Every finding on record at Fairview Haven

Based on observation, interview and record review the facility failed to monitor medication room freezer temperatures and failed to store medications separately from food. This failure affects all 47 residents residing in the facility. Findings include: The facility's Storage of Medications policy with a revised date of 9/10/24 documents, Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored in a separate compartment from food. On 9/10/24 at 10:15 AM, V3 Licensed Practical Nurse opened the medication storage room refrigerator and there was food and drink in the refrigerator. There was bisacodyl suppositories and acetaminophen suppositories in the bottom drawer of the refrigerator and there was a medication card of Florastor (probiotic) for R251 in the top shelf of the refrigerator door. V3 opened the freezer and there was no thermometer in the freezer. The freezer contained individual ice cream cups and popsicles. V3 confirmed there was no thermometer in the freezer and confirmed there was no log to monitor the temperatures of the freezer. V3 also confirmed that the food and drinks in the refrigerator and freezer were for the residents. V3 confirmed there was another smaller refrigerator in the medication room that contained more medications. R251's Order Summary dated 9/10/24 documents an order for Florajen Acidophillus Oral Capsules (probiotic) with a start date of 8/22/24. On 9/10/24 at 11:08 AM, V2 Director of Nursing provided a list of items in the medication room refrigerator and confirmed that food and medications were contained in the same refrigerator. This list documents the medication refrigerator contained nutritional drinks, nutritional/extra calorie shakes, juice, soda, pudding, yogurt, apple sauce and sandwiches. This list documents the medications contained in the medication refrigerator were Bisacodyl Suppositories, Acetaminophen Suppositories, Hydrocortisone cream and Probiotic. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 9/9/24 documents 47 residents reside in the facility.

Based on observation, interview and record review the facility failed to implement fall prevention interventions for one of three residents (R27) reviewed for falls in the sample list of 34. Findings include: The facility's Falls-Clinical Protocol with a revised date of 5/3/13 documents, Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. R27's Order Summary Report dated 9/10/24 documents diagnoses including Unspecified Dementia, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety and Osteoarthritis. R27's Nurse's Notes dated 5/14/24 documents R27 was found on the floor in his room with an abrasion to the left elbow and to the forehead. R27's Care Plan dated 5/3/22 documents R27 is at risk for falls and documents an intervention dated 5/18/22 that non-skid footwear should be worn at all times. On 9/9/24 at 10:06 AM, 9/10/24 at 10:09 AM and on 9/10/24 at 2:18 PM, R27 was lying in bed sleeping with regular socks on his feet. On 9/10/24 at 2:18 PM, V2 Director of Nursing confirmed R27 had regular socks on and confirmed that R27's Care Plan documents he should have gripper socks on his feet at all times.

Based on observation, interview, and record review the facility failed to initiate Enhanced Barrier Precautions for one (R14) of sixteen residents reviewed for infection control in a sample list of 34. Findings include: The facility's policy Enhanced Barrier Precautions dated 9/10/24 documents Enhanced Barrier Precautions expand the use of Personal Protective Equipment and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multidrug Resistant Organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization As well as for residents with MDRO infection or colonization. R14's physician's orders dated 9/6/24 documents, R14 was readmitted to facility with an order for an indwelling urinary catheter. These orders did not contain an order for enhanced barrier precautions. On 9/9/24 at 10:00 AM, R14 was in bed with the indwelling urinary catheter secured on the side of the bed. There was clear yellow urine contained in the bag and tubing. There was no Personal Protective equipment outside R14's door. There was no sign posted outside R14's door to indicate Enhanced Barrier Precautions were being implemented for R14. On 9/10/24 at 2:00 PM, V2 Director of Nursing stated (R14) has a urinary catheter and he definitely should be on Enhanced Barrier Precautions. V2 verified R14 has not been placed on Enhanced Barrier Precautions.

Based on observation, interview and record review the facility failed to dispose of unused medications from unknown residents. This failure has the potential to affect all 46 residents residing in the facility reviewed for medication disposal in the sample list of 18. Findings include: The facility's undated Discarding and Destroying Medications policy provided on 7/12/23 documents, Medications that cannot be returned to the dispensing pharmacy (e.g. {example} non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed. Non-controlled and Schedule V controlled drugs must be destroyed in the presence of two (2) licensed nurses. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. On 7/12/23 at 10:41 AM during the medication room tour, V15 Registered Nurse opened an unlocked drawer labeled CD (hall cart CD) and there were medication cards in the front of the drawer. V15 stated that V15 did not know where those medication cards came from or why they were in the drawer. The medication cards had the resident's name blacked out with black marker and were unidentifiable. The first medication card was for Ondansetron (anti-nausea) 4 mg (milligrams). The residents name was marked out and the word stock handwritten on the card. There were 23 tablets left on the medication card. The second medication card was for Phenergan (anti-nausea). The strength of the medication and the resident's name were marked out in black marker and unidentifiable. The name of the medication Phenergan had black marker through it but was readable. There were 25 tablets left on the medication card. The third medication card was for Hyoscyamine (antispasmodic) 0.125 mg. The resident's name was marked out with black marker and unidentifiable. The word stock was handwritten on the card and there were 28 tablets left on the medication card. The fourth medication card was also for Hyoscyamine 0.125 mg with the resident's name marked out in black marker and unidentifiable. The word stock was handwritten on the medication card and there were 28 tablets left on this medication card. On 7/12/23 at 11:26 AM, V2 Director of Nursing stated that those medications should not have been left in the medication room in that drawer where they were. V2 stated that that is not their policy. V2 stated the nurse should have put them in the locked box in the medication room. V2 stated that two nurses go through those discontinued medications and dispose of them together in a drug disposal solution. V2 stated that V2 was not sure which resident those medications were prescribed for. V2 stated V2 assumes it was for a resident that has passed away recently. On 7/12/23 at 2:02 PM, V2 confirmed that all nurses that administer medications have access to the medication room and would have access to those medications in the drawer. The facility's Resident Census and Conditions of Residents form dated 7/10/23 documents 46 residents reside in the facility.

Based on observation, interview and record review the facility failed to prevent injury during care transfers for a resident requiring total assist and protective sleeves to both arms. This failure affects one (R12) of three residents reviewed for transfers from a total sample list of 18. Findings include: R12's Minimum Data Set, dated dated dated [DATE] documents R12 as cognitively intact and requiring total assistance for transfers, including a mechanical lift. R12's skin care plan dated 6/19/23 documents R12 is to wear protective sleeves to both arms and may remove for hygiene. R12's progress notes document the following: 3/11/23 document a skin tear approximately one centimeter on the left leg 4/12/23 documents during a shower, R12 sustained a skin tear on the left elbow from the yellow (transfer) sling which had scraped R12's left elbow, approximately 1.5 cm .0.5cm. in size 5/9/23 document that R12' sustained a skin tear to R12's right forearm when transferring the resident. 5/25/23 documents, Bruising and skin tear noted to right upper arm. Bruise is dark purple in color. 6/18/23 document, Resident noted to have a skin tear to left forearm measuring at one centimeter. Small amount of blood. 6/20/23 document, During (bedtime) cares (Certified Nursing Assistant) noted a spot on the back of (R12's) right leg, lateral under the crease of her knee. It appears to be scabbed. The area is 1cm x 1cm x 0.1cm. On 7/10/23 at 11:35 AM, R12 stated that she had a skin tear on her leg. At this time multiple bruises were visualized on both arms and no protective sleeves were being worn. On 7/11/23 at 12:00PM, R12 was eating in the dining room and no protective sleeves were being worn. On 7/12/23 at 9:50AM, R12 showed a healing wound on her right forearm with a purple bruise on her right forearm. No protective sleeves were being worn. On 7/12/23 at 9:52AM, R12 stated, I get these (pointing to the right forearm bruise) when they grab me to move me in the (mechanical lift). On 7/12/23 at 10:00AM V16 Certified Nursing Assistant stated, (R12) is one who gets skin tears and bruises easily. On 7/11/23 at 10:00AM, V2 Director of Nursing said that the facility was having some issues with mechanical lift transfers resulting in skin tears and bruises.

Based on interview and record review the facility failed to complete residents initial assessment for an antidepressant and failed to complete quarterly assessments for antidepressants and an antipsychotic medication. This failure affects one of five residents (R22) reviewed for unnecessary medications in the sample list of 18. Findings include: The facility's undated Psychotropic Medication Use policy provided on 7/12/23 documents, Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Discussion of non-medication behavior management strategies that could be implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment as well as on an ongoing basis. Primary care physician, PA (Physician's Assistant) or APN (Advanced Practice Nurse) Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month of initiating, increasing or decreasing dose and during routine visits thereafter. Nursing Reviews the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. R22's Order Summary dated 7/12/23 documents R22 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Altered Mental Status, Insomnia, Other Bipolar Disorder and Depression. This Order Summary documents orders for Remeron 30 mg (milligrams) (Antidepressant) at bedtime for Insomnia with a start date of 1/4/23, Risperdal 0.5 mg (Antipsychotic) one tablet twice a day for Bipolar Disorder with a start date of 1/4/23 and Trintellix 5 mg with the noon meal for Depression with a start date of 1/4/23. R22's medical record documents a Psychotropic Justification for Trintellix and Risperdal dated 1/4/23 but does not include an assessment for the Remeron. R22's medical record documents a Psychotropic Medication Review entered on 7/10/23 for Trintellix, Risperdal and Remeron. There is no Psychotropic medication assessment for these medications in April 2023 (the first quarter after initiation) in R22's medical record. R22's medical record documents a psychotropic medication assessment for these medications dated 4/13/23 but this assessment documents it was not completed until 7/10/23. On 7/11/23 at 1:32 PM, V7 Resource Nurse/Infection Control Nurse stated that R22 admitted with those medications. V7 stated that V18 Medical Director follows R22 and prescribes R22's medications now. V7 stated that they complete a medication justification when they enter the facility and complete quarterly assessments after that. On 7/12/23 at 12:40 PM, V2 Director of Nursing confirmed that R22's Psychotropic Justification dated 1/4/23 does not include Remeron.

Based on observation, interview and record review, the facility failed to complete a self administration of medication assessment for residents with medications at bedside for two of two residents (R4, R29) reviewed for self administration of medications on the sample list of 18. Findings Include: The facility's undated Self Administration of Medication Policy documents residents in our facility who wish to self administer their medications may do so if it is determined that they are capable of doing so. The staff and practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self administering medications and document their findings and the choices of the residents who are potentially capable of self administering medications. Self administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible, the medications will be kept in the medication cart and nursing will transfer the unopened medication to the resident when the resident requests them. The resident's ability to self administer medications will be reevaluated periodically (for example, during quarterly MDS (Minimum Data Set) reviews). 1.) On 7/10/23 at 11:54 AM, R29 was sitting up in the recliner in R29's room, without staff present, with a medication cup containing three pills; a white capsule, a white tablet and black gel coated pill sitting on the over bed table. When asked about the pills, R29 stated I will take them and dumped them out of the cup and onto a tray but didn't take them at this time. The only Self Administration of Medication Assessment in R29's medical record is dated 1/26/23. On 7/10/23 at 11:57 AM, V4 LPN (Licensed Practical Nurse) stated V4 left R29's vitamins and cranberry pill in the room with R29 because V4 had already prepared them however R29 wanted to wait to take them. V4 stated the facility used to be able to leave medications with R29 but they are not supposed to anymore because R29 isn't limber enough to take them independently. On 7/11/23 at 3:23 PM, V2 DON (Director of Nursing) stated a Self Administration Medication Assessments should be completed quarterly, at the time of the MDS, and if a resident is able to self administer medications, there should be a physician's order for that. R29's July 2023 Physician Order's do not contain an order for R29 to self administer medications. R29's Care Plan dated 5/17/23 does not document that R29 is able to self administer medications. 32853 2.) On 7/10/23 at 9:31 AM there was a container of chewable antacid tablets on the bedside table in R4's room. R4 stated that R4's family brings in R4's medications to the facility. R4's Order Summary dated 7/12/23 does not document an order for a chewable antacid. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. On 7/11/23 at 1:32 PM, V2 Director of Nursing stated that if a resident is able to self administer medications, they can keep them in their room and they would complete a self administration of medication assessment and it would be entered into the resident's electronic medical record. On 7/11/23 at 3:24 PM, V2 confirmed that R4 does not have a self administration of medication assessment completed at this time. V2 stated that they discussed with R4 and R4's Power of Attorney that if R4 would like to keep the antacids in R4's room they could complete a self administration of medication assessment. V2 stated at this time the medication is in the nurse's medication cart.

Based on interview and record review, the facility failed to document completion of a thorough investigation to determine the root cause of falls for three of three residents (R1, R2, R3) reviewed for falls on the sample of three. Findings include: 1. R1's Progress Notes dated 2/20/23 at 11:15am document at approximately 11:15, an unidentified CNA heard a thud and found R1 had fallen out of bed. No additional injuries except pain to the right leg. R1's Progress Notes dated 2/27/23 document R1 had been hospitalized on [DATE] after a fall and R1 has multiple closed fractures of pelvis, femur and knee. R1' Fall Incident Report documents R1 was found on the floor on 2/20/23. This report documents R1 reported R1's right leg is extremely painful. R1 was sent to the hospital for further evaluation of the right leg. This report documents predisposing physiological factors including incontinent, impaired memory and confused. This report documents R1 has lived at the facility for over [AGE] years, and transfers with 2 assist and a full mechanical lift. This report also documents R1 has no prior history of falls or history of self transfer. R1's Final Investigative Report for R1's fall on 2/20/23 documents imaging at the hospital revealed R1 had a fracture to the right superior and inferior rami. This report documents the root cause of the fall as R1 unintentionally rolled from bed while asleep. The facility's investigation for R1's fall on 2/20/23 does not document staff interviews with V11, Certified Nursing Assistant (CNA) or the additional staff who assisted in laying R1 down in bed on 2/20/23 prior to R1 being found on the floor. This investigation does not document the facility checked the air mattress function for R1's air mattress. There is no documentation in the investigation as to how R1 was positioned in bed prior to the fall or when R1 was last observed prior to the fall. On 3/7/23 at 11:30am, V12, Registered Nurse (RN) stated R1 requires staff assist for bed mobility and that R1 may be able to grab onto the side of the mattress, however V12 has never seen R1 move anything other than a leg. V12 stated trunk wise, V12 had never seen R1 move by R1's self. On 3/7/23 at 12:49pm, V2, Director of Nursing (DON) stated V11, Certified Nursing Assistant stated they laid R1 in bed a few minutes after 9:00am on 2/20/23. V2 stated V2 is unsure of who assisted V11 to lay R1 down in bed, but R1 transfers with a mechanical lift. V2, DON stated R1 was lying supine in center of bed, with R1's head elevated a little bit but there is no documentation of this information in the investigation. V2 stated the facility does not usually document interviews conducted during investigations. V2 stated R1 requires assist with bed mobility and is unsure of how R1 could have rolled out of bed if R1 cannot reposition/roll self in bed. V2 stated R1 was the only one in there, R1 was lying in bed and the facility believes R1 had rolled out on the floor. On 3/7/23 at 2:18pm, V11, Certified Nursing Assistant (CNA) could not recall the additional staff member who had assisted with transferring R1 into bed after breakfast on 2/20/23. V11 stated R1 has been a resident at the facility many years and never turns over without assistance. 2. R2's Fall Incident Report dated 2/21/23 documents R2 was found sitting on the floor in R2's bathroom in front of the toilet and had a skin tear to the left elbow. This report documents R2 was assisted from the floor with a full mechanical lift. This report does not document statements/interviews with additional staff working with R2 at the time of the fall. This report documents R2 transfers with one assist with a gait belt and walker and R2 stated R2 needed to use the restroom. This report does not document the last time R2 was assisted to use the restroom. On 3/7/23 at 12:49pm, V2, Director of Nursing (DON) stated V2 doesn't recall talking to a certified nurse assistant responsible for R2 that day and was unsure of who that would have been. V2 stated R2 was trying to use the restroom and had gotten up per self to do so. V2 stated nurses round hourly, and staff do two bed checks during the night. V2 stated V2 did not recall when R2 was last observed or if the facility looked at that during the investigation. V2 was unsure of when R2 had last been toileted prior to R2's fall on 2/21/23. 3. R3's Fall Incident Report dated 1/28/23 at 12:10am documents staff responded to a pressure alarm sounding and found R3 on the floor on R3's bottom and was leaning back. R3's feet were facing recliner and R3's head was by R3's bed. R3 had non-skid socks on R3's feet, but they were starting to come off. R3 reported R3 slid out when (R3) was trying to go. R3 sustained a skin tear to the left forearm. This report documents R3's predisposing physiological factors of incontinent and R3 ambulating without assistance. This report documents R3 requires the use of a stand up lift and a carrier sling. This report also documents R3 has a history of falls and has had a recent increase in restlessness. This report documents the root cause as R3 was trying to transfer out of R3's bed and R3's feet slipped and R3 slid out of the bed. Intervention identified was to provide smaller non-skid socks, although R3 was attempting to get up to use the restroom. There is no documentation in the investigation as to when R3 was last toileted or seen prior to the fall. On 3/7/23 at 11:30am, V12, Registered Nurse (RN) stated R3 was trying to go to the bathroom when R3 fell . V12 stated staff are to check residents at least twice per night and ask if R3 needs to go to the restroom. V12 stated V12 is unsure of when R3 was last observed/toileted before the fall and did not recall the staff that were involved. V12 stated V12 would have to look. V12 stated V8, RN was the nurse that night and would have gotten all the information from the CNA. V12 stated the floor nurses talk with the staff to get details of the falls and know to ask when the resident was last seen, toileted, etc. and would document details under the risk management fall incident reports. R3's Progress Notes dated 2/3/23 at 3:24 am document R3 was found on the floor after staff heard someone yelling, Help me, somebody help me. R3 was found sitting at the side of his bed on the floor. This note documents R3 appears to have slid off R3's bed on to the floor. R3's Progress Notes dated 2/3/23 at 3:35am, document R3's bed alarm was in place but did not activate until R3 was back in bed after the fall. On 3/7/23 at 12:49 pm V2, DON stated V2 doesn't think R3 was positioned correctly on the alarm pad. V2 stated V2 would have to check into where the sensor pad was positioned as V2 does not recall looking into that. V2 stated the facility has changed the positioning of the sensor pad alarm so pressure points are where they need to be on the sensor pad to activate the alarm. V2 stated V2 only spoke with an unidentified nurse but no additional staff caring for R3 that night. On 3/7/23 at 12:07pm, V12, RN stated R3 was trying to transfer R3's self to use the restroom when R3 fell on [DATE]. On 3/7/23 at 12:49pm, V12, RN stated the facility had a bed alarm issue and the alarm did not activate this time at all. V12 stated the facility talked about the bed alarm not activating. V12 stated the facility is unsure why the alarm did not sound on 2/3/23 when R3 fell . V12 stated R3's sensor alarm did not go off when R3 got out of bed, but the facility did not look in to why it didn't. On 3/7/23 at 2:30pm, V2, Director of Nursing stated the facility is unable to provide additional documentation of thorough investigations for R1, R2 or R3. V2 stated the facility needs to document the entire investigation to ensure thoroughness and documentation of thoroughness of the investigations. The facility's undated fall procedure documents the purpose of the procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. This procedure documents the nursing staff will observe for delayed complications of a fall for approximately 48 hours after a fall and document findings in the medical record. Documentation will include any observed signs/symptoms of pain, swelling, bruising, deformity, and/or decreased mobility. This procedure also documents that documentation will note the presence or absence of significant findings. Staff will evaluate chains of events or circumstances preceding a recent fall including, the time of day of the fall, what the resident was doing, whether the resident was standing, walking, reaching or transferring from one position to another, whether the resident was among other people or alone, trying to get to the toilet, whether any environmental factors were involved, if there is a pattern of falls for the resident. Data will continue to be collected and evaluated until they identify the cause of falling or determine cause cannot be found. When a resident falls, the condition in which the resident was found, assessment data, interventions/treatment administered, physician and family notifications, appropriate interventions taken to prevent future falls will be recorded in the resident's medical record.

Based on observation, interview, and record review, the facility failed to maintain equipment and utensils in a safe, clean, sanitary condition to prevent the potential for cross-contamination of food from physical contaminants. These failures have the potential to affect all 47 residents in the facility. Findings include: 1.) On 6/21/2022 at 9:45 am on tour of the kitchen, accompanied by V8, Dietary Manager, there was a manual tabletop can opener. The tabletop can opener had thick, dark brown grease-like build-up on the blade and an accumulation of metal shavings in gears. V8, Dietary Manager stated I see the metal shavings. I will get that taken care of right away. That is bad and is a potential hazard that could affect all the residents in the facility. 2.) On 6/21/2022 at 9:50 am continuing on the tour of the kitchen accompanied by V8, there was one large 24 inch by 18 inch acrylic cutting board and two smaller 18 inch by 12 inch acrylic cutting boards. The three cutting boards each had deep slice-like divots over the majority of the boards The center sliced divot had imbedded builds-up of brown and yellow food-like debris in the slice-like crevices. V8, Dietary Manager stated These (cutting boards) need to be thrown out. I will replace them. They can't be used in that condition. 3.) On 6/21/22 at 9:55 am continuing on the tour of the kitchen accompanied by V8, there were four large rubber spatulas. The four large rubber spatulas had slice-like divots with food-like debris. The same four rubber spatulas had uneven chew-like pieces of the rubber missing at the edges. V8, Dietary Manager stated I have to throw those (spatulas) away too. They can't be used. The facility policy Cleaning Instruction: Can Opener dated 2020 documents the following: 2. Protocol for counter-mounted can openers: * Remove can opener shaft from the base; wash in sink with soap and water. * Pay close attention to the blade and other moving parts. * Rinse, sanitize and air dry. * Wash the base carefully with mild detergent and hot water; be sure to get rid of all food particles from the blade and the base. * Sanitize and then air dry. * Reassemble can opener once dry. The Resident Census and Conditions of Residents report dated 6/21/22 documents 47 residents reside in the facility.

Based on interview and record review, the facility failed to ensure PRN (as needed) medications were not ordered for more than 14 days maximum duration permitted for PRN medications without justification, failed to complete a [CONDITION(S)] medication assessment prior to starting a [CONDITION(S)] medication, and failed to care plan non-pharmacological interventions to assist with behavior management for three of five residents (R27, R30, and R36) reviewed for [CONDITION(S)] medications on the sample list of 25. Findings include: 1.) R36's Physician Order Summary Report Sheet (POS) dated June 1-30, 2022, documents the following diagnosis: Unspecified Dementia Without Behavioral Disturbance, Anxiety Disorder Due to Known Physiological Condition, and Delusional Disorder. R36's Physician Order Summary Report Sheet (POS) dated February 1-28, 2022, documents the following [CONDITION(S)] medication order: [MEDICATION(S)] Tablet 0.5 MG( milligram) Give 1(one) tablet by mouth as needed (PRN) for Anxiety take every 12 hours. Active 2/01/22. There is no physician order to discontinue or change the as needed (PRN) [MEDICATION(S)] medication order after the maximum required duration for prn [CONDITION(S)] medications. R36's Note To Attending Physician/Prescribe documented by V12, Pharmacist, signed by V11, Physician on 03/24/22, documents the following: Resident was started on [MEDICATION(S)] 0.5 milligrams q (every) 12 hours added 2/8/22 (actual order as noted on February 2022 POS above has a start date of 2/1/22). The same Note To Attending Physician/Prescribe documents: Please provide a rational and duration for a PRN [CONDITION(S)] order that exceeds 14 days per CMS requirements as indicated above. V11, Physician documented duration updated as 180 days for intermittent anxiety (dated 3/24/22). As documented below, R36 received 31 doses after the 14 day maximum duration. R36's Medication Administration Record dated February 1-28, 2022, documents R36 received prn [MEDICATION(S)] 0.5 mg, 31 times after the 14 day maximum prn order permits. R36 [MEDICATION(S)] administration occurred on the following dates: February 15-19, 21-24, and the 27, 2022. R36's Medication Administration Record dated March 1-31, 2022, documents R36 [MEDICATION(S)] was also administration on the following dates, March 1-13th, March 15-23, 2022. On 6/23/22 at 9:45 am V10, Director of Clinical Services/ Registered Nurse and V2, Director of Nursing (DON) confirmed R36 was admitted to the facility on [DATE] with an order for [MEDICATION(S)] 0.5 mg by mouth, as needed every 12 hours. V2 and V10 acknowledged R36's [MEDICATION(S)] order did not document the 14 day maximum duration. V2, DON and V10, Director of Clinical Services/RN also confirmed R36 continued to receive administration of [MEDICATION(S)] 0.5 mg po every 12 hours until V11, Physician responded to V12, Pharmacist request to provide a rational and duration for a [CONDITION(S)] order that exceeds 14 days as required by CMS. 2. R30's Physician Order Recap dated June 2022 documents the following orders: 5/13/22 [MEDICATION(S)] {Antidepressant} 30 mg (milligrams) daily for depression 6/3/22-6/16/22 [MEDICATION(S)] Concentrate {Benzodiazepine} 2 mg/ml (milliliters) - give 0.25 ml every 4 hours PRN for agitation 5/13/22 [MEDICATION(S)] {Serotonin Modulator} 50 mg - give 0.5 tablets every HS (bedtime) for sleep R30's medical record does not contain a [CONDITION(S)] medication assessment prior to starting the above medications. R30's Care Plan dated 5/11/22 documents R30 requires mood/behavior monitoring due to yelling out and situations of anger. This Care Plan documents interventions of implementing the above medications but does not include any non-pharmacological interventions. On 6/22/22 at 3:13 PM, V7 RN (Registered Nurse)/Psychiatric Nurse explained that when R30 returned from the hospital on 4/28/22, R30 was not on any [CONDITION(S)] medications but then hospice recommended R30 be started on the above medications. V7 stated there should have been a justification assessment completed at that time but V7 doesn't see that one was completed, (after checking the computer). V7 also confirmed R30's [CONDITION(S)] care plan does not include any non-pharmacological interventions. 3. R27's Order Summary Report dated June 22, 2022, documents an order for [MEDICATION(S)] { Benzodiazepine} 0.5 mg - one tablet every three hours PRN for anxiety and shortness of breath until 7/14/22 due to resident being on Hospice. R27's Progress Notes dated 4/25/22 by V5 RN (Registered Nurse) documents R27 has been discharged from hospice due to no longer being terminally ill, and R27's condition is stable. On 6/22/22 at 3:13 PM, V7 RN/Psychiatric Nurse stated when a resident comes off of hospice, they should be re-evaluated for the use of the PRN [CONDITION(S)] medication, to ensure they still need them and to adjust the length of time medications are ordered for. R27's medical record does not contain a [CONDITION(S)] medication assessment since being discharged from hospice services. The facility [CONDITION(S)] Medication Use Policy dated May 13, 2022, documents the following: Physicians and mid-level providers will use [CONDITION(S)] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. [CONDITION(S)] medication refers to drugs which are used for anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic purposes. It is the policy of this facility to keep each resident's medication regime free from unnecessary drugs, yet we support the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. [CONDITION(S)] medications will not be administered for the purpose of discipline, staff convenience and will only be used when it is necessary to treat a specific condition. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. The resident's need for the [CONDITION(S)] medication will be monitored by the [CONDITION(S)] Drug Monitoring Team. The monitoring will include: * Identification and daily monitoring of the resident's behaviors that the [CONDITION(S)] drug could conceivably address (i.e., target behaviors). * Assessment of potential causes of the behaviors that , if addressed, could eliminate the behaviors without the use of [CONDITION(S)] drugs.* Discussion of non-medical behavior management strategies that could be implemented in an attempt to reduce/eliminate the behaviors prior to the initiation of drug treatment as well as on an ongoing basis. This policy also documents, Policy Interpretation and Implementations number 8. Orders for PRN (as needed) [CONDITION(S)] medications will be time limited (i.e., times two weeks) and only for specific clearly documented circumstances.

Based on observation, interview and record review, the facility failed to administer medications according to Manufacturers Recommendations and facility policy for one (R35) of six residents reviewed for medication administration in the sample list of 25. The facility had 2 errors out of 33 opportunities for a medication error rate of 6.06%. Findings Include: R35's June 2022 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] {Long Acting Insulin} 10 units SQ (Subcutaneously) every morning and [MEDICATION(S)] {Rapid Acting Insulin} 100 units /ml per sliding scale coverage SQ before meals and at bedtime{based on blood glucose level}: 151-175 = 1 unit, 176-200 = 2 units, 201-225 = 3 units, 226-250=5 units, 251-275=7 units, 276-300 = 9 units, 301-325 = 12 units, 326-350=15 units, and if greater than 351, call physician On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) stated V7 had already checked R35's blood glucose level, which was 162, therefore R35 would be receiving one unit of [MEDICATION(S)]. V7 pulled an unlabeled [MEDICATION(S)] [MEDICATION(S)] from the medication cart and prepared the ordered [MEDICATION(S)]. At this time, V7 stated V7 knew it was R35's as it was in the bag with R35's name on it. V7 pulled a bag from the medication cart that contained needles for the [MEDICATION(S)] and an unlabeled [MEDICATION(S)] pen. The bag had a worn pharmacy label on it which included R35's name, which was barely legible and no other information, due to it being worn. V7 then pulled up 10 units of [MEDICATION(S)] from the unlabeled [MEDICATION(S)] Pen that was in the bag. At 8:44 am, after the medication was prepared, V7 administered the medications to R35. R35 had R35's breakfast plate on the table in front of R35, which was empty. R35 stated R35 had already finished breakfast as it was served around 7:45 am {an hour prior}. R35 stated this is not unusual, they always give me (R35) insulin after eating. The Manufacturers Recommendations for [MEDICATION(S)] dated March 2008 documents [MEDICATION(S)] should be given immediately (within 5-10 minutes) prior to the start of a meal. The facility's undated Administering Medications Policy documents medications must be administered in accordance with the orders, including any required time frame. This policy also documents the individual administering the medications must verify the right medication, right dosage, right time and right method before giving the medications. The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date.

Based on record review, observation, and interview, the facility failed to keep a resident's oxygen tubing off the floor and failed to label portable oxygen tubing according to facility policy. This failure affects two of three residents (R14 and R16) reviewed for respiratory care on the sample list of 25. Findings include: 1.) On 06/21/22 at 11:22 AM R14 was seated in a wheelchair at the side foot area of R14's bed. R14 had an oxygen bedside concentrator that was plugged into the wall outlet at the head of the bed. R14 had a portable oxygen tank on the back of R14's wheelchair. The bedside oxygen concentrator tubing was stretch out on the floor three feet from the concentrator to reach R14's wheelchair. The oxygen concentrator tubing had several feet of oxygen tubing coiled on the floor at the side of R14s wheelchair. R14 stated R14 just changed over to the portable oxygen in preparation to leave R14's room. R14 stated The oxygen tubing dangles from the concentrator and onto the floor sometimes. R14's portable oxygen with the nasal cannula tubing was not dated to indicate when it was last changed. R14 stated R14 is not sure when the portable concentrator tubing was last changed. R14's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 13 out of 15, indicating no cognitive impairment R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Increase oxygen) to 3L (three liter per minute) with activity. 2.) R16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS documents: May use O2 (oxygen)per NC (nasal cannula) at 2.5L (2.5 liters per minute) when at rest and up to 4L (four liters) with walking to keep SpO2 (oxygen saturation) greater than 90%. Active 12/14/2021. On 06/21/22 12:15 pm - 12:40 pm R16 was feeding herself in dining room. R16's portable oxygen tank was attached to the back of R16's wheelchair and was in the on position, administering 2.5 liters per minute via nasal cannula. The oxygen tubing that attached the nasal cannula to the portable oxygen tank had several feet of excess oxygen tubing that dropped to the floor. The oxygen tubing on floor was directly behind R16's wheelchair tire and was partially coiled. On 6/21/22 at 12:40 pm R16 's oxygen tubing continued to lay on the floor. Several unidentified staff members passed by R16. V5, Registered Nurse acknowledged R16's oxygen tubing was on the floor. V5, Registered Nurse stated All oxygen tubing and humidifier bottle are dated when they are changed weekly. The oxygen tubing is never supposed to be on the floor. It can be a trip hazard as well as an infection control issue. On 6/23/22 at 3:15 pm V2, Director of Nursing (DON) stated residents' oxygen tubing should never be on the floor. The facility policy Oxygen Procedures dated January 12, 2018, documents the following: 5. Date the humidifier bottle and tubing. 6. Ensure there is a storage bag attached to the concentrator for storage of unused nasal cannula and excess tubing. 7. Change tubing and nasal cannula /mask every two weeks ,or as needed. 8. Change the humidifier bottle every two weeks, or as needed. 9. Place nasal cannula/mask and excess tubing in the storage bag attached to the concentrator when not in use. Tubing should not rest on the floor.

Based on interview and record review the facility failed to develop a comprehensive care plan for anticoagulant therapy for one of 13 residents (R19) reviewed for care plans in the sample list of 25. Findings include: The facility's Care Plan - Comprehensive policy dated 3/28/19 documents, Policy Statement(:) An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion so the resident's comprehensive assessment (MDS). 8. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. R19's Order Summary dated 6/21/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's Order Summary documents orders to obtain PT/INR (Prothrombin Time/International Normalized Ratio) on 7/7/22, one time only. This Order Summary documents orders for [MEDICATION(S)] (anticoagulant) 2 mg (milligrams) by mouth, every evening on Monday, Tuesday, Wednesday, Thursday and Friday. This Order Summary also documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's Minimum Data Set (MDS) dated [DATE] documents resident is moderately cognitively impaired and this MDS documents that R19 receives an anticoagulant seven days a week. R19's Care Plan provided on 6/22/22 by V3 Director of Nursing does not document anticoagulant therapy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22 at 9:05 AM, V9 Clinical Care Coordinator/Care Plan Coordinator confirmed that R19's anticoagulant therapy is not on R19's Care Plan. V9 stated that it should be on there because R19 has a history of having an Embolism.

Based on observation, interview and record review, the facility failed to ensure dignity was maintained by administering an injection in the dining room for one of six residents (R35) reviewed for medication administration on the sample list of 25. Findings Include: On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's ordered insulin injections and entered the dining room to administer it. R35 was sitting at the dining room table with R44 when V7 stated V7 needed to administer R35's insulin. R35 lifted R35's shirt to make R35's abdomen accessible to V7, and V7 administered the two insulin injections. On 6/22/22 at 8:44 am, R35 stated, staff normally don't give R35 insulin in the dining room but instead make R35 go to R35's room to get it. On 6/22/22 at 1:38 pm, V1 Administrator stated the facility does not have a policy for dignity. On 6/23/22 at 8:30 am, V10 RN (Registered Nurse)/Director of Senior Services stated we {facility} prefer staff not give injections in the dining room but there are some residents who request it though due to not wanting to go back to their room. V10 stated those wishes should be care planned. R35's Care Plan dated 5/18/21 does not document that R35 wishes to have R35's insulin administered in the dining room.

Based on observation, interview and record review, the facility failed to ensure medications are labeled appropriately for one of six residents (R35) reviewed for medication labeling in the sample list of 25. Findings Include: The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date. On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's morning medications which included insulin's: [MEDICATION(S)] {Rapid Acting Insulin} and [MEDICATION(S)] {Fast Acting Insulin}. V7 pulled the unlabeled [MEDICATION(S)] and [MEDICATION(S)] from a bag in the medication cart that had a worn pharmacy label on it. The label had R35's name on it, which was barely legible due to being worn and no other information. V7 stated, V7 knew that the [MEDICATION(S)] and [MEDICATION(S)] belonged to R35 due to being in the bag that was labeled for R35.

Based on observation, interview, and record review, the facility failed to implement infection control procedures in accordance with State Health Department guidance and CDC (Centers for Disease Control and Prevention), and update and follow facility policy to prevent the spread of a highly contagious disease to residents and staff. The facility failed to ensure staff wore proper Personal Protective Equipment during an Outbreak of COVID-19 and failed to prohibit an employee who had close contact exposure to COVID-19 from working with residents. These failures affect 13 (R2, R3, R9, R10, R14, R15, R16, R17, R18, R19, R20 R21, R22) of 22 residents sampled for infection control. Subsequently R2, R3, R9, and R14 tested positive for COVID-19 after being unnecessarily exposed to COVID-19 in the facility resulting in the likelihood of serious complications, hospitalization , and/or death. These failures resulted in an immediate jeopardy. While the immediate jeopardy was removed on 8/30/21, the facility remains out of compliance at a severity level 2. Findings include: 1. R10's Nursing Notes document: On 8/9/21 at 1:51 PM R10 tested positive for COVID-19. R10 had a congested non-productive cough noted on 8/9/21 and 8/11/21. R10 had a temperature of 102.4 degrees Fahrenheit on 8/13/21. The facility's Line Listing- LTC (Long Term Care COVID-19 Testing documents R10's rapid COVID-19 test was positive on 8/9/21. The facility's 8/12/21 Certified Nursing Assistant (CNA) schedules document: On 8/12/21 and 8/13/21 document V23 Certified Nursing Assistant was assigned to R10's hall. On 8/14/21 V23 worked day shift on R9's hall. The facility's undated COVID-19 Log documents: On 8/14/21 V23 had symptoms of runny nose, low grade fever, stuffy nose, slight headache and low energy. On 8/15/21 V23 tested positive for COVID-19. V23 was in close contact with the Country Court hall. R9 (COVID-19 Negative) was identified to be a close contact when V23 pulled down V23's N95 mask so R9 could hear V23 talk. V23 believed V23's source of COVID-19 was when V23 pulled V23's N95 back when talking to R10 (COVID-19 positive resident.) On 8/19/21 R9 developed fever and cold symptoms and tested positive for COVID-19. R9's source of COVID-19 was when V23 removed V23's N95 mask so R9 could hear V23. R9's Census dated 8/27/21 documents R9 has resided on Country Court since May 13, 2019. R9's Admission Record dated 8/27/21 documents R9 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A rapid test was conducted and R9 tested positive for COVID-19. On 8/26/21 at 11:02 AM V23 stated: V23 developed symptoms of COVID-19 on 8/14/21 and tested positive for COVID-19. V23 had been assigned to care for COVID-19 positive residents including R10 during the week prior to V23 testing positive. V23 was in R10's room and R10 had difficulty hearing V23. V23 pulled down V23's N95 mask, exposing V23's nose and mouth, to talk to R10. V23 was within 6 feet from R10 and R10 was not wearing a face covering. I know now I shouldn't have taken my mask off. On an unidentified date V23 was within 6 feet of R9. V23 pulled down V23's N95 mask to talk to R9, who was not wearing a face covering. On 8/26/21 at 11:53 AM V2 Director of Nursing (DON) stated: On 8/12/21 V23 cared for R10 who was COVID-19 positive. V23 pulled down V23's N95 mask while providing care for R10. On 8/14/21 V23 pulled down V23's N95 mask to talk to R9. V23 tested positive for COVID-19 on 8/14/21, and R9 tested positive on 8/19/21. Staff are not to remove their masks during resident care. 2. The facility's undated COVID-19 Log documents: On 8/22/21 V28 CNA had symptoms of cough, stuffy nose, body aches, and headache. V28 tested positive for COVID-19 on 8/23/21. V27 had lunch with V28 and V28 was identified to be a close contact to V27. On 8/24/21 V27 had symptoms of headache, cough, scratchy throat, sniffles, body aches, and fever. V27 tested positive for COVID-19 on 8/24/21. V27 rode with V28 to work on 8/21/21 and 8/22/21. V27 can't wear an N95 mask, face shield and mask are on all the time. R2 and R3 tested positive on 8/25/21. R2's source of COVID-19 was V27, and R3's source of COVID-19 was V28 and V27. V28's COVID-19 Screening dated 8/23/21 at 5:17 AM documents V27 answered no to all of the questions. The facility's schedule document on 8/23/21 V27 worked day shift on Daffodil Drive. The facility's Daily Census dated 8/23/21 document the residents R2, R3, and R14-R22 resided on Daffodil Drive. R2's Admission Record dated 8/27/21 documents R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Nursing Notes document on 8/24/2021 at 9:44 PM R2 had a fever of 100.2 degrees Fahrenheit and refused supper. 8/25/2021 6:19 PM R2 tested positive for COVID-19. R3's Admission Record dated 8/27/21 documents R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Nursing Notes document on 8/23/2021 at 7:30 PM R3 complained of a runny nose and sore throat. On 8/24/2021 at 3:02 PM R3 had a dry cough, felt tired, and had a temperature of 101.5 degrees Fahrenheit. On 8/25/2021 at 6:06 PM R3 tested positive for COVID-19. R14's Nursing Notes document: On 8/26/21 at 5:00 PM R14 was placed on isolation for fever and vomiting. At 9:12 PM R14's oxygen saturation dropped to 81% (normal range is greater than 95%.) On 8/27/21 at 1:15 PM R14 tested positive for COVID-19. On 8/26/21 at 10:04 AM V28 stated: V28's symptoms of headache and nausea started on the evening of 8/22/21 after V28 arrived home from work. On the morning of 8/23/21 V28 came to the facility to be tested and tested positive for COVID-19. On 8/26/21 at 10:47 AM V27 stated: V27 tested positive for COVID-19 on 8/24/21 after V27 developed symptoms that morning of headache, scratchy throat, occasional cough, and feeling tired. On 8/23/21 V27 provided care for COVID-19 negative residents on Daffodil Drive. V27 wore a surgical mask and face shield in the building and in rooms of COVID-19 negative residents. On 8/21/21 and 8/22/21 V27 and V28 rode together to work, in the same car, and neither V27 nor V28 wore a face mask. V27 and V28 had lunch together on 8/22/21 at the same table, within 6 feet of each other, and were not wearing a face covering. V27 was present when V28 tested positive for COVID-19 on the morning of 8/23/21. V1 Administrator and V2 Director of Nursing (DON) were not notified that V27 had close contact exposure to V28 until 8/24/21 (after V27 worked in the facility on 8/23/21.) On 8/26/21 at 11:53 AM V2 DON stated: V28 tested positive for COVID-19 on the morning of 8/23/21. Neither V1 or V2 were aware that V27 and V28 had rode to work together on 8/21/21 and 8/22/21, until after V27 tested positive for COVID-19 on 8/24/21. V1 Administrator stated V1 knew that V27 and V28 had lunch together on 8/22/21, but V1 was not aware that V27 and V28 were within 6 feet of each other. Staff are instructed to be 6 feet apart for eating and during breaks, and the tables are spaced out in the dining area to accommodate this. V1 would not have allowed V27 to work on 8/23/21 if V1 was aware of V27's exposure to V28. V27 would have been instructed to quarantine. V1 confirmed R2 and R3 tested positive after V27 worked on their hallway on 8/23/21. On 8/26/21 at 2:30 PM V2 stated: V27 answered no to all of the screening questions on 8/23/21. The system would have flagged if V27 answered yes to COVID-19 exposure and sent an alert to V1 and V2. If V27 found out about V27's exposure to V28 after V27 completed the screening, then V27 should have reported V27's exposure to V1 or V2. On 8/26/21 at 10:12 AM V32 Local Health Department DON stated: The Local Health Department (LHD) has sent updated COVID-19 guidance from IDPH to the facility regularly. The LHD refers to IDPH COVID-19 guidance for long term care facilities. Best practice is to wear an N95 face mask and eye protection during a COVID-19 outbreak. If an employee is considered to have had close contact exposure to someone who tested positive for COVID-19, they should be placed on quarantine for 14 days, and not allowed to work. If staff are not wearing appropriate PPE, and they are asymptomatic, this can lead to the spread of the virus. V32 confirmed V23 pulling down V23's N95 mask while within 6 feet of a COVID-19 positive resident would put V23 at increased risk of exposure and contracting COVID-19. V32 confirmed V23 pulling down V23's N95 mask while within 6 feet of a COVID-19 negative resident, would put that resident at increased risk for contracting COVID-19. 3. On 8/26/21 at 8:05 am, V1 Administrator and V2 DON (Director of Nursing) were wearing a surgical face mask without eye protection. V1 and V2 both walked from the front reception area through the resident lounge/sitting area and through the 300 hall where residents reside, to the conference room. V1 and V2 both stated the facility has been in COVID-19 (a highly infectious disease) outbreak since 7/31/21, and that the facility has had eight residents who have tested positive for COVID-19, along with 10 staff members. On 8/26/21 at 8:40 am, V3 Administrative Assistant was in the 200 resident hall wearing a surgical face mask and face shield with V4 Volunteer/RN (Registered Nurse), who was wearing an N95 mask and eye protection. V3 was assisting V4 with COVID testing of residents; marking the COVID test with the time and applying the activation drops to the test. V3 stated V3 does not have an N95 and has not been fit tested for one due to not having direct contact with the residents. On 8/26/21 at 8:45 am, V5 Activity Assistant was walking down the 200 resident hall wearing a surgical mask only, no eye protection. V6 Student was with V5 and wearing a cloth face mask. V5 stated V5 has been fit tested for an N95 face mask but isn't wearing it due to not having close contact with residents with just walking down the hall. On 8/26/21 at 9:05 am, V7 Care Team Supervisor was refilling PPE (Personal Protective Equipment) in the 300-resident hall. V7 was wearing a surgical face mask only, no eye protection. V7 stated if staff go into a resident room, they have to wear an N95 face mask and eye protection but if they are just in the hall, all they are required to wear is a surgical face mask. On 8/26/21 at 9:15 am, V8 Activity Director was sitting in V8's office without any mask. Upon surveyor knocking on the door, V8 applied a surgical face mask. V8 stated it is okay to wear a surgical mask if staff are in their office or in the hallway, as long as residents aren't around, but if residents are around, you have to wear an N95 and eye protection. On 8/26/21 at 9:22 am, V10 CNA (Certified Nursing Assistant) was wearing a surgical mask and eye protection, with a N95 mask hanging around V10's neck. V10 stated staff only needed to wear the N95 when they were within six feet of a resident. On 8/26/21 at 9:30 am, V11 Therapy Program Assistant/CNA was standing in the resident lounge/sitting area, where all resident units/halls gather, wearing a surgical face mask and no eye protection. V11 stated staff only need to wear an N95 mask and eye protection if within six feet of a resident for more than 15 minutes. On 8/26/21 at 11:53 AM, V1 stated the facility policy is that surgical masks are to be worn on the resident hallways, and no eye protection is needed. N95 and eye protection are required only in resident rooms when providing care for residents including those who aren't on isolation. This facility policy is not consistent with IDPH (Illinois Department of Public Health) COVID-19 Updated Interim Guidance for Nursing Homes and Other Long-Term effective August 14, 2021. The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes revised March 29, 2021, documents Establish a process to ensure HCP (Healthcare Personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) entering the facility are assessed for symptoms of COVID-19 or close contact outside the facility to others with [CONDITION(S)]-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, HCP report absence of fever and symptoms of COVID-19, absence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This guidance documents residents with suspected or confirmed COVID-19 infection should be cared for by HCP using an N95 or higher-level respirator, eye protection, gown, and gloves. The CDC's Interim United States Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to [CONDITION(S)]-CoV-2 revised March 11, 2021 documents HCP who had prolonged (cumulative total of 15 minutes or more within 24 hours) close contact with a COVID-19 positive individual and did not wear eye protection or a facemask must be excluded from work for 14 days after the last exposure. The IDPH COVID-19 Updated Interim Guidance for Nursing Homes and Other Long-Term effective August 14, 2021 documents During an outbreak (one case is considered an outbreak): Staff must wear an N95 respirator and eye protection on all units until there are no new positive cases for 14 days. The facility's Infection Prevention and Control Policy Suspected or Confirmed Coronavirus (COVID-19) dated August 10, 2021 documents the following: COVID-19 is a respiratory illness (caused by the coronavirus) that is primarily transmitted from person to person via droplets generated by coughing and sneezing. Elderly individuals are at an increased risk of becoming infected due to compromised immunity and comorbidities. The facility will screen all persons entering any of the buildings on our campus for signs and symptoms of COVID-19. A universal screening kiosk is set up at the entrance to the main building of (the facility). The screening process will ask the following questions and a temperature will be recorded. All screening records will be maintained for a minimum of 30 days. 1. Have you been diagnosed with COVID-19? If yes, has it been less than 10 days since your symptoms started or your testing date, do symptoms continue, and/or have you had a fever or 100 in the past 24 hours? 2. Have you been in close contact (within 6 feet for 15 minutes or longer) with anyone experiencing COVID-19 symptoms or testing positive for COVID-19 within the past 14 days? 3. Are you experiencing any of the following symptoms: new or worsening cough, new or unexplained shortness of breath, unusual fatigue, unexplained muscle or body aches, new or unusual headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting or diarrhea. All team members, service providers (employed and contractual), volunteers and essential caregivers will report to the main entrance of (facility). Team members will sign-in to the kiosk system answering the appropriate questions. In the event that a team member does not pass the screening process, an alert will be sent to the Administrator and Director of Nursing for investigation. If a team member presents with symptoms but has a logical explanation for the symptoms, a nurse will conduct a rapid, POC test to confirm they are negative for COVID. Any team member who does not pass the screening process must obtain approval from the Administrator or Director of Nursing for admittance to the building. All team members will wear all recommended PPE (N95, eye protection, gloves, and gown) for care of all residents infected with COVID-19 or facility wide depending on the situation or as directed by the local health department. (The facility) will enter outbreak status when ONE facility acquired or facility associated positive COVID-19 case is identified. The outbreak status will continue until there have been no new positive cases for 14 days. During an outbreak: Team members will be required to wear an N95 respirator and eye protection on all units for any resident contact during the duration of the outbreak. Eye protection will be required whenever a team member is near a resident or enters a resident's room. This policy is not updated to include the IDPH (Illinois Department of Public Health) current COVID-19 Guidelines. An immediate Jeopardy situation was identified on 8/27/21. The immediate Jeopardy was identified to have begun on 8/12/21, when V23 CNA exposed V23's self to R10, a COVID-19 positive resident, by pulling down V23's face mask. On 8/27/21 at 4:15 PM V1 Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 8/27/21 V1 Administrator updated the facility's infection control policies/procedures to include during an outbreak of COVID-19, team members will be required to wear an N95 respirator and eye protection on all units of the facility for the duration of the outbreak. 2. On 8/27/21 V37 Director of Building Operations placed bins of N95 and face shields in the alcove of Daffodil Drive and at the front desk, and the PPE supply for each hallway was replenished. 3. On 8/28/21 at 11:46 AM V1 Administrator sent out an electronic mail to the nurses and receptionists instructing them to verbally ask staff upon screening about potential exposure to COVID-19 positive individuals. 4. On 8/29/21 all staff had received training by V2 on the facility's revised COVID-19 infection control policies and procedures and were re-educated on immediately reporting potential exposure to COVID-19. 5. Required PPE (Personal Protective Equipment) Audits started on 8/28/21. The audit for 8/28/21 completed by V1 Administrator documents all staff were wearing appropriate PPE correctly. The audit for 8/29/21 completed by V34 RN (Registered Nurse) documents proper PPE was not being worn by V35 Dietary (didn't have N95 or face shield on) and V36 (had eye protection on forehead). Both V35 and V36 were educated at the time by V34 RN. 6. On 8/30/21 at 10:12 am, V2 DON, stated the audits on 8/29/21 were both kitchen staff that were not following policy. V35 just had COVID so V35 didn't think it applied to V35, and V36 had her mask on but had her eye protection on her forehead. V2 stated ongoing audits are going to be completed by V24 Infection Preventionist, V1 Administrator, V2 and/or floor nurses. 7. A Quality Assurance meeting was held on 8/28/21 with V1, V2, V24 Infection Preventionist, and V38 Medical Director to discuss the facility's abatement plan and the audit for PPE monitoring.

Based on interview and record review the facility's Quality Assurance committee failed to meet on a quarterly basis and failed to ensure the medical director was in attendance for three of the four Quality Assurance meetings. This facility failure had the potential to affect all 47 residents residing in the facility. Findings include: The facility's Census and Condition report dated 5/24/21 provided by V1 Administrator documents there are 47 residents residing in the facility. The facility's Quality Assurance Meeting sign in sheet dated 8/13/20 documents that the 8/13/20 meeting was canceled. The facility's Quality Assurance Meeting sign in sheet for 11/19/2020 does not document that V17 Medical Director attended the 11/19/20 meeting. The facility's Quality Assurance Meeting sign in sheet for 2/11/21 does not document that V17 attended the 2/11/21 meeting. The facility's Quality Assurance Meeting sign in sheet for 5/13/21 does not document that V17 Medical Director attended the 5/13/21 meeting. On 5/25/21 at 11:38 AM, V2 Director of Nursing stated the facility's Quality Assurance meetings were scheduled on 8/13/20, 11/19/20, 2/11/21, and 5/13/21. V2 stated the facility canceled the 8/13/21 meeting and did not reschedule it. V2 stated V17 did not attend two of the three remaining meetings. V2 stated V17 came to the 2/11/21 meeting. V2 stated the facility is supposed to meet quarterly and V17 is a required member.

Based on observation, interview, and record review the facility failed to post isolation signage and failed to wear an N95 respirator during an aerosol generating procedure. This failure has the potential to affect 20 residents (R200, R40, R22, R43, R13, R30, R5, R36, R1, R31, R34, R197, R39, R198, R199, R42, R16, R26, R24, R11) in the sample list of 35. Findings include: The facility's Infection Prevention and Control Policy Suspected or Confirmed Coronavirus (COVID-19) dated 4/1/21 documents For minimal to no community transmission (based upon the CMS (Centers for Medicare/Medicaid Services) COVID-19 published positivity rate for (County), staff members should continue to adhere to Standard Precautions (including facemask for source control) if COVID-19 is not suspected in a resident. When aerosol-generating procedures are performed an N95 mask will be worn. This policy documents Residents who have not tested positive for COVID-19 in the past 90 days or who are not fully vaccinated will be admitted /readmitted to (the facility) under a 14-day quarantine period with full transmission based precautions (treat as isolation) to monitor for signs and symptoms of a COVID-19 infection. This policy does not document what Personal Protective Equipment (PPE) is to be worn for the care of a newly admitted resident on quarantine. The facility's Isolation - Notices of Transmission-Based Precautions policy dated 5/3/2013 documents Appropriate isolation notices will be used to alert staff of the implementation of Transmission-Based Precautions, while protecting the privacy of the resident. 1. When Transmission-Based Precautions are implemented, an appropriate sign (example: color coded) will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of Transmission-Based Precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy. 1.) R199's Face Sheet dated 5/26/21 documents R199 admitted to the facility on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R199's Care Plan dated 5/25/21 documents R199 is at risk for COVID-19, has not received the COVID-19 vaccine, and R199 is on isolation until 6/1/21. R199's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R199's May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R199's Nursing Notes document the following: On 5/25/21 at 1:44 PM R199 had a productive cough with yellow sputum. On 05/24/21 at 10:45 AM, 12:13 PM, and 3:50 PM there was a plastic container on R199's door that contained PPE including surgical masks and gloves. Next to R199's doorway was an overbed table with gowns. There was no isolation signage posted on R199's door. On 5/24/21 at 4:07 PM V7 Licensed Practical Nurse (LPN) states R199 is on isolation due to not being vaccinated. On 5/24/21 at 4:57 PM V7 entered R199's room wearing a surgical mask, gown, and gloves. V7 applied [MEDICATION(S)]-[MEDICATION(S)] Solution into the nebulizer chamber and handed R199 the handheld nebulizer. V7 sat in the chair directly in front of R199 while R199 self-administered the nebulizer. R199 completed the nebulizer treatment at 5:06 PM. On 5/26/21 at 10:05 AM V2 Director of Nursing provided a list of residents (R40, R22, R43, R13, R30, R5, R36, R1, R31, R34, R197, R39, R198, R199, R42, R16, R26, R24, and R11) that V7 would have provided care for on 5/24/21. On 5/26/21 at 12:00 PM V2 stated V2 would expect the staff to follow the facility's policy when administering nebulizer treatments to residents who are on quarantine. 2.) R198's Face Sheet dated 5/26/21 documents R198 admitted to the facility on [DATE]. R198's Care Plan dated 5/25/21 documents R198 is on isolation until 5/27/21 when R198 is fully vaccinated for COVID-19. On 05/24/21 at 10:30 AM and 3:50 PM there was a plastic container on R198's door that contained PPE including surgical masks and gloves. Next to R198's doorway was an overbed table with gowns. There was no isolation signage posted on R198's door. On 5/24/21 at 4:49 PM V7 LPN confirmed there was no isolation signage posted on R198's and R199's doors. V7 stated R198 and R199 should have isolation signs posted on the doors. 3.) R200's Face Sheet dated 5/26/21 documents R200 admitted to the facility on [DATE]. R200's Care Plan dated 5/25/21 documents R200 has not received the COVID-19 vaccine, and R200 is on isolation until 6/4/21. On 5/24/21 at 4:30 PM there was a plastic container on R200's room that contained PPE including surgical masks, gowns, and gloves. There was no isolation signage posted on R200's door. On 5/24/21 at 4:52 PM V8 LPN confirmed there was no isolation signage posted on R200's door. V8 stated R200 is on quarantine for 14 days. On 05/26/21 at 9:21 AM V2 Director of Nursing stated residents who are on quarantine or isolation should have isolation signs posted on the door or doorway to the resident's room.

Based on observation, interview, and record review the facility failed to obtain weekly measurements for a pressure ulcer for one of two residents (R42) reviewed for pressure ulcers in the sample list of 35 residents. Findings include: R42's Minimum Data Set, dated dated dated [DATE] documents R42 has moderate impaired cognition, requires extensive assistance of one staff person for bed mobility and transfers, and has a facility acquired stage II pressure ulcer. R42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's April and May 2021 Treatment Administration Records document a [MEDICATION(S)] dressing was applied every 7 days from 4/15/21 through 5/13/21, and barrier cream was administered three times daily beginning on 5/13/21. R42's Nursing Notes document the following: On 4/8/21 an open area to R42's coccyx was identified and measured 3 cm (centimeters) by 1 cm. Orders were obtained for a [MEDICATION(S)] dressing. R42 transferred to the local hospital on 4/23/21 and returned to the facility on [DATE]. There are no documented measurements of R42's pressure ulcer after 4/8/21 until 5/6/21. R42's pressure ulcer measured 0.7 cm by 0.2 cm on 5/6/21, and 0.4 cm by 0.1 cm on 5/20/21. On 05/25/21 at 1:13 PM V18 Certified Nursing Assistant entered R42's room. R42 was lying on an alternating pressure mattress. V18 pulled down R42's incontinence brief. There was a small, pink, open wound to R42's coccyx. On 5/25/21 9:56 AM V2 Director of Nursing stated the floor nurses are responsible for obtaining weekly measurements of R42's wound. V2 stated skin assessments and wound measurements should be completed when residents readmit to the facility, and wound measurements should be recorded in the progress notes. V2 confirmed R42's medical record does not contain wound measurements after 4/8/21 until 5/6/21. The facility's Pressure Ulcer Treatment policy revised on 5/3/13 documents to record wound assessment dated including color, size, pain, and drainage in the resident's medical record. This policy documents if a stage II pressure ulcer does not improve in 2 to 3 weeks, notify the physician, and consider a skin consult with a wound specialist.

Based on observation, interview, and record review the facility failed to obtain a physician's order for oxygen and assess a resident before and after administering a nebulizer treatment for two of four residents (R3, R42) reviewed for respiratory care in the sample list of 35. Findings include: 1.) On 5/24/21 at 10:03 AM R42 was lying in bed with Oxygen administered per nasal cannula at 2 Liters per minute (L/min). On 5/25/21 at 9:02 AM R42 was lying in bed with Oxygen administered per nasal cannula at 2 L/min. R42's Physician's Orders dated 5/25/21 do not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Physician's Standing Orders dated 3/25/21 document Oxygen per nasal cannula at 2-3L/min for pulmonary conditions; 4-5L/min for cardiac or brain condition (Per mask at 4-6 L/min. Start STAT (immediately). Note lung sounds, presence/absence of cough, SPO2 (oxygen saturation), vitals and report to the physician. R42's Nursing Notes document the following: On 4/23/21 at 7:02 PM R42 had shortness of breath, wheezing, and Spo2 86% (percent). Oxygen was administered per standing order at 3 L/min per nasal cannula. R42 was transferred to the hospital and admitted with exacerbation of [CONDITION(S)] and Pneumonia. On 5/15/21 at 10:23 AM R42 became short of breath while working in therapy and R42's SPO2 was 90-91% on room air. On 5/15/21 at 2:45 AM R42 was short of breath, R42's SPO2 was 70 %, Oxygen was administered at 2 L/min, and R42's SPO2 increased to 94%. On 5/15/21 at 4:03 AM R42's SPO2 was 86% on Oxygen at 2 L/min, Oxygen was increased to 2.5 L/min, and R42's SPO2 increased to 94%. On 5/15/21 at 10:03 R42's SPO2 was 90% on Oxygen at 2 L/min. On 5/21/21 at 7:02 AM R42's SPO2 was 79%, Oxygen was applied and titrated to 4 L/min, and R42's SPO2 increased to 93%. On 5/23/21 at 2:37 PM R42's SPO2 was 87 % and Oxygen 2 L/min was applied. On 5/25/21 at 8:53 V9 Licensed Practical Nurse (LPN) stated: There should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R42 uses oxygen as needed. On 05/25/21 at 11:00 AM V2 Director of Nursing stated when oxygen is administered from a standing order, the order should be implemented as a physician's order and transcribed to the MAR. 2.) R3's Physician's Orders dated 5/25/21 documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] {Hydrochloride}) 1.25 milligrams (mg)/3 milliliters (ml)1 vial inhaled by nebulizer three times daily for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/24/21 at 4:33 PM V8 LPN entered R3's room to administer [MEDICATION(S)] 1.25 mg/3 ml vial nebulizer. V8 applied the [MEDICATION(S)] into the nebulizer chamber, placed the nebulizer mask on R3, and turned on the nebulizer. V8 did not assess R3's lung sounds, pulse, or SPO2 prior to administering the nebulizer. V8 left R3's room and returned at 4:47 PM to remove R3's nebulizer mask. V8 rinsed R3's nebulizer mask and chamber with water and placed on a clean towel to air dry. V8 did not assess R3's lung sounds, pulse, or SPO2 after administering the nebulizer treatment. On 05/25/21 at 11:00 AM V2 stated the resident should be assessed before administering a nebulizer treatment. The facility's undated Administering Medication through a Small Volume (Handheld) Nebulizer documents to obtain a baseline pulse, respiratory rate and lung sounds prior to administering a nebulizer treatment. This policy documents to record in the medical record the resident's lung sounds before and after the treatment.