buttock pain. The Shower/Abnormal Skin Report notes refusal of the scheduled shower on 7-17-12, 7-24-12, 7-31-12, 8-10-12, 8-14-12, and 8-24-12. The Shower Reports fail to indicate why R3 was refusing showers or note any complaints of pain during the showers. There was no coordination of pain medication with shower days per interview with R3 at 12:15PM on 8-28-12. This was confirmed by review of dates on Shower Reports not coinciding with any of the six dates (noted above) when prn Tylenol was given for pain. R3 noted pain is at a 10 out of 10 when in the shower chair. R3 stated she has told staff many times she refuses showers due to the pain it causes. R3 indicated she told staff today after her shower to try padding the shower chair for next time. R3 stated, "I don't think they realize how bad it hurts." R3 has a Behavior Monitoring Record for August 2012 for a Target Behavior of non compliance with care: not trying to help herself, not getting up etc. This Behavior Record documents R3 was hollering in the hallway disturbing others at 11:45AM on 8-16-12 , "My butt hurts! Lay me down!" Review of the PRN Medication Sheet indicates a pain medication was not given on this day. The complaint of pain was documented as a behavior. The Care Plan dated 7-19-12 states potential for alteration in comfort/pain. The goal is to report effective pain management throughout the next 90 days. Approaches include to assess location and duration of pain and any contributing factors, to protect painful areas with positioning, to administer [MEDICATION NAME] as ordered, and to assess effectiveness. The facility's failure to aggressively assess/address R3's pain and failure to communicate causes of pain was confirmed with E1, (Administrator), at 3PM on 8-29-12.