Every finding on record at Elms, The

Based on Observation, Interview and Record Review, the facility failed to ensure residents were informed of how to file a grievance and ensure that written complaints can be filled anonymously. This failure has the potential to affect all 66 residents residing in the facility.Findings include:The facility's Grievance/ Complaint policy and procedure, dated 3/25/26, documents Each resident and/or resident representative may file a grievance or complaint regarding any resident right, quality of life, or quality of care concern. The party filing the grievance may present the grievance anonymously and every effort to preserve the identity of the referring source will be attempted. The Social Services Director/ Director of Nursing are the designated coordinators of this policy. The forms are located in the social services office, north and south nurses' stations and front reception desk.On 6/2/26 at 10:40 AM, during a resident group meeting. R10, R14, R64 and R66 all denied knowing how to file a written complaint or grievance. These residents also all stated the facility does not have a complaint box or a place to put anonymous suggestions or complaints.On 6/2/26 at 12:25 PM V7 (Social Service Director) confirmed that the facility does not have a grievance box or a formal complaint form that can be submitted anonymously. V7 stated We have missing item/concern forms at the receptionist desk in the main lobby and those are submitted to the receptionist. We also have those forms at the nurse's stations.On 6/2/26 at 12:30 PM V7 located the concern form at the North Hall nurse's station. This form was in a wall filing slot behind the nurse's station and above V7's head. V7 confirmed that this concern form would need to be given to a resident by facility staff since it is out of sight and reach of residents. V7 stated there is not a grievance box, sign or a way to submit the form anonymously.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/1/26 and signed by V1 (Administrator), documents 66 residents reside within the facility.

Based on observation, interview, and record review the facility failed to label opened food items in the refrigerators. These failures have the potential to affect all 66 residents residing in the facility.Findings Include:The facility's Food Receiving and Storage policy dated 11/2022 documents, Policy statement, foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. The facility's Refrigerators and Freezers policy dated 11/2022 documents, Policy statement, this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation, 7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened.On 6/1/2026 at 9:15 AM, during the initial kitchen tour, the refrigerator contained a bag of bacon bits that was not marked with an opening date. Additionally, several opened food containers were not properly date marked, including macaroni salad, mustard potato salad, Summer Fresh pasta salad, tuna salad, cottage cheese, pickles, two containers of sauteed vegetable base, two containers of strawberries, cheesecake, sour cream, mustard salad, western salad dressing, mayonnaise, pickle relish, Caesar dressing, and Thousand Island dressing.On 6/1/2026 at 9:25 AM, V8 (Director of Food Service) stated he does not label foods opened with a use by date and assumes the expiration date is the date to use opened foods.

Based on interview and record review the facility failed to notify the state mental health authority once a resident experienced an increase in behaviors, was diagnosed with a new psychiatric condition, and was prescribed a new anti-psychotic medication for one of two residents (R16) reviewed for a significant change in condition in the sample of 30.R16's MDS (Minimum Data Set) dated 10/15/25 documents R16 does not receive anti-psychotic medication.R16's Behavior Note dated 12/4/25 at 10:58 AM documents, (R16) is very angry and anxious this am (morning). (R16) states that she does not want to move to south. It is not fair that I have to leave my home. Attempted to talk with resident but she just walks away.R16's Behavior Note dated 12/4/25 at 8:23 AM documents, (R16) is yelling at roommate. (R16) states that it is not fair that (R16) has to move to south hall. (R16) is yelling at her roommate and stating, I hope no one does this to you!R16's Progress Notes dated 12/7/25 documents, (R16) has coat on. Went up front by the doors and states I am leaving. Several staff attempted re-direction. (R16) set alarms off twice. Once (R16) was back to her room became even more upset threw her cell phone when her friend called and said it wouldn't be until 10:00 AM before she came. Yelling at staff. Told the staff to get out of her room.R16's Progress Notes dated 12/10/25 documents, New order from (V14/Psychiatric Nurse Practitioner) to start Rexulti (anti-psychotic medication) 0.5 mg (milligrams) daily. This same Order does not include the behaviors or diagnosis to warrant the use of Rexulti.R16's Electronic Health Record does not include evidence of a notification to the state mental health authority once R16 started to exhibit an increase in behaviors and was started on Rexulti on 12/10/25.On 6/3/26 at 8:15 AM, V4 (Infection Preventionist) verified that once R16 started exhibiting new behaviors and was started on an anti-psychotic medication for a mood disorder the state mental health authority was not notified.

Based on Observation, Interview and Record Review, the facility failed to follow their policy/procedure for incontinence care, complete hand hygiene and glove changes during incontinence care for one of two residents (R41) reviewed for incontinence care in the sample of 30.Findings include: The Perineal Care policy dated 2/2018 documents The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Equipment and Supplies - The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Towels; 3. Washcloth; 4. Soap (or other authorized cleansing agent); and 5. Personal protective equipment (e.g. (example), gowns, gloves, mask, etc. (etcetera), as needed). Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 7. Put on gloves. R41's computerized Medical Record documents that R41 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Essential (Primary) Hypertension, Acute Kidney Failure, and Bacterial Infections.R41's Care Plan documents that R41 is incontinent related to activity intolerance.On 6/1/26 at 10:15 AM, V12/Certified Nursing Assistant/CNA and V16/CNA came into R41's room to provide incontinence care for R41. They were wearing gowns and gloves before they entered R41's room. They removed R41's disposable brief and V12 opened a package of disposable wipes to use to clean R41. V12 did not wash her hands or change her gloves before starting incontinence care. V12 took five wet wipes from the package and stacked them on the incontinent pad that was under R41. V12 then took all five wipes and wadded them in her hand to clean R41's vaginal area. V12 used the same wipes to clean R41's vaginal area and the area between R41's legs and torso. R41 was then turned to her left side. V12 then took another five wet wipes from the package and stacked them on R41's incontinent pad. V12 then wadded the wipes in her hand and cleaned R41's buttocks. During R41's incontinent care V12 did not change her gloves or wash her hands. V12 then applied cream to R41's buttock without washing her hands or changing her gloves.On 6/1/26 at 10:17 AM, V12/CNA was asked if she usually changes her gloves and washes her hands when providing incontinent care. V12 stated Sometimes, it depends on how much mess there is.On 6/2/26 at 1:20 PM, V4/Infection Preventionist stated that V12/CNA should not have placed the wipes on a dirty surface before cleaning R41. V4 also stated that V12 should have changed her gloves and washed her hands when providing incontinent care for R41. V4 was told by this surveyor how the incontinent care was done and V4 stated That is a problem.On 6/3/26 at 11:20 AM, V3/Assistant Director of Nursing verified that it is not in the policy to use wet wipes, and the CNAs should have used a wash basin and washcloths to do incontinent care. V3 also verified that V12/CNA should have washed her hands and changed gloves.On 6/3/26 at 11:25 AM, V1/Administrator stated the entire incontinent care process was done incorrectly for R41.

Based on record review and interview the facility failed to prevent resident-to-resident verbal abuse for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.Findings include:The facility's Abuse and Neglect Prevention Policy undated, documents, It is the policy of (the facility) to not tolerate abuse or neglect of its residents by an individual. (The facility) is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.R16's Behavior Note dated [DATE] at 6:00 AM and signed by V17 (RN/Registered Nurse) documents, (R16) up in room standing at foot of roommate's (R76's) bed, yelling, and cursing at roommate stating, You need to get the h**l out of this bed and go pay the bill, your nothing but a bi**h just lying there all day not doing anything. Pay the TV (Television) bill while you are not doing anything. This same note documents R16 left her room and went down to the south dining room and started calling other residents in the south dining room bi**hes.R16's Progress Notes dated [DATE] at 10:37 AM and signed by V17 (RN) document, (R16) moved to (another room) related to concerns with roommate.R16's Progress Notes dated [DATE] document R16 expired while in the facility.On [DATE] at 2:00 PM V17 (RN) stated, (On [DATE]) I heard (R16) yelling at (R76) and calling (R76) a bi**h.On [DATE] at 2:26 PM V1 (Administrator) stated, A resident cursing towards other residents is considered verbal abuse.

Based on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT) conducted and documented a comprehensive evaluation prior to the initiation and dosage increase of an antipsychotic medication to determine whether a resident was experiencing an underlying condition contributing to their symptoms, failed to document behaviors and diagnoses to support the use of an antipsychotic medication, failed to ensure a consistent and clinically documented diagnosis was used to justify the use of an anti-psychotic medication, failed to complete psychotropic assessments, and failed to follow physician's orders related to an antipsychotic medication for two of three residents (R7 and R16) reviewed for antipsychotic medication use with diagnoses of dementia in a sample of 30. Findings include: The facility's Psychotropic Medication Use policy, dated 2/2025, documents Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes determining adequate indications for use. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff. When determining to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's: physical, behavioral, mental, and psychosocial status; comorbid conditions; expressions or indications of distress; changes in functional status; resident complaints, behaviors, and symptoms; and the state PASARR (Preadmission Screening and Resident Review) evaluation. Circumstances that warrant an evaluation of the residents' underlying medical condition and medications include new or worsening change in condition or status; a new medication is ordered as an emergency measure. This same policy documents Adequate indications for use refers to the identified, documented clinical rational for administering medication that is based on an assessment of the resident's condition and therapeutic goal. The clinical rational for the use of psychotropic medication, or change from one type of psychotropic to another, is documented in the medical record. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated. Alternatively, documentation from a physician must describe that alternative treatments are clinically contraindicated and the rationale for the conclusion. Diagnosis alone does not necessarily warrant the use of psychotropic medication. If a psychiatric diagnosis is part of the rationale for the use psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for diagnosis (based on the current diagnostic and statistical manual of mental disorders). 1.R16's MDS (Minimum Data Set) dated 10/15/25 documents R16 does not receive anti-psychotic medication. R16's Behavior Note dated 12/4/25 at 10:58 AM documents, (R16) is very angry and anxious this am (morning). (R16) states that she does not want to move to south. It is not fair that I have to leave my home. Attempted to talk with resident but she just walks away. R16's Behavior Note dated 12/4/25 at 8:23 AM documents, (R16) is yelling at roommate. (R16) states that it is not fair that (R16) has to move to south hall. (R16) is yelling at her roommate and stating, I hope no one does this to you! R16's Progress Notes dated 12/7/25 documents, (R16) has coat on. Went up front by the doors and states I am leaving. Several staff attempted re-direction. (R16) set alarms off twice. Once (R16) was back to her room became even more upset threw her cell phone when her friend called and said it wouldn't be until 10:00 AM before she came. Yelling at staff. Told the staff to get out of her room. R16's Progress Notes and Physician's Order signed by V14 (Psychiatric Nurse Practitioner) dated 12/10/25 documents, New order from (V14/Psychiatric Nurse Practitioner) to start Rexulti (anti-psychotic medication) 0.5 mg (milligrams) daily for agitation associated to (R16's) Dementia. R16's Physician's Order dated 1/9/26 given by V14 (Psychiatric Nurse Practitioner) documents, Rexulti 0.5 mg one time a day for agitation related to Alzheimer's Disease. R16's Physician's Order dated 1/9/26 given by V14 (Psychiatric Nurse Practitioner) documents, Rexulti one mg at bedtime related to Bipolar Disorder. R16's Physician's Order dated 1/13/26 and signed by V12 (Neurologist) documents, Rexulti one mg give 1.5 mg one time day related to Bipolar Disorder. R16's Physician's Order dated 3/4/26 and signed by V12 (Neurologist) documents to increase R16's Rexulti to two mg every bedtime. R16's current Physician's Orders document R16 continues to receive Rexulti two mg at bedtime for the diagnosis of Major Depression. R16's Electronic Health Record dated 12/1/25 (prior to the start of Rexulti) through 6/2/26 does not include an IDT assessment to determine if R16 had an underlying condition prior to initiating Rexulti and does not include an IDT assessment to assess R16's physical, behavioral, mental, and psychosocial status, comorbid conditions, expressions or indications of distress, changes in functional status, resident complaints, behaviors, or symptoms as directed by the facility's policy. R16's Electronic Health Record dated 12/10/25 (start of Rexulti) through 6/2/26 does not include a psychotropic drug assessment for the use of Rexulti. R16's Informed Consent Form dated 12/10/15 and signed by V20 (R16's Power of Attorney) documents R16 was prescribed Rexulti for the diagnosis of Dementia with Behaviors and Agitation. On 6/1/26 at 10:15 AM R16 was in the activity room and exhibiting no behaviors. On 6/2/26 at 12:10 PM R16 was sitting in the dining room. R16 was in the dining room. R16 was pleasant and exhibiting no behaviors. On 6/3/26 at 8:15 AM V4 (Infection Preventionist) stated the IDT team did not perform an assessment to determine if R16 had an underlying condition prior to the start of Rexulti and did not perform and IDT assessment to determine R16's physical, behavioral, mental, and psychosocial status, comorbid conditions, expressions or indications of distress, changes in functional status, resident complaints, behaviors, or symptoms as directed by the facility's policy. On 6/3/26 at 10:20 AM V2 (Director of Nursing) verified the facility has not performed any anti-psychotic assessments for the use of R16's Rexulti. 2. On 6/2/2026 at 10:00 AM, R7 was in the hallway in front of the nurse's station, dressed, and in her wheelchair. R7 was pleasant and polite. R7 was not interviewable. R7's Physician Medication Informed Consent form, dated 9/23/2025, documents that R7 is taking Seroquel (antipsychotic) medication. R7's MDS (Medical Data Set) dated 4/15/2026, section E (behaviors) does not document any potential indicators for psychosis. R7's Care Plan dated 6/2/2026 documents R7 is severely impaired with a BIMS (basic interview of mental status) of 4 (severely impaired) with no delirium indicators present. R7's Provider Recommendations dated 1/4/2026 documents decrease quetiapine (antipsychotic) to 12.5 mg (milligrams) PO (by mouth) at qHS (at bedtime) for Dementia with Psychosis. R7's Physician's Orders dated 6/1/2026, Seroquel (antipsychotic) 25mg at bedtime. On 06/01/2026 at 12:34 PM, V22 (R7's Family Member/Power of Attorney) stated that in the past, R7 had hit staff at times during care. V22 stated she has seen R7 saying she sees people that are not there and reaches in the air for them. V22 stated R7 has never hit another resident and has never been verbally abusive towards residents. V22 stated R7 has calmed down a lot in the last several months. On 6/2/2026 at 10:05 AM, V10 (Activities Aide) stated that R7 does not exhibit behaviors. V10 stated that R7 is always happy-go-lucky and in a pleasant mood. On 6/2/2026 at 10:10 AM, V11 (Certified Nurse Assistant) stated R7 has never had any behavior towards her. V11 stated R7 has had a morning a few times that she didn't want to get up and she was upset about it, but she has never been violent towards me and has never hit or yelled at any other resident. On 6/2/2026 at 10:15 AM, V12 (Certified Nurse Assistant) stated that R7 has never been violent toward her and that she has never seen R7 act violently toward other residents. V12 stated R7 has never exhibited any behaviors. On 6/2/2026 at 10:20 AM, V13 (Registered Nurse) stated R7 does not have any behaviors that she is aware of.

Based on record review and interview, the facility failed to report resident-to-resident verbal abuse to the administrator and state agency for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.Findings include:The facility's Abuse and Neglect Prevention Policy, undated, documents, Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a Department Head or the Administrator. Initial reports will be completed immediately but no later than 24 hours after incident of alleged abuse to IDPH (Illinois Department of Public Health).R16's Behavior Note dated 1/13/26 at 6:00 AM and signed by V17 (RN/Registered Nurse) documents, (R16) up in room standing at foot of roommate's (R76's) bed, yelling, and cursing at roommate stating, You need to get the h**l out of this bed and go pay the bill, your nothing but a bi**h just lying there all day not doing anything. Pay the TV (Television) bill while you are not doing anything. This same note documents R16 left her room and went down to the south dining room and started calling other residents in the south dining room bi**hes.On 6/2/26 at 2:00 PM V17 (RN) stated, (On 1/13/26) I heard (R16) yelling at (R76) and calling (R76) a bi**h. I did not notify the administrator.On 6/2/26 at 2:26 PM V1 (Administrator) stated, I do not recall (V17) notifying me regarding (R16) cursing at her roommate. I should have been notified immediately. V1 confirmed the verbal abuse allegation of R16 cursing at her roommate (R76) on 1/13/26 has not been reported to the state agency.

Based on record review and interview, the facility failed to investigate and submit a final report to the state agency regarding resident-to-resident verbal abuse for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.Findings include:The facility's Abuse and Neglect Prevention Policy, undated, documents, Internal investigation of (abuse) allegations and response: An investigation will begin by obtaining a copy of any documentation relative to the incident and follow the Investigation Procedure Policy. The administrator is responsible for forwarding a final written report of the results of the investigation and of any corrective action take to the Department of Public health within five working days of the reported incident.R16's Behavior Note dated 1/13/26 at 6:00 AM and signed by V17 (RN/Registered Nurse) documents, (R16) up in room standing at foot of roommate's (R76's) bed, yelling, and cursing at roommate stating, You need to get the h**l out of this bed and go pay the bill, your nothing but a bi**h just lying there all day not doing anything. Pay the TV (Television) bill while you are not doing anything. This same note documents R16 left her room and went down to the south dining room and started calling other residents in the south dining room bi**hes.On 6/2/26 at 2:26 PM V1 (Administrator) verified the verbal abuse allegation of R16 cursing at her roommate (R76) on 1/13/26 has not been investigated and a final report has not been sent to the state agency.

Based on record review and interview the facility failed to perform a significant change comprehensive assessment after residents exhibited an increase in behaviors, were diagnosed with new psychiatric conditions, and were prescribed new ant-psychotics medications for two of two residents (R3 and R16) reviewed for signification change in condition in the sample of 30. The Centers for Medicare and Medicaid Services (CMS) (Resident Assessment Instrument) RAI 3.0 Manual dated 10/2025 documents a resident with MI or ID/DD must have a Resident Review conducted when there is a significant change in the resident's physical or mental condition. Therefore, when an SCSA is completed for a resident with MI/DD, the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability authority (depending on which operates in their state) to notify them of the residents change in status. Section 1919 of the social Security Act requires the notification or referral for a significant change. 1.R3's medical diagnosis list documented Hallucinations added on 8/19/2023, Delusional Disorder added on 9/27/2023, and Unspecified Psychosis added on 5/16/2024. R3's physician orders documented Seroquel 25 milligrams daily was initiated on 8/21/2023 for confusion and hallucinations. On 06/02/2026 at 10:15 AM, V2 (Director of Nursing) stated the facility completed an audit of PASARR determinations in January 2026. V2 stated resident diagnoses and medications were reviewed and residents identified as requiring a Level II PASARR were referred accordingly. V2 confirmed R3 was identified through the audit as requiring a Level II PASARR and acknowledged a Significant Change in Status Assessment should have been completed but was not. On 06/02/2026 at 10:26 AM, V7 (Social Services Director) stated R3 was identified as requiring a Level II PASARR due to increased hallucinations and the initiation of a psychotropic medication. V7 stated this information was communicated to the MDS Nurse for follow-up. On 06/03/2026 at 11:00 AM, V18 (MDS Nurse) stated she was aware of the January 2026 PASARR audit findings and knew R3 had been identified as requiring Level II PASARR. V18 stated she did not complete a Significant Change in Status Assessment because she believed completion of the PASARR process alone addressed the issue. 2.R16's Behavior Note dated 12/4/25 at 10:58 AM documents, (R16) is very angry and anxious this am (morning). (R16) states that she does not want to move to south. It is not fair that I have to leave my home. Attempted to talk with resident but she just walks away. R16's Behavior Note dated 12/4/25 at 8:23 AM documents, (R16) is yelling at roommate. (R16) states that it is not fair that (R16) has to move to south hall. (R16) is yelling at her roommate and stating, I hope no one does this to you! R16's Progress Notes dated 12/7/25 documents, (R16) has coat on. Went up front by the doors and states I am leaving. Several staff attempted re-direction. (R16) set alarms off twice. Once (R16) was back to her room became even more upset threw her cell phone when her friend called and said it wouldn't be until 10:00 AM before she came. Yelling at staff. Told the staff to get out of her room. R16's Progress Notes dated 12/10/25 documents, New order from (V14/Psychiatric Nurse Practitioner) to start Rexulti (anti-psychotic medication) 0.5 mg (milligrams) daily. R16's MDS (Minimum Data Set) Tracking dated 10/15/25 through 4/14/26 does not include evidence of a Significant Change in Status MDS being completed after R16 started to exhibit increased behaviors and was started on Rexulti on 12/10/25.

Based on record review and interview the facility failed to accurately code the MDS (Minimum Data Set) Assessments for two of 17 residents (R3 and R4) reviewed for MDS Accuracy in the sample of 30. Findings include: The facility's Comprehensive Assessments policy dated 2001 documents, Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. CMS's (Center's for Medicaid and Medicare) RAI Version 3.0 Manual dated 10/25 documents, Coding Instructions: Code 1, yes if PASARR (Pre-admission Screening and Resident Review) Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition. 1.R4's PASARR Level II Outcome dated 3/9/25 documents, You meet PASARR inclusion criteria for Serious Mental Illness with diagnoses of Major Depressive Disorder and Psychosis. Your day-to-day life has been impacted by your illness. R4's MDS (Minimum Data Set) Assessments Section A1500 Preadmission Screening and Resident Reviews dated 1/27/26 and 4/28/26 are coded as R4 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/2/26 at 10:10 AM V2 (Director of Nursing) verified R4's MDS Section A1500 Assessments dated 1/27/26 and 4/28/26 were inaccurately coded and should have been coded as R4 does have a serious mental illness according to R4's state level II PASARR dated 3/9/25. 2.R3's Physician Orders documents Seroquel 25 milligrams daily was initiated on 8/21/2023 for confusion and hallucinations. On 06/02/2026 at 10:15 AM, V2 (Director of Nursing) stated the facility completed an audit of PASARR determinations in January 2026. V2 stated resident diagnoses and medications were reviewed and residents identified as requiring a Level II PASARR were referred accordingly. V2 confirmed R3 was identified through the audit as requiring a Level II PASARR and acknowledged the residents' MDS assessment was not updated to reflect the PASARR findings. On 06/02/2026 at 10:26 AM, V7 (Social Services Director) stated R3 was identified as requiring a Level II PASARR due to increased hallucinations and the initiation of psychotropic medication and communicated this information to the MDS Nurse. On 06/03/2026 at 11:00 AM, V18 (Minimum Data Set/MDS Nurse) stated she was aware R3 had been identified as requiring a Level II PASARR but did not update the resident's MDS assessment because she believed completion of the PASARR process alone addressed the issue.

Based on observation, interview and record review, the facility failed to replace oxygen tubing/nebulizer masks weekly or store/label oxygen tubing/nebulizer masks correctly for three of six residents (R8, R21, R50) reviewed for oxygen in the sample of 30.Findings include: 3. On 6/1/2026 at 10:15 AM, R8 was in her room, in her wheelchair, dressed, wearing a nasal cannula with oxygen flowing at 3L (liters). Oxygen tubing was dated 5/23. R8's Physician's Order sheet dated 5/18/2026 documents, O2 (oxygen) at 3L(liters) per NC (nasal cannula) keep stats greater than 92% as needed for respiratory distress or to maintain stats above 92%. R8's Care Plan dated 6/2/2026 documents, R8 is at risk for altered respiratory status/difficulty breathing related to COPD (Chronic obstructive pulmonary disease), COPD exacerbation, Pneumonia. Oxygen settings: O2 via NC at 3L to maintain status more than 92%. Humidified. On 6/2/2026 at 1:16 PM, V4 (Infection Preventionist) stated nursing staff are expected to change oxygen tubing every week, and it is expected to date oxygen tubing after changing the tubing. Administering Medications through a Small Volume (Handheld) Nebulizer policy dated 10/2010 documents Purpose -The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. 22. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. wash pieces with warm, soapy water; b. rinse with hot water; c. allow to air dry on a paper towel. 24. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 25. Change equipment and tubing every seven days, or according to facility protocol. 2. R21's computerized Medical Record documents that R21 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease. R21's Order Summary Report printed 6/2/26 at 10:03 AM, documents oxygen at two to five liters as needed for respiratory distress to maintain oxygen level above 90 percent. Order date 5/20/26. The same order summary also documents to change oxygen tubing weekly on Fridays on third shift. Order date 5/27/26. On 6/1/26 at 9:50 AM, R21 was sitting in her recliner with her oxygen machine next to the recliner. The oxygen tube with nasal cannula was on the floor behind R21's chair. The tube was not dated. On 6/1/26 at 9:52 AM, R21 stated that she has needed oxygen once since she was admitted . R21 also stated that she was not sure of when she used the oxygen, but no one has changed the tubing. On 6/2/26 at 11:10 AM, V5/Registered Nurse/RN verified that R21's oxygen tube with nasal cannula was on the floor behind R21's recliner and was not dated. 3. R50's computerized Medical Record documents that R50 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Unspecified Part of Bronchus or Lung, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Failure with Hypoxia. R50's Order Summary Report printed 6/2/26 at 10:05 AM, documents oxygen at three liters per nasal canula as needed for respiratory distress or to maintain oxygen level above 90 percent. Order date 5/28/25. The same order summary also documents to change oxygen tubing weekly on Fridays on third shift. Order date 10/8/25. On 6/1/26 at 10:40 AM, R50 was sitting on the side of her bed. The oxygen tubing was dated 5/23/26. R50 had a nebulizer mask laying on the nightstand and it was dated 5/23/26. The mask was not stored in a plastic bag. On 6/1/26 at 10:41 AM, R50 stated that oxygen tubing is supposed to be changed once a week but does not always get done that often. On 6/2/26 at 11:16 AM, V5/RN verified that the oxygen tubing and nebulizer mask had both been changed that morning and were dated 6/2/26. V5 also verified that the nebulizer mask was not stored in a plastic bag. On 6/2/26 at 1:15 PM, V4/Infection Preventionist stated that oxygen tubing and nebulizer masks should be changed every week and dated. V4 also verified that the nebulizer mask should be cleaned and stored after use.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions/EBP during direct cares for one of three residents (R41) reviewed for infection control in the sample of 30.Findings include:The Enhanced Barrier Precaution policy dated 8/2022 documents Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 3.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: c. transferring 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the residents' stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.R41's computerized Medical Record documents that R41 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Essential (Primary) Hypertension, Acute Kidney Failure, and Bacterial Infections.R41's Order Summary Report printed 6/2/26 documents Enhanced Barrier Precautions: Wear gloves and gown for High-Contact Resident Care Activities. (Dressing, Bathing, Transfers, Linen changes, Hygiene, Toileting, Wound care, and/or device care such as catheter, feeding tube, trach, central line) every shift.R41's Care Plan documents the Goal for R41 is that R41 will have intact skin free of redness, blisters, or discoloration. Intervention - Enhanced Barrier Precautions: Wear gloves and gown for High- Contact Resident Care Activity. (Dressing, Bathing, Transfers, Linen changes, Hygiene, Toileting, Wound Care) R41's door had an Enhanced Barrier Precaution Sign on her door. The sign documents that all providers and staff must Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting. On 6/1/26 at 10:12 AM, This surveyor entered R41's room. R41 was lying in bed with V16/Certified Nursing Assistant/CNA, and V19/Agency CNA standing next to R41's bed checking R41 for incontinence. V16 and V19 did not have a gown on.On 6/1/26 at 10:13 AM, V16/CNA stated that R41 had just been transferred from R41's wheelchair to the bed to change R41. V16 also stated that V16 and V19 did not wear a gown during the transfer. On 6/2/26 at 11:20 AM, R41 stated that staff do not always wear gowns and gloves when they provide care for her.On 6/3/26 at 10:30 AM, V4/Infection Preventionist stated that R41 was placed on EBP because R41 had a pressure wound and a G (Gastrostomy) - tube. The pressure wound is now healed, and the G-tube was removed on 5/20/26 but R41 was left on EBP until the G-tube site is healed. V4 also stated that R41 now has a skin tear to her left lower extremity and is still on EBP for the skin tear. V4 stated that a gown and gloves should be worn when transferring or providing care for R41.

Based on Observation, Interview and Record Review, the facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and post a notice that survey results are available for review. This failure has the potential to affect all 66 residents residing in the facility.Findings include:The Ombudsman Resident Rights for People in Long Term Care Facilities booklet, dated 11/2018, documents You have the right to see reports of all inspections by the Illinois Department of Public health from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the problem.On 6/2/26 at 10:40 AM, during a resident group meeting. R10, R14, R64 and R66 all denied being aware of a (state agency) survey binder or the availability to review those results. R64 confirmed she is the resident council president and stated, I wasn't aware that was even something we could look at or see those (past survey) results.On 6/2/26 at 11:15 AM, the facility (state agency) survey book observed in the lobby behind the receptionist desk in a three-ring binder, not freely accessible for residents to access. The facility's lobby area and hallways do not contain a posting about the state agency survey results being available for review.On 6/2/2026 at 12:25 PM, V7 (Social Service Director) confirmed the state survey book is located behind the receptionist desk in the front lobby and stated she is not aware of any signage about the survey results binder. V7 verified that some residents travel to the front lobby but not all of them do and that items behind the reception desk would most likely not be accessible for residents, without asking for assistance.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/1/26 and signed by V1 (Administrator), documents 66 residents reside within the facility.

Based on Observation and Interview, the facility failed to ensure the daily resident census and facility staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 66 residents residing in the facility.Findings include:On 6/2/26 at 11:20 AM, the facility's common areas and hallways were toured and did not contain a daily staffing posting. On 6/2/26 at 11:30 AM, V2 (Director of Nursing) stated the facility daily staffing is kept at the receptionist's desk. On 6/2/26 at 11:35 AM, V2 pulled a clipboard out of an upright file slot behind the receptionist desk in the lobby entrance. V2 verified that the daily staff posting is placed on the clipboard and stored in the file slot every day. V2 confirmed this clipboard is not viewable unless you go behind the desk and remove the clipboard from the file where it's stored.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/1/26 and signed by V1 (Administrator), documents 66 residents reside within the facility.

Based on interview and record review the Facility delayed immunotherapy oncology services for a Medicare Part A payor source causing missed scheduled appointments for one of three Residents (R1) reviewed with a Medicare Part A payor source in a sample of three.Findings include:R1's Contract Between Resident and the Facility Medicare, dated and signed on 12/3/25, documents: sets forth the quantity of rights, duties and obligations of the Resident and the Facility; this contract is made on 12/3/25 and shall be in effect on a year-to-year basis; Resident Rights include that the Resident is fully informed of his/her rights and responsibilities as a Resident and of all rules and regulations governing Resident conduct and responsibilities and such information shall be provided prior to, or at the time of admission or in case of Residents already in the Facility; a Resident is fully informed in writing prior to, or at the time of admission and during stay, of services available at the Facility, and of related charges including Facility services not covered under the Title XIX program or not covered by the Facility's per diem rate; Resident is fully informed by a Physician, of his/her health and mental condition unless medially contraindicated and is afforded the opportunity to participate in the planning of his/her total care and medical treatment; and the Resident is treated with consideration, respect and full recognition of his/her dignity and individually, including care for his/her personal needs.The Facility Resident Rights Policy, undated, documents: it is the policy of the Facility to inform the Resident, both orally and in writing, of his/her rights and rules and regulations governing conduct and responsibilities during his/her stay in the Facility; prior to, and upon admission to the Facility, the Resident will be informed of his or her rights, grievance procedures and rules/regulations governing his or her conduct and responsibilities while a Resident; the Facility will inform the Resident of his/her rights and responsibilities in a language that is both clear and understandable to the Resident; and the Facility will make every effort to assist the Resident in exercising his/her rights and to assure that the Resident is always treated with respect, kindness and dignity.The Facility Assessment, dated 1/15/26, documents: Resident Support/Care Needs specific care of practices for Cancer Treatments (no Residents identified); and includes services for Neoplasm (Cancer).The Facility Census Details Report, dated 3/12/26, documents R1 on Medicare Part B insurance.R1's Physician Order Sheet, dated 3/12/26, documents orders for Physical Therapy, Occupational Therapy and Speech Therapy.V10's Progress note, dated 3/3/26, documents: Right Hip Fracture following ground-level fall with Right Hip Arthroplasty performed on 11/26/2025; remains at a skilled rehabilitation facility (Facility) on self-pay so that (R1) can continue receiving therapy and also resume treatment for Squamous Cell Carcinoma; long history of multiple skin lesions being excised from various parts of body, including Basal Cell Carcinoma on the Nose in 2017; - Squamous Cell Carcinoma in deep and peripheral edges of the Left Scalp shave biopsy (09/20/2024); residual Squamous Cell Carcinoma in the left scalp (12/06/2024); - Squamous Cell Carcinoma of the Left Forearm (3/21/2025); Squamous Cell Carcinoma, moderately differentiated, Right Scalp (04/04/2025); Squamous Cell Carcinoma, Right Cheek (05/17/2025; on 08/01/2025 an imaging test (PET scan) showing substantial changes; there is thickening of the Left [NAME] Bowl into the Left External Auditory Canal consistent with Squamous Cell Carcinoma; additional irregularities in the Right Parietal Scalp; Hypermetabolic mass in the Left Kidney with concerns for Renal Cell Carcinoma; Hypermetabolic Pulmonary Nodule in the Left Upper Lobe; the lesion in the Kidney has increased to 5.1 x 4.3 x 5.0 centimeter/cm and was 3.1 x 2.7 cm in 11/2021 with the uptake value (SUV) now of six. The uptake value (SUV) in the left [NAME] Bowl is ten; and on 10/21/2025 initiation of Cycle One treatment with single agent immunotherapy (Cempilimab); on 11/26/2025 a Right Hemiarthroplasty was performed following ground-level fall, (R1) hospitalized from [DATE] until 12/1/2025 following a fall which resulted in a Right Femoral Neck Fracture and was discharged to rehabilitation facility (Facility) and has been unable to attend treatment during that time; (R1) is now residing at the (Facility) on private pay so that (R1) can return to finish the planned 8 cycles of treatment (immunotherapy).V10's Progress Note, dated 12/3/25, documents: V5 (R1's Daughter) called regarding R1 residing at a skilled nursing facility (Facility) and will be the ones to bring R1 in for treatment on 12/9/25; on 12/3/25 at 1:55 pm, V4 (Assistant Director of Nursing/ADON) called wanting to discuss R1's immunotherapy and is wanting to know if it would be able to be put pt on hold while R1 is at the Facility and to please call V4 back. On 12/4/25 at 3:33 pm, V10's office tried to call V4 back and got V4's voicemail, left a detailed voicemail asking for a call back, and explained would need okay from the provider in order to withhold treatment; on 12/3/25 at 4:00 pm, a return call from V4 was received and V10's office explained that R1 has just started treatment (immunotherapy), with R1's next one scheduled on 12/9/25, and explained will need to discuss this with V10 (Oncologist) and make sure V10 is aware that R1 had surgery a week ago and call V4 back with updates; on 12/3/25 at 4:25 pm, reviewed with V10 and push out appointments till mid-December and if R1 is able to get here to be seen, we will work on getting surgical clearance once R1 is seen at that point, called V4 back with updates and no answer, so left a detailed message.R1's local Hospital Medical Record, dated 11/29/25, documents R1 presented after a ground level fall at home and sustained a Right Femoral Neck Fracture requiring surgical intervention; history of Autoimmune Pancreatitis, Prostate Cancer and Squamous Cell Cancer of Left Ear and to continue home medication; and imaging results noted Left Upper Lobe (Lung) Pulmonary Nodule. R1's Progress Note, dated 12/1/25 at 4:45 pm, documents R1 admitted to the Facility from the local hospital on subacute skilled therapy.R1's Progress Note, dated 12/4/25 at 8:25 am, documents R1 had follow up appointments scheduled with V10 (R1's Oncologist) for immunotherapy infusion and that V10 would like to push out R1's next infusion just a few weeks due to (R1) just having surgery.R1's Progress Note, dated 12/13/25 at 4:50 pm, documents R1 has skin cancer to the left ear and external auricular canal and has multiple areas for skin issues including treatment at the cancer center (V11's office) for skin areas needing treatment and care.R1's Nursing Note, dated 1/28/26, documents a history of Prostate Cancer, Chronic Autoimmune Pancreatitis and managed by Oncology (V10).R1's Progress Note, dated 2/10/26 at 2:20 pm, documents the V9 (Social Services) received a phone call from V5 (R1's Daughter) inquiring if R1 returns to immunotherapy once at home.R1's Progress Care Plan Meeting Note, dated 2/10/26 at 1:23 pm, documents family voiced understanding that (R1) could start immunotherapy once off of skilled therapy.R1's Progress Note, dated 2/17/26 at 10:30 am, documents V5 (R1's Daughter) came into V9's (Social Service) office and asked when (R1) will come off of skilled therapy because she really wants to get everything set up for treatments. V5 was informed by V9 that there will be a meeting today and (V9) will be able to call (V5) and let her know after talking to therapy. R1's Progress Note, dated 2/17/26 at 3:16 pm, documents, Per (R1's) and (V5's) request R1 will have a last covered day of Medicare A skilled therapy on 2/20/26. (R1) will then transition to private pay for private room, and Part B. (V5) is going to call (V10) and set up (R1's) immunotherapy and let staff know when (R1's) appointments are so they can be placed in the (calendar).R1's Progress Note, dated 2/23/26 at 1:24 pm, documents (V5) called and stated that (R1) has an appointment with V10 (Oncologist) on 3/3/26 and family will transport.R1's Progress Note, dated 3/3/26 at 11:29 am, documents (R1) out of Facility to (V11's) office.R1's Progress Note, dated 3/2/26 at 4:16 pm, documents laboratory results were faxed to (V11's) office for review.R1's Progress Notes, dated 3/5/26 at 10:00 am, documents communication between V9 (Social Service) and R1's family and answered questions regarding Medicare A and Medicare B therapy and family provided multiple appointments which were placed on the calendar.On 3/12/26 at 11:12 am, V5 (R1's Daughter) stated, I was told that we had to stop Dad's (R1's) immunotherapy because (R1) was receiving therapy on Medicare benefits, and once (R1) went off Medicare, we could start (R1's) immunotherapy again. I never knew, until after (R1) got admitted to the (Facility), that (R1) would not be able to go to the Oncologist. From what I understood, the only way we could take Dad (R1) for his cancer treatment was after he got off Medicare and went private pay. I never really understood it, it never made any sense to me, but (R1) was already there. Once (R1) came off Medicare, I was the one that called to set up the appointments to resume, no one offered.On 3/12/26 at 1:28 pm, R1 (alert and oriented) stated, I was told that I could not go to (V10/Oncologist) while I was on Medicare getting my therapy after my hip surgery. I just started going again because I am now on private pay. Now that I am the one paying, I guess I am the one that can pay for my immunotherapy. It never made any sense to me.On 3/12/26 at 11:18 am, V8 (V10s Oncology Nurse) stated, It looks like our progress notes document that our office received telephone calls from (V4/Assistant Director of Nursing/ADON) on 12/3/25, requesting that we put a hold on (R1's) immunotherapy due to insurance reasons. On 12/5/25, we received another phone call from (V3/Infection Preventionist) requesting to put (R1's) immunotherapy on hold until mid-December. On 12/15/25, someone from the Facility called and stated they would call when ready to reschedule (R1's) immunotherapy appointment and no caller name is documented. On 2/19/26, we received a phone call from (V5/R1's Daughter) informing us that (R1) was not on Medicare benefits anymore and wanted to schedule (R1's) immunotherapy.On 3/12/26 at 12:40 pm, V9 (Social Service) stated, When we have a new referral for an admission, our entire team reviews the medical record. I am not a nurse, but I do review things such as behaviors, transportation needed for appointments and things like that. I did not see that (R1) was supposed to receive immunotherapy at that time, I think we realized it after (R1) admitted .On 3/12/26 at 11:56 am, V6 (Admissions) stated, I did not see that (R1) was receiving any immunotherapy when I was screening (R1) for admission. Usually, our team will identify expensive medication during the screening process. I do not think that they realized (R1) had appointments for immunotherapy until the on-boarding/admission process.O 3/12/26 at 12:03 pm, V4 (Director of Nursing/DON) stated, We were not aware of (R1) being on immunotherapy for (R1's) cancer. Around (R1's) admission on [DATE], I called (V10) to see if it was okay to hold the immunotherapy for a few weeks.On 3/12/26 at 1:00 pm, V1 (Administrator) stated, (R1) did admit to our Facility with Medicare benefits. I think we realized after the fact, when (R1) was already in the building, that (R1) was receiving immunotherapy. They called to reschedule some of the appointments. We usually will catch these types of expenses prior to admission, that is what our screening process is for.

Based on observation, interview, and record review, the Facility failed to ensure contact precautions were maintained for one resident (R7) with a known MDRO (Multidrug-resistant organism). This failure had the potential to affect all 14 residents (R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66) with assistancebeing provided by the same CNAs (Certified Nursing Assitants), and failed to perform hand hygiene/don gloves according to standards of practice while administering medications for two residents (R64 and R66) of seven residents reviewed for infection control in a total sample of 40. Findings Include: The Facility's undated Isolation-Categories of Transmission-Based Precautions Policy documents, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Facility's Isolation-Categories of Transmission-Base Precautions policy documents, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for the resident, staff will change gloves after having contact with infective material; gloves are removed, and hand hygiene performed before leaving the room; Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 1. On 3/25/25 at 9:30 AM, R6 and R7 were roommates. R6 and R7 were sitting side by side in their wheelchairs in the middle of the room speaking to each other. On the door outside of the room there was a sign that said, Enhanced Barrier Precautions. R6's Physician Order Sheet, dated March 2025, documents, Enhanced Barrier Precautions related to wounds. R7's Physician Order Sheet, dated March 2025, documents, Contact Precautions related to ESBL (Extended Spectrum Beta-Lactamase) in the urine. R7's Urinalysis with Culture and Sensitivity, dated 3/17/25, documents ESBL: Positive. R7's Physician Order Sheet, dated March 2025, documents an order dated 3/17/25 for an antibiotic Nitfrofurantoin 100 mg (milligrams) twice daily for ten days for ESBL in the urine. R7's MDS (Minimum Data Set), dated 1/23/25, documents R7 is frequently incontinent of urine. Throughout the day on 3/25/25, CNAs (Certified Nurse Aids) were noted to be walking in and out of R6 and R7's room for various different reasons with no PPE (Personal Protective Equipment) on. On 3/25/25 at 11:30 AM, V5 (Registered Nurse) stated she thought R6 was in Enhanced Barrier Precautions for wounds and, I don't believe (R7) has any (precautions in place.) On 3/25/25 at 1:30 PM, V6 (Certified Nurse Aid) stated both R6 and R7 were in Enhanced Barrier Precautions. V6 reported she wears a gown and gloves when giving cares for R6 and R7, but does not wear any PPE upon entering the room. V6 confirmed both R6 and R7 are incontinent of urine. On 3/26/25 at 10:00 AM, V4 (Registered Nurse/Infection Preventionist) stated, It got missed somehow that (R7) had an active infection of ESBL. (R6) and (R7) should not have been put in the same room. Contact Precautions would require (R7) to have her own room. On 3/25/25 at 1:30 PM, V6, CNA, stated the CNAs that are responsible for providing assistance to the room that R6 and R7 occupy would also be responsible for providing assistance throughout the day to the rooms that are occupied by R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66. 34542 2. On 03/26/25, at 8:20 AM, V5/Registered Nurse, without hand sanitizing/donning gloves, reached into R66's medicine cup, removed a pill capsule-Fluoxetine 10 mg/milligrams capsule x's 3 capsules for a total dose of 30 mg, twisted the capsules apart, and emptied the capsule contents in a cup of applesauce; then administered the medication to R66. On 3/26/25, at 8:30 AM, V5 confirmed, I should have worn gloves and probably should have hand sanitized prior to removing/pulling apart the capsules and dumping them into the applesauce. On 3/26/25, at 8:35 AM, V2/Director of Nursing confirmed V5 should have hand sanitized and worn gloves when touching R66's medication capsules and pulling them apart. On 03/27/25, at 8:05 AM, V7/Licensed Practical Nurse-LPN, without hand sanitation/donning gloves, opened an acetaminophen 325 mg bottle, poured 4 tablets into the cap, held two tablets down with her fingers, dumped the other two tablets in R64's medicine cup, and then dumped the two tablets V7 held with her fingers back into the container. On 3/27/25, at 8:30 AM, V7 confirmed V7 should have performed hand sanitation and worn gloves before touching R64's medication.

2. The Electronic Medical Record for R30 documents the following diagnoses for R30 as: Unspecified Dementia with other Behavioral Disturbance, Type 2 Diabetes, Anxiety Disorders, Affective Mood Disorder, Primary Insomnia, and cognitive Communication Deficit. The current Order Summary for R30 documents a Physician Order, dated 5/6/24, for Quetiapine (antipsychotic) 25 mg (milligrams) twice daily for Dementia with Behavioral Disturbance. The MAR (Medication Administration Record) for R30, dated 3/1/25 through 3/31/25, documents R30 has received Quetiapine 25 mg twice daily. This MAR includes a generalized listing of potential behaviors, however, does not include targeted behaviors for R30. The current Care Plan for R30 does not include targeting behaviors or clinical indication for R30 to receive Quetiapine. The Psychiatry Note for R30, dated 2/27/25, documents, Psychiatric History: Diagnosed Mental Illness: anxiety, insomnia, nicotine dependence, and dementia. Reports she was not aware she had ever been diagnosed with any mental health disorders. Patient denies previous mental health related hospitalizations. Patient denies previously followed mental health group. Patient denies failed psychotropic trials. Patient denies adverse reactions to psychotropic medications. Based on observation, interview, and record review, the facility failed to identify an appropriate indication for use of an antipsychotic medication, and failed to identify target behaviors for two residents (R30, R40) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 40. Findings include: Facility Policy/Psychotropic Drug Policy, dated 2/2018, documents: Resident's placed on Anti-psychotic medication will have target symptoms tracked every shift and non-pharmacological interventions tracked for effectiveness every shift by nursing staff in behavioral notes in (electronic medical record). Facility Policy/Anti-psychotic Medication Use, dated/revised 2022, documents: Residents will not receive medications that are not clinically indicated to treat a specific condition. Residents will only receive anti-psychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Delusional Disorder Mood Disorders (Bipolar, Depression with Psychotic Features, and treatment refractory Major Depression) Psychosis in the absence of Dementia Medical Illnesses with psychotic Symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids) Tourette's Disorder Huntington's Disease, Hiccups Nausea and vomiting associated with cancer or chemotherapy. Diagnoses alone do not warrant the use of anti-psychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; and --the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or --behavioral interventions have been attempted and included in the plan of care, except in an emergency. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: not due to a medical condition or problem that can expected to improve or resolve as the underlying condition is treated; and persistent or likely to reoccur without continued treatment; and not sufficiently relieved by non-pharmacological interventions; and not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety; and not due to psychological stressors or anxiety stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering, Poor self care, Restlessness, Impaired Memory, Mild Anxiety, Insomnia, Inattention or indifference to surroundings, Sadness or crying alone that is not related to depression or other psychotic disorders, Fidgeting, Nervousness or Uncooperativeness. 1. On 3/25/24 at 10:20am, R40 was in bed, was social and appropriate. On 3/26/25 at 12:30pm, R40 was in bed sleeping. Current Physician Order Report indicates R40 has diagnoses that include Unspecified Moderate Dementia with Mood Disturbance, Unspecified Dementia with Behavioral Disturbance, Major Recurrent/Moderate Depressive Disorder and Primary Insomnia. Order Report indicates R40 receives Risperdal (antipsychotic) 0.5mg (milligrams) at bedtime related to Major Depressive Disorder (date initiated 12/20/24 and Risperdal 0.25mg daily related to Unspecified Dementia with Behavioral Disturbance. Psychoactive Medication Informed Consent Form, dated 4/18/24, indicates, Psychotropic Medication prescribed: Risperdal (no dosage documented) for Diagnosis of BPSD (Behavioral and Psychological Symptoms of Dementia). Form did not include the type of psychotropic medication (antipsychotic) being ordered. Specific condition(s) being treated include .: was left blank on the form. Psychiatry Note, dated 1/17/25 and 2/27/25, both indicate R40 receives Risperdal for Agitation related to Dementia. Note indicates R40 continues to have occasional episodes of verbal agitation and No symptoms of depression. Note also indicates no symptoms of psychosis or mania observed/reported. and no symptoms of auditory or visual hallucinations. Note, dated 1/17/25, indicates despite occasional episodes of verbal agitation, no specific episodes or behaviors have been charted thus far this month. Current MAR (Medication Administration Record) indicates to monitor for the following behaviors: Restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. No documented behaviors of any type, by R40, were noted to have occurred March 1 - March 26, 2025. February 2025 MAR indicates R40 had behavior on 2/11/25. MAR does not include a description of the behavior. MAR indicates when a behavior occurs - a progress note should be documented to describe the behavior in detail. Progress Note dated 2/11/25 at 7:34pm indicates Was a behavior observed? Yes. No description of the behavior was included in the note. January 2025 MAR indicates R40 had behavior on 1/19/25 and 1/24/25. MAR does not include a description of the behavior(s). Progress Note, dated 1/19/25 at 1:01pm, indicates, Yes, a behavior was observed. (R40) was cussing at staff because he requested noogies nicotine pouches. He just had some (earlier) and it is not time for him to have more. Current Care Plan indicates R40 takes an anti-psychotic for Dementia with BPSD/Mood/Behaviors/Disturbances (date initiated 4/19/24). Care Plan also indicates R40 uses psychotropic medications related to behavioral or psychological symptoms of Dementia and Risperdal added on 4/18/24 per (physician). Care Plan does not identify target behaviors or justification for use of an antipsychotic medication. On 3/27/25 at 1:35pm, V3, ADON (Assistant Director of Nursing) stated the behaviors listed on the MAR are not specific to R40, and R40 does not exhibit most of those behaviors. V3 stated the care plan should include target behaviors specific to R40. V3 stated the only behaviors she is aware of for R40 are often mimics other residents and can become agitated related to receiving his nicotine pouches-- Never physical. V3 stated the diagnosis should be consistent throughout the medical record.

Based on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions to prevent pressure wound development, develop a pressure relieving care plan, and implement a physician-ordered treatment for a deep tissue injury for one of two residents (R31) reviewed for facility acquired pressure ulcers in the sample of 28. These failures resulted in R31 developing a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe. Findings include: The facility's Support Surface Guidelines policy, dated 9/2013, documents, Purpose: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing relieving devices for residents at risk for skin breakdown. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure: Guidelines for Selecting Appropriate Pressure-Relieving Devices- 2. Use a pressure ulcer risk scale such as the Braden Scale to help determine need for an appropriate type of pressure-relieving devices. The facility's Prevention of Pressure Injuries policy, dated 4/2020, documents, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Use a standardized pressure injury screening tool to determine and document risk factors. Skin Assessment: 1.Conduct a comprehensive skin assessment up (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Device-Related Pressure Injuries: 1.Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application an ability to secure the device. 2.Monitor regular for comfort and signed of pressure-related injury. Monitoring: 2. Review the interventions and strategies for effectiveness on an ongoing basis. R31's Hospital Discharge Orders, dated 3/15/2024, documents R31 had surgery with orthopedics for a right hip repair and needed to be placed in a facility. R31's Admission Record documents R31 was admitted on [DATE]. This same form documents R31 has the following, but not limited to, diagnoses: Fracture of Unspecified Part of Neck of Right Femur, Unsteadiness on Feet, Generalized Muscle Weakness, Difficulty in Walking, Repeated Falls, and Hypertension. R31's MDS (Minimum Data Set) Assessment, dated 3/22/24, documents R31 is cognitively intact. This same assessment documents R31 requires total assistance for bed mobility and transfers. R31's Admission/Readmission Assessment, dated 3/15/24, documents R31 did not have any wounds upon admission to the facility, except for a right hip repair incision. This same assessment documents R31's initial Braden scale for skin integrity risk score of 15, indicating R31 is at risk for developing pressure ulcers. R31's Care Plan dated, 4/9/24, was not updated to indicate R1 was at a high risk of pressure ulcer development with pressure relieving interventions, after R1's initial Braden scale for skin integrity assessment, dated 3/15/24, indicated R1 was at risk for pressure ulcer development. R31's Wound Management note, dated 3/19/24, and signed by V23/Wound Physician documents, (R31) seen today for reports of a large blister to (R31's) right heel. Upon assessment (R31) has a large stage two PI (pressure injury) to her right heel presenting as a serous-filled blister. Stage two pressure ulcer to the right heel, Progress: Initial Exam, Wound Size: 6cm (centimeters) x 6cm x 0cm. Treatment orders updated 3/19. Recommend bilateral offloading bootie (heel protector) to right heel and floating heels with pillows while in bed. (R31) had a recent hip fracture. Encourage nutrition as appropriate. R31's Wound Management note, dated 4/2/24, and signed by V23/Wound Physician documents, (R31) seen today for large stage two PI (Pressure Injury) to her right heel previously presenting as a serous-filled blister that has erupted and is now open. Unstageable Pressure Ulcer to the right heel, Progress: Deteriorating, Wound Size: 5cm (Centimeter) x 6cm x 0.1cm. Treatment orders updated 4/2. Upon assessment 4/2, (R31's) wound bed is covered completely with unstable eschar, treatment orders updated. Please only cleanse wound with NS (normal saline) when using Santyl products. Recommend to continue bilateral offloading (heel protector) to right heel and floating heels with pillows while in bed. (R31) had a recent Right Hip Fracture. Nutritional consult recommended if not already completed, encourage high calorie high protein diet. R31's Wound Management note, dated 4/16/24, and signed by V23/Wound Physician documents, Unstageable Pressure Ulcer to the right heel, Wound Size: 3cm x 4.2cm x 0.1cm. Treatment Plan: Apply (Collagenase) once a day and wrap with (gauze roll). This same note documents a DTI (Deep Tissue Injury) to R31's left great toe, Etiology: Pressure, Progress: Initial Exam,Wound Size: 1cm x 1.5cm x 0cm. Treatment Plan: Apply (Povidone-iodine) to R31's left great toe once a day. Treatment orders updated 4/16. Presence of a new PI to R31's left great toe found upon assessment 4/16/24. Recommend continuing bilateral offloading (heel protectors) and floating heels with pillows while in bed. R31's TAR (Treatment Administration Record), dated April 2024, does not document a treatment order to R31's left great toe from 4/16/24 to 4/24/24. On 4/22/24 from 9:53 AM through 10:03AM, R31 was sitting in her wheelchair in her room. R31 was groomed and dressed appropriately with nonskid socks applied to both feet. R31's right heel was resting directly on the floor. R31's left foot was resting directly on her wheelchair pedal. R31 stated, Prior to coming back to (this facility) I was getting around great. I ended up falling and breaking my right hip and had to get surgery and had to be admitted at (the facility) for therapy.I just broke my left hip last month. I require assistance with everything now. That is why I got my sores after I admitted here. My right heel hurts pretty bad, especially when the staff changes my dressing. On 4/24/24 from 10:50 AM through 11:00AM, R31 was sitting in her wheelchair with non-skid socks applied to both feet. R31's right heel was resting directly on her wheelchairs foot pedal, and R31's left foot was resting directly on her other foot pedal. On 4/24/24 at 12:03 PM, V27/Registered Nurse lifted R31's right foot and assessed R31's right heel. R31's right heel had a golf-ball sized area that was soft and mushy. The area was black in color. V27 stated, We (the facility) are applying (Collagenase) to R31's right heel wound bed and wrapping it with (gauze roll). While V27 was applying R31's right heel pressure ulcer treatment, R31 was crying out in pain stating the area was extremely painful. V27 stated she had given R31 Tylenol 40 minutes prior to the wound treatment so it would lessen the pain during R31's wound care. V27 then assessed R31's left great toe. R31's left great toe had a black dime sized area noted with a small pinpoint area open in the center. V27 stated, We (the facility) are currently applying (Povidone-iodine) to the area. On 4/24/24 at 10:05AM, V3/Assistant Director of Nursing stated, We (the facility) did not implement any pressure relieving interventions prior to (R31) developing a facility acquired right heel pressure ulcer or left great toe deep tissue injury. (R31's) right heel and left great toe wound development was caused by pressure. (R31's) right heel and left great toe should always be offloaded. V3/Assistant Director of Nursing also verified that R31's plan of care was not updated with pressure relieving interventions after R31's Braden scale indicated R31 was at risk for pressure ulcer development. On 4/24/24 at 11:03AM, V23/Wound Physician stated, (R31's) right heel wound was avoidable and was caused by pressure after (R31) sustained a right hip fracture. The heels should always be offloaded with (heel protectors) as per my recommendations in (R31's) wound notes. The (heel protectors) would help assist to prevent the pressure ulcers from worsening or new pressure ulcers from developing. V23/Wound Physician also stated R31's left great toe deep tissue injury was avoidable and was also caused by pressure. On 4/25/24 at 11:00AM, V26/Infection Preventionist verified R31's physician order for betadine to be applied to R31's left great toe did not get processed correctly, therefore it was not on the TAR for the nurses to complete the treatment.

Based on observation, interview, and record review, the facility failed to ensure a gait belt was in place during a transfer of a resident who requires staff assistance with transfers for one of four residents (R29) reviewed for ADL (activities of daily living) assistance in the sample of 28. Findings Include: The facility's Transfer Belt Policy, dated 12/2013, documents, Transfer belts are to be applied to any resident that requires hands on assist unless the careplan gives a reason not to use the belt. R29's current care plan, dated 3/29/24, documents, (R29) needs assistance with ADL's (Activities of Daily Living) and mobility related to decreased mobility, poor cognition, poor activity tolerance,behaviors, and balance deficits. I have ROM (Range of Motion) deficits bilateral upper and bilateral lower extremities. I also have dysphagia (difficulty swallowing). Restorative: Transfer Program: (R29) has the ability to move between surfaces with Substantial/Maximal Assistance, usual performance one person assistance. (R29) does not use an assistive device. Lock wheels on wheelchair, apply gait belt and stand in front of her and lift pivot transfer her. She does not bear weight well. Be aware (R29) is not always willing to participate and it may be necessary to re-approach or to get extra help for transfer. On 4/22/24 at 10:23 PM, V8 (Certified Nursing Assistant) was in R29's room and assisting R29 with making her bed. V8 asked R29 if she wanted to get into bed and R29 nodded her head yes. At this time, V8 placed her forearms under R29's armpits and lifted her up from her wheelchair then placed her in her bed. V8 then stated she doesn't use a gait belt (transfer belt) when she transfers R29. V8 stated, She doesn't usually get up on her own. I don't usually use a gait belt with (R29). She doesn't put much support on her legs. I just usually help her transfer like that (by carry, under arms). On 4/24/24 at 8:25 AM, V24 (Licensed Practical Nurse) stated, (R29) does not transfer herself. She requires the assistance of one staff usually to transfer. We do not use a machine to assist with her transfer, but we use a gait belt for her transfers.

Based on interview, observation, and record review, the facility failed to assess, monitor, and document ongoing status of a venous stasis ulcer for one of one residents (R18) reviewed for non-pressure wounds in the sample of 28. Findings Include: The facility's Wound Care policy (dated 2010) documents the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. This policy also documents, Documentation- The following information should be recorded in the resident's medical record: The type of wound care given; The date and time the wound care was given; The name and title of the individual performing the wound care; Any change in the resident's condition; All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; Any problems or complaints made by the resident during the procedure; If the resident refused the treatment and the reason(s) why; The signature and title of the person recording the data. R18's current care plan documents the following focus: (R18) has a high risk for impaired skin integrity related to edema, obesity, fragile skin, limited mobility, use/side effects of medications, history of MASD (moisture-associated skin damage). She is currently being treated for stasis ulcer on right calf. R18's Current Physician's Order Sheet documents the following order: Cleanse RLE (right lower extremity) with soap and water and clean wounds with saline and gauze. Place Adaptic or (Non-adherent) Not Telfa, or Xeroform to wounds and then place silver calcium alginate over this, apply ABD (abdominal) pad, then wrap with kerlex clear to the toes. Change on Thursdays and Saturdays, and prn (as needed) when soiled. Assume treatment to right lateral ankle, also. Patient is to wear (pressure relieving) boots at all times. On 04/22/24 at 10:52 AM, R18 was lying in bed partially covered with a blanket. A dressing was in place on R18's right lower leg, and R18 stated she has a venous stasis ulcer, It started as a scratch. I've had it for a while. Several years now. R18 stated she is seen at the wound clinic weekly, and facility staff change her dressing, every few days. On 04/25/24 at 10:06 AM, V2 (Director of Nursing) and V3 (Assistant Director or Nursing) stated they are both working the floor providing direct patient care. V2 and V3 applied a gown and gloves prior to entering R18's room to perform a dressing change to her right lower leg wound. V2 assisted R18 to hold her right leg up while V3 removed the current dressing in place. R18 had scattered reddened areas with multiple open areas present around the circumference of the lower half of her lower leg. R18's right lower leg had a large open area extending up the duration of her lower calf with a moderate amount of sanguineous drainage noted. V3 then cleansed the intact skin on R18's right lower leg with soap and water, and cleaned R18's wounds with saline, and applied a new, clean dressing. R18 tolerated the dressing change well and physician orders were followed for the wound care and dressing change. R18 stated she has had her wound for several years, It started as just a little scratch. R18's medical record does not contain any wound measurements, wound assessments or wound progress notes documented by facility staff. On 04/24/24 at 2:10 PM, V3 (Assistant Director of Nursing) stated the facility does not conduct ongoing wound measurements or any type of wound assessment on R18's right lower leg venous stasis wound. V3 stated, (R18) is seen weekly at the local wound clinic. We just keep a copy of their documentation. On 04/25/24 at 09:55 AM, V2 (Director of Nursing) reviewed R18's medical record and confirmed the facility does not conduct ongoing assessments or wound measurements in R18's medical record. V2 stated, We do the dressing changes as scheduled, but do not document anything other than it was completed. The wound clinic does all of that.

Based on record review and interview, the facility failed to initiate assistive safety device recommendations and provide supervision during activities of daily living for one of three residents (R1) in a sample of three reviewed for falls. R1 fell and fractured a hip. Findings include: A POS (Physician order [REDACTED]. R1's physician orders [REDACTED]. A Nursing Admission Screen/History dated 12/22/15 documents R1 was admitted for rehabilitation for a DVT (Deep Vein Thrombosis). The assessment states R1 was alert, had an unsteady gait and short term memory problems. The assessment also states R1's left leg was very swollen from the groin to the foot due to the DVT and R1 requires assistance of staff for transfers, walking, and toileting. R1's Morse Fall Scale assessment dated [DATE] shows R1's score was 85, indicating R1 was at high risk for falls. The assessment documents R1 had a history of [REDACTED]. R1's Progress Notes, written by E5 (RN - Registered Nurse), dated 12/28/15 at 8:05 a.m. state E5 (RN) was called to R1's room and found R1 lying on the bathroom floor. E5 documents R1 was complaining of left hip pain and R1 could not move R1's left leg. E5 reported R1 rated R1's hip pain level at a ten (zero to ten scale with ten being the worse pain). E5 also documented R1 was actively bleeding from a one inch laceration on the occipital lobe (back of head) and a pin point area on the left parietal lobe (side of the head). E5 (RN's) Progress note states R1 was transferred to a local hospital by ambulance and was admitted with a fractured left hip. A TRIPS (Tracking Record for Improving Patient Safety) From for Falls dated 12/28/15 and completed by E5 (RN) documents the cause of the incident was loss of strength/weakness during transfer off the toilet. E5 (RN) also documented predisposing factors to R1's fall were impaired memory, confusion, and gait imbalance. On 1/07/16 at 9:35 a.m., E4 (CNA) stated, I went to get (R1) for breakfast. I toileted (R1) before taking (R1). (R1) walked hand in hand (with E4) to the bathroom. (R1) walked. (R1) was a really good walker. If they (residents) are an assist it would be on their care plan. We look at them (care plans). It would tell us. I can't recall (R1's) instructions. I know (R1) was a one assist and for long distances (R1) was in the wheelchair. I helped (R1) with clothing and then went to make the bed. I came around to make sure (R1) was doing alright. (R1) was standing up pulling up (R1's) pants. Before I could get there (R1) took a couple steps and lost (R1's) balance and fell . There was no wheelchair or roller walker in the bathroom or the doorway. I think (R1) said (R1) lost (R1's) balance. (R1's) left leg was really swollen and that hadn't changed since (R1's) admission. I walked out to give (R1) privacy but the door was open so I could see (R1). When I was making the bed I kept turning around all the time (to see R1). E4 (CNA) indicated R1 did not have a gait belt on or use a roller walker during (R1's) transfer or toileting. E4 (CNA) stated, A one assist is just one person unless it states a gait belt in needed. A Transfer Belt Policy dated 12/2013 states, (Gait) belts are to be used on all residents requiring assistance with transfers. Disciplinary actions will occur if this policy is not followed. On 1/07/16 at 2:05 p.m., E5 (RN) stated, At the beginning of the shift (E4 CNA) alerted me and I went in and (R1) was lying on the floor. (R1) was awake and lying on (R1's) back on the floor in the bathroom. (R1) was alert and responding. (R1) had complaints of pain in the left hip. (R1) also hit (R1's) head on the wall or corner of the door. (R1) had a laceration on the back of the head. We applied pressure and ice. (R1) remained alert and talking the entire time. (E5 (RN) also reported, I've transferred (R1) before and (R1) was always very easy to transfer. (R1) was a one person assist with a gait belt. It was (R1's) balance. You had to help (R1) maintain balance. A Physical Therapy Plan of Care, signed by E6 (Physical Therapist) dated 12/23/15 states R1's level of functioning on 12/23/15 was as follows: Ambulates up to 40 feet with CGA (Contact Guard Assistance); Demonstrates standing balance - minimal assist to maintain; static can maintain, but easily thrown off balance; Functional transfer requiring contact guard assist (contact with patient due to unsteadiness. Patient Daily Treatment Notes from 12/23/15, 12/24/15, and 12/26/15 document R1's progression using a roller walker, supervision, and cues for hand placement for safety awareness when sitting/standing from wheelchair or toilet. An Occupational Therapy Plan of Care dated 12/23/15 indicates R1 required moderate assistance with toileting. On 1/08/16 at 10:40 a.m., E6 (Physical Therapist) stated, (R1) was a pretty high level but was only oriented to self. The main thing is (R1's) cognition. (R1) needed mostly verbal cues and to make sure (R1) was steady on (R1's) feet with the gait belt. They usually put one (a gait belt) on everybody. They look it up in the computer what they are supposed to do. Regarding R1's fall on 12/28/15, E6 stated, I would have chosen to stay in the bathroom with (R1) in my professional opinion. Especially with not having a walker in front of (R1). E6 indicated anytime a resident requires assistance a gait belt should be used. A Fall Prevention Program Policy dated 04/2014 states staff are responsible for reading, knowing, and following the resident's plan of care. R1's Interim Care Plan dated 12/22/15 states R1 requires assistance with transferring, ambulating, personal hygiene, and toileting. R1's Interim Care Plan does not include the use of a roller walker, contact guard assistance, or supervision and cues for safety documented in the Physical Therapy Plan of Care. On 1/08/16 at 11:30 a.m., regarding CNAs having access to resident care plans, E2 (DON - Director of Nursing) stated, We make a copy and hang it up the the clean utility room for all the new residents. Physical Therapy generally tells (E7 - Restorative Nurse) and then (E7) issues a memo or a note. E2 (DON) stated, Assist is hands on with a gait belt unless and there are very few we deem don't need a gait belt. On 1/08/16 at 11:50 a.m., regarding communicating Physical Therapy recommendations to direct care staff, E7 (Restorative Nurse) stated, Usually Physical Therapy tells me or if I'm not here they write a note and leave it on the desk. When I do the MDS (Minimum Data Set assessment) I ask (Physical Therapy) about their (the residents') balance and information for the MDS but (R1) wasn't here long enough for a MDS. Usually Physical Therapy, Occupational Therapy, and Speech Therapy print out their care plans and I get a copy. I look them over. One gets sent to the physician and I put a copy in the chart. I type an up date and put it on the floor. I notify the nurse and give a copy to the nurse and hang a copy (for the CNAs to review) in the clean utility room. I was off (not working) from 12/24/15 until 12/28/15. When I came in Monday the ambulance was pulled in the drive for (R1). I have no back up. There are three Restorative Aides but they don't do anything with the care plan revisions. On 1/07/16 at 12:38 p.m., regarding R1's 12/28/15 fall, Z2 (R1's Attending Physician) stated, Did (R1) have (R1's) walker? I would expect (R1) to use (R1's) walker. (R1) always uses it here when (R1) comes for visits at the clinic. I admitted here there for a very bad DVT (Deep Vein Thrombosis) of (R1's) left leg. It was completely swollen from (R1's left) hip down. I'm sure it affected (R1's) balance too. (R1) should have had (R1's) walker and someone should have been there to remind (R1) not to get up. But even if they told (R1) not to get up with (R1's) short term memory problems (R1) might not remember their instructions and get up anyway.

Based on observation, interview, and record review, the facility failed to prevent injury for two of 17 residents (R10 and R16) reviewed for activities of daily living and failed to develop and implement fall interventions for one of six residents (R23) reviewed for falls in the sample of 20. R10 sustained a dislocated shoulder during improper dressing. R16 sustained a bruise during a mechanical lift transfer, and R23 sustained a fractured hip after a fall. Findings include: 1. On 4/01/14 at 11:00 a.m. and on 4/02/14 at 11:00 a.m., R10 was in the dining room seated in a padded reclining chair attending an activity. R10 was confused and unable to participate in conversation. A MDS (Minimum Data Set) assessment dated [DATE] documents R10 has severe cognitive impairment and requires extensive assistance of two staff for dressing. R10's care plan dated 12/04/13 documents R10 is dependent on two staff for dressing Nurses' notes for R10 written by E8 (RN - Registered Nurse) dated 12/14/13 at 6:10 a.m., states, "CNA (Certified Nursing Assistant - E7) came up to desk and reported that while putting on (right) sleeve of shirt (E7 CNA) had 'heard a pop'. E7 was the only care giver working with R10 at the time. This nurse entered room and (R10) sitting in recliner and (right) shoulder appears to be out of socket. Appears sleepy and (complains of) some discomfort. Moans occasionally. Went to (emergency room ) and shoulder put into place." A Resident Occurrence Report dated 12/14/13 at 6:10 a.m., indicates R10 was sent to the local emergency room for treatment. A Radiology Report dated 12/14/13 indicates R10 experienced an "anterior inferior dislocation of the humeral head (dislocated shoulder)" on the right shoulder. A progress note written by Z1 (R10's Attending Physician) dated 12/29/13 states, "In my absence, there was an issue that (R10) had an anterior inferior dislocation of the humeral head (dislocated shoulder). This was discovered on x-ray on 12/14/13. It is not particularly clear exactly what happened because of the nurses' notes stop in November and that was switched over to computer recording and I do not have access to those notes... (R10) was getting dressed and apparently dislocated (R10's) shoulder. While putting on the right sleeve, (R10's) shoulder 'popped out of place'. Apparently this is the first time it has happened... Impression: 1. Dislocation of right shoulder. 2. History is doubtful to (Z3). I do not see, even with Alzheimer's that (R10) dislocated (R10's) shoulder while helping get dressed without any antecedent history of previous dislocation. I suspect there was more trauma then is reported. Shoulder immobilizer - Use full time for six weeks." On 4/02/14 at 11:50 a.m., Z1 (R10's Attending Physician) stated, "I was trying to find out what happened. Like, did they manually put (R10's) arm into (R10's) shirt? Was it not just (R10) doing it by (R10's) self. (R10) is combative. Sometimes with the elderly if it was twisted the wrong way it could have happened but (R10) doesn't have a history of this. I was trying to determine if it was an issue of the nurse or the CNA turned (R10's) arm. Did someone have them role play what happened? That's what I was trying to find out. I wanted to look at what was in the record, the history of the incident. Like, was the nurse or CNA just holding the shirt out for (R10) to put (R10's) arm in the sleeve or did the nurse or CNA physically do it?" On 4/02/14 at 10:55 a.m., E7 (CNA) stated, "I work for (staffing agency). I have been working at (the facility) on a regular basis 32 to 40 hours a week. I was working the first shift (on 12/14/13). I was getting (R10) dressed in the (geriatric) chair. I was getting (R10's) shirt on. I got the left arm in first and moved (R10) forward and shoved the shirt in the back of the chair and tried to get (R10's) other arm. (R10's right arm) was in flexion and (R10) wouldn't straighten the arm up. I pushed (R10's) elbow up to see if that would straighten (R10's) arm up but it didn't straighten. The shirt was bunched up on the shoulder. I thought (R10) would straighten (R10's) arm. It was a long sleeve shirt. (R10's) shoulder popped and I went and got the nurse (E8 RN - Registered Nurse) immediately. (E8 RN) asked me what happened but nobody else has. Nobody in Administration. It was a weekend. I did write a report." On 4/02/14 at 2:30 p.m., E1 (Administrator) provided E7 (CNA's) hand written statement concerning R10's care on 12/14/13. (CNA's) hand written statement, dated 12/14/13 at 6:10 a.m., states, "Took (R10) from the (main dining room) to dress (R10) for morning ADL's (Activity of Daily Living). I was able to put (R10's) pants and T-shirt on (R10). I was attempting to put (R10's) long sleeve shirt on (R10). At this time was (R10) being combative with this portion of (R10's) ADL's. I was able to put (R10's left) sleeve on, then I struggle(d) with putting on (R10's right) sleeve on. I had (R10's) elbow at a 90 (degree). I raised (R10's) elbow up, when heard a 'pop' on (R10's right) shoulder. (R10) did not yell. I wasn't sure if (R10) was injured. I notified (E8 RN - Registered Nurse) of (R10's) condition." On 4/02/14 at 10:40 a.m., regarding R10's injury on 12/14/13, E8 (RN - Registered Nurse) stated, "I was the nurse on duty when the shoulder happened. The CNA came to me and said (R10's) arm had popped out of the socket while the CNA was putting on (R10's) shirt. I went down to the room. (R10) was sitting in the (geriatric) chair and all I had to do was look at (R10) and I could see (R10's) shoulder was slumping down and looked like it was out of place." E8 (RN) stated (E8) did not see that R10 had any other injuries. E8 (RN) reported E1 (Administrator) was called and notified of the incident and R10's injury. E8 (RN) verified E7 (CNA) was the only staff person in the room caring for R10 when R10's shoulder was dislocated. 2. On 4-1-14 at 1:10 pm, E5 (Certified Nursing Assistant/CNA) and E6 (CNA) transferred R16 from the wheelchair to the bed, using a mechanical lift. When lowering the mechanical lift, R16's left arm was pinched between the mechanical lift and the arm of R16's wheelchair, causing a bruise to R16's left arm. E5 and E6 did not encourage R16 to cross R16's arms over the chest, before attempting to transfer R16 with the mechanical lift. On 4-1-14 at 2 pm, E4 (Registered Nurse/RN) verified R16 received a bruise measuring 2 (centimeter/cm) x 1.5 cm, due to injury from a transfer. On 4-2-14 at 11:30 a.m., E2 (Director of Nursing/DON) confirms staff is to at least encourage R16 to cross arms and ensure arms are out of the way of other objects, to prevent injury, while transferring R16 with a mechanical lift. R16's mechanical lift care plan dated 2-26-14, documents R16 should cross arms across the chest during transfers. Mechanical Lift Policy dated 12/2013, documents staff should always be aware of residents' placement of their extremities before transferring and encourage residents to place their arms over their chest, or hold onto an item, during transfers. 3. A Physician Notification Fax dated 8/12/13, documents R23 was admitted with injuries from a fall prior to admission. A Physician Notification Fax dated 8/12/13, documents R23's injuries included fractured ribs, bruising, skin tears, and abrasions. An Admission Nurses Note dated 8/12/13 (time unknown), documents R23's Power of Attorney informed the facility that R23 is "likely to get up on own" if not taken to the bathroom promptly; R23's gait is unsteady at times and R23 is too weak to stand independently. Nurses Notes dated 8/13/13 through 8/24/13, document R23 had an unsteady gait and balance problems. A Fall Risk assessment dated [DATE], documents R23 is at high risk for falls. A Minimum (MDS) data set [DATE], documents R23 scored seven out of fifteen (impaired cognition) on the Brief Interview for Mental Status; requires extensive assist with transfers and ambulation; and had a fall with fracture prior to admission. A Care Area Assessment Summary dated 8/19/13, documents R23 is at risk for falls due to weakness, de-conditioned state and a fall prior to admission. R23's Care Area Assessment Summary dated 8/19/13, documents fall precautions were implemented upon admission and will be added to R23's plan of care. R23's Plan of Care dated 8/19/13, documents R23 is at risk for falls and staff are to "place call bell and frequently used items in reach; encourage to wait for assistance." An Incident Report dated 8/24/13 at 11:30 p.m., documents R23 was found on the floor and sent to the hospital emergency room for evaluation. An Investigation form (TRIP Form) dated 8/25/13, documents R23 attempted to get out of bed independently, attempted to walk independently and fell . An Investigation form (TRIP Form) dated 8/25/13, documents R23 did not have a personal alarm in place or any other device to help to reduce the risk of R23 falling. A Hospital Discharge Summary dated 8/29/13, document R23 sustained a fractured right hip. A Fall Policy dated 12/2013, documents "ensure resident receives adequate supervision and assistive devices to prevent accident." On 4/3/14 at 10:35 a.m., E22 (Licensed Practical Nurse) stated R23 had a history of [REDACTED]. E22 stated "I do recall (R23) attempting to get up independently from (R23's) wheelchair and bed." On 4/3/14 at 10:45 a.m., E23 (Certified Nurse Aide) stated R23 was frequently confused and attempted to get up independently out of bed and wheelchair. E23 stated R23 also attempted to toilet self. On 4/3/14 at 11:17 a.m., E2 (Director of Nursing) stated E2 would expect staff to implement safety alarms for a resident with confusion and a known history of falls. E2 verified R23's plan of care interventions were not appropriate for R23 due to R23's known confusion and history of a fall prior to admission.

Based on observation, interview, and record review the facility failed to follow their policy and procedure for fall prevention and failed to identify, implement, evaluate and monitor interventions to prevent resident falls for four of eight residents (R3, R6, R12, R17) reviewed for falls in a sample of 21. These failures resulted in R3 falling and fractured a hip and R12 fell and received a head contusion. Findings include: The facility "Fall Prevention Program Policy" documents that, "...the nurse needs to ...initiate appropriate interventions, document the fall on the care plan including the interventions...". The same policy also documents that, "Care plans are to be updated at the time of the incident to include any new safety interventions." On 2/24/12 at 2:00pm E2 stated that the Nurse is to fill out the Resident Occurrence Report and to investigate the cause of the fall. E2 stated the Nurse should add a new intervention after each fall. E2 stated the Care Plan Coordinator is to place any new interventions on the Care Plan after the fall meeting. 1. Fall Risk Assessments dated 5/18/11, 8/17/11, 11/9/11, 12/19/11 and 12/26/11 all score R3 at being high risk for falls. The 11/9/11 MDS shows R3 as being an extensive assist of two for transfers and ambulation (walking). The 12/26/11 MDS shows R3 as now using a mechanical lift for transfers and is not ambulatory. The nurses notes for R3, dated 11/28/11 documents that R3 fell and was sent to the hospital. Xray results dated 11/28/11 documents R3 suffered a nondisplaced spiral fracture to her right femur (long bone of right leg). Surgical Report dated 11/30/11 records that R3 received surgical intervention on 11/30/11. Prior to this fall R3 had falls on 8/12/11, 7/18/11 and 5/8/11 per Resident Occurrence Reports. Resident Occurrence Reports do not indicate any new interventions to prevent falls. Care Plans dated 11/16/11, 8/24/11 and 5/25/11 do not show any documentation as to new interventions put into place for fall prevention. Nurses Notes record R3 was readmitted to the facility on [DATE] from the hospital after receiving surgery to her right femur. No fall prevention interventions for R3 were documented on 11/16/11 Care Plan after R3 readmission on 12/12/11. Resident Occurrence Reports document that R3 fell again on 12/13/11 and 12/17/11. The care plan for R3 does not include any new interventions after those falls. On 2/23/12 at 11:00 am, E5 RN/CPC (Registered Nurse/Care Plan Coordinator), stated, "All interventions should be on the Care Plan". E5 said that she didn't see any updates or new interventions on the care plans dated 5/25/11, 8/24/11, 11/16/11, 12/28/11, 1/4/12 or 1/17/12. E5 stated the nurses should have put something on the Resident Occurrence Reports. E5 also stated, "We didn't add anything to (R3) after her falls or I would have put them on her Care Plan. I only update the care plan if we add something new as a fall intervention. I don't put every little thing on the care plan." On 2/21/12 at 11:00 am, R3 was sitting in a high back reclining wheelchair with elevating leg rests in the elevated position. On 2/24/12 at 11:15am, E9 CNA (Certified Nursing Assistant), stated that R3 uses a high back reclining wheelchair with elevating leg rests and has not been able to stand or walk since her (R3) fracture. 2. Facility "Resident Occurrence Report" for R12 dated 09/03/11 documents that R12 slid out of the bed to the floor then scooted off the mat. The same occurrence report does not contain any recommendations to prevent further falls. The care plan for R12 does not contain any new interventions after the fall of this date. "Resident Occurrence Report" for R12 dated 10/3011 documents that R12 got out of bed and slid to floor. Recommendations to prevent further problems on same form document to lie the resident down later when the resident seems more sleepy. This recommendation did not appear on R12's care plan. "Resident Occurrence Report" for R12 dated 01/07/12 documents that resident was found sitting upright in room at bedside. The same form does not contain any documentation of recommendation to prevent further problems. The care plan for R12 on the same date does not contain any new interventions after this fall. "Resident Occurrence Report" for R12 dated 02/12/12 documents that R12 was found on the floor beside the wheelchair. The same form does not contain any documentation of recommendation to prevent further problems. The care plan for R12 on the same date does not contain any new interventions after this fall. "Resident Occurrence Report for R12 dated 02/14/12 at 4:20PM documents that R12 was found sitting on the floor at the end of the bed. An injury noted above left eye is 4cm (centimeters) by 4cm swollen bruised area. Resident's physician was notified and resident was sent to the emergency room . The same form does not contain any documentation of recommendation to prevent further problems. The care plan for R12 on the same date does not contain any new interventions after this fall. Hospital emergency room report for R12 dated 02/14/12 documents that R12 was seen in the emergency room for a closed head contusion. On 02/21/12 at 1:30PM R12 was sitting in the wheelchair. R12 had extensive bruising from the left eyebrow area stretching down across the left eye and face to underneath the left jaw area. The bruising was dark purple at the face and yellowish purple at the jaw line. 3. The Resident Occurrence Reports document R6 falling on 8/2/11, 11/12/11, 1/17/12 and 2/18/12. R3 Fall Risk Assessment documents R6 as being at risk for falls on 3/24/11, 6/20/11, 9/8/11 and 12/1/11. The care plan for R6 does not include any updates or new fall interventions after any those falls. 4. The Resident Occurrence Reports document R17 falling on 10/28/11, 10/30/11, 11/3/11, 11/18/11, 11/26/11, 11/30/11, 12/29/11, 1/8/12 and 1/17/12. R17 Fall Assessment documents R17 as being high risk for falls on 6/22/11, 9/14/11 and 12/7/11. The care plan for R17 does not include any updates or new fall interventions after those falls.