Every finding on record at Fayette County Hospital

Based on interview, observation, and record review, the facility failed to follow infection control standard of practice for hand hygiene while providing care for 2 (R25 and R28) of 6 residents reviewed for infection control in the sample of 20. Findings include:1. R25's admission Record documented an initial admission date of 04/10/2018 and included diagnoses of chronic kidney disease, type 2 diabetes mellitus, iron deficiency anemia, disorder of kidney and ureter, cardiac murmur, and sepsis. R25's Order Summary Report with a print date of 01/15/2026, documented an order for blood glucose monitoring before meals and at bedtime, with an order date of 02/15/2025.R25's Minimum Data Set (MDS) assessment dated [DATE] documented R25 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R25 is cognitively intact.R25's Care Plan with a date of 11/08/2024, includes a focus area of resident is diabetic. Diet changed to no concentrated sweets. She gets blood sugars checked as ordered by physician. Interventions listed include accu-checks as ordered by physician.On 01/14/2026 at 11:12 AM, V5 (Licensed Practical Nurse/LPN) applied gloves and removed wrapped Sani cloth from blood glucose monitoring machine that was sitting on the medication cart. V5 then removed gloves, sanitized hands and applied a new pair of gloves. V5 then opened the medication cart, removed alcohol pad and lancet, then shut the medication cart. V5 placed a strip into the blood glucose monitoring machine, then knocked on the door and entered R25's room. V5 cleaned R25's left first finger with an alcohol wipe. V5 waited several seconds and placed the lancet on R25's finger and pushed the plunger down. V5 obtained a blood sample from R25's finger, then exited the room and placed the machine on the barrier on the medication cart. V5 opened the medication cart, removed the Sani-cloth cleaning cloth, then cleaned the machine and wrapped it in the cloth. V5 removed her gloves. On 01/16/2025 at 10:41 AM, V5 (LPN) stated she usually puts her gloves on prior to doing the blood glucose check. V5 stated she usually does not wear her gloves while she is gathering all her supplies for the blood glucose check.On 01/15/2026 at 1:13 PM, V2 (Director of Nursing/DON) stated nurses should not put their gloves on and gather supplies to complete blood glucose testing. V2 stated it is her expectation that the nurse would gather the supplies needed, sanitize their hands, place their gloves on, then proceed with obtaining a blood glucose sample. The facility policy titled ACCU-CHEK Inform II Blood Glucose Monitoring System with a date of 12/29/2025 documented under section titled Procedure: D. Turn the meter on. Select Patient Test, enter the operator ID number. Verify test strip lot numbers by scanning the barcode on the side of the test strip bottle. E. Insert strip into meter as directed on the meter's screen. F. [NAME] gloves, thoroughly clean patient's finger with an alcohol wipe, and allow the finger to dry completely.2. R28's admission Record documented an admission date of 08/01/2025 and included diagnoses of chronic obstructive pulmonary disease, heart failure, essential hypertension, chronic kidney disease, and retention of urine.R28's Order Summary Report with a print date of 01/15/2025, documented an order for catheter care every shift and as needed, with a date of 10/20/2025.R28's Care Plan dated 10/21/2025 includes a focus area of Resident has a new diagnosis of urinary retention. Resident now has an indwelling foley catheter. Corresponding interventions documented to anchor foley tubing to thigh, enhanced barrier precautions, and foley catheter care every shift and as needed.R28's MDS assessment dated [DATE] documented R28 has a BIMS score of 15, indicating R25 is cognitively intact.On 01/14/2026 at 1:48 PM, V4 (Certified Nurse Assistant/CNA) washed her hands and put on Personal Protective Equipment (PPE) of gown and gloves. R28's indwelling catheter bag was observed to be in a privacy bag. V4 closed the door and had supplies set up on a bedside table. V4 placed a basin of water on the bedside table. V4 removed the gloves she previously donned, pulled a new pair of gloves from her scrubs pocket and placed them on her hands. V4 added no rinse soap to the basin and placed clean wash cloths in the basin. V4 removed a washcloth from the basin and cleaned the right side of R28's peri area. V4 then placed the washcloth in the trash bag and removed her gloves. V4 pulled another pair of gloves from her scrubs pocket and placed them on her hands, then took a washcloth from the basin and cleaned the left side of R28's peri area. V4 placed the washcloth in the trash bag and removed her gloves. V4 pulled another pair of gloves out of her scrub pocket and placed them on her hands, took a washcloth out of the basin, and cleaned the front of R28's peri area. V4 placed the washcloth in the trash bag and removed her gloves. V4 took another pair of gloves out of her scrub pocket and placed them on her hands. V4 took another washcloth from the basin and cleaned the catheter from the peri area to the tubing. V4 placed the washcloth in the trash bag and removed her gloves. V4 took another pair of gloves from her scrub pocket and placed them on her hands, took a dry washcloth and dried the left side of R28's peri area, placed the washcloth in the bag and removed her gloves. V4 proceeded to get another pair of gloves from her pocket but was out. V4 walked across the room and placed more gloves in the pocket of her scrubs. V4 then placed a pair of gloves on her hands, took a dry washcloth and dried the right side of R28's peri area. V4 placed the washcloth in the trash bag, removed her gloves and went to reach for gloves in her scrubs pocket and the gloves fell on the floor. V4 walked across the room, took more gloves out of the box and placed them in her scrub pocket. V4 then placed a pair of gloves on her hands and dried the center of R28's peri area. V4 put the washcloth in the trash bag, removed gloves, reached in her pocket to get a pair of gloves and placed them on her hands. V4 took a dry washcloth and dried R28's indwelling catheter tubing, then placed the washcloth in the trash bag. V4 gathered the basin and took it to the bathroom, emptied it and placed the basin on the shelf. V4 removed her gloves and placed them in the trash. V4 again removed a pair of gloves from her scrub pocket and placed them on her hands, gathered the bag of trash, removed her gown and took the bag of trash to the soiled room. On 01/14/2026 at 2:01 PM, V4 (CNA) was questioned about the gloves in her pocked and stated she does not usually put gloves in her pockets. V4 stated she did it today because she was being observed. On 01/15/2026 at 1:13 PM, V2 (DON) stated staff should not have gloves in their pockets while providing care and stated staff should sanitize their hands before placing new gloves on while providing care. On 01/15/2026 at 1:17 PM, V6 (Infection Preventionist) stated it is her expectation for staff to not keep gloves in their pocket. V6 stated staff are educated on proper procedure for changing gloves during peri care. V6 stated staff should have placed gloves on the bedside so they are available during care. V6 stated it was a clean procedure, and scrubs are clean, but it is not a good practice. Facility Policy titled Perineal / Catheter Care with a date of 11/1/2025 documents under Preparation to Wash hands thoroughly before and after care. Under Procedure it documents to apply gloves.remove soiled gloves and put on clean gloves before touching any items at bedside to avoid contamination with soiled gloves.and at the end of peri-care, gloves are to be removed and disposed of and good handwashing is to be done.

Based on interview and record review, the facility failed to provided the services of a Registered Nurse (RN) for 7 days a week for 8 consecutive hours per day. This failure has the potential to effect all 29 residents living at this facility. Findings Included: On 10/22/2024 at 1:50 PM, V2 (Director of Nursing/DON) stated the facility did not have the required 8 hours per day, 7 days a week of RN coverage for the dates of 5/11/24, 5/19/24, 5/27/24, 6/9/24 and 6/30/24. V2 said they did not have a policy for Registered Nurse coverage. On 10/22/2024 at 10:00 AM, V1 (Administrator) stated that nurse's calling off has contributed to a few days of not having Registered Nurse coverage. The facility nursing schedule for May and June of 2024 revealed the facility did not have the required 8 hours of Registered Nurse coverage for the following dates: 5/11/24, 5/19/24, 5/27/24, 6/9/24 and 6/30/24. The Long Term Care Application for Medicare and Medicaid (Form CMS 671) dated 10/21/24 documents that there are 29 residents living in the facility.

Based on interview and record review, the facility failed to document the findings of monthly Medication Regimen Review's (MRR) for 5 (R6, R17, R18, R22, R26) of 5 residents reviewed for unnecessary medications in a sample of 22. Findings include: 1. R6's Admission Record documented an admitted [DATE] with diagnoses that included major depressive disorder, adjustment disorder with mixed anxiety and depressed mood. R6's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating that R6 was cognitively intact. R6's Order Summary sheet documented an active order for twenty-two oral medications. R6's Progress Notes documented that Medication Regimen Reviews (MRR's) were completed for R6 on 3/20/24, 4/22/24 and 5/22/24. A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R6 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024. 2. R17's Admission Record documented an admitted [DATE] with diagnoses that included Alzheimer's, major depressive disorder, delusional disorders, anxiety and insomnia. R17's MDS dated [DATE] documented a BIMS score of 13, indicating R17 was cognitively intact. R17's Order Summary sheet documented an active order for seventeen oral medications. R17's Progress Notes documented that MRR's were completed for R17 on 4/22/24, 5/22/24 and 6/5/24. A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R17 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024. 3. R18's Admission Record documented an admitted [DATE] with diagnoses that included dementia with mild anxiety, major depression disorder, generalized anxiety disorder, and post-traumatic stress disorder. R18's MDS dated [DATE] documented a BIMS score of 7, indicating R18 was severely cognitively impaired. R18's Order Summary sheet documented an active order for seventeen oral medications. R18's Progress Notes documented MRR's were completed for R18 on 3/20/24, 4/22/24, 5/22/24 and 6/5/24. A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R18 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024. 4. R22's Admission Record documented an admitted [DATE] with diagnoses that included Alzheimer's disease with late onset, insomnia, hallucinations, anxiety, restlessness and agitation. R22's MDS dated [DATE] documents a BIMS score of 3, indicating that R22 was severely cognitively impaired. R22's Order Summary sheet documented an active order for eighteen oral medications. R22's Progress Notes documented a MRR was completed for R22 on 5/22/24. A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R22 had a MRR completed on 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024. 5. R26's Admission Record documented an admitted [DATE] with diagnoses that included anxiety disorder, Alzheimer's disease, depression, and insomnia. R26's MDS dated [DATE], documented a BIMS score of 7, indicating R26 was severely cognitively impaired. R26's Order Summary sheet documented an active order for sixteen oral medications. R26's Progress Notes documented MRR's were completed for R26 on 3/20/24, 4/22/24, 5/22/24 and 6/5/24. A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R26 had MRR's completed for 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024. On 10/22/24 at 2:41 PM, V2 (Director of Nursing/DON) stated the missing months of MRR's were because the pharmacist ran out of MRR papers. On 10/23/24 at 2:40 PM, V2 stated there would be a progress note if a MRR had been done. On 10/24/24 at 10:03 AM, V11 (Consultant Pharmacist) stated he did MRR's for the residents every month at the pharmacy but was not in the facility. V11 stated that he had not documented them in the resident's medical record. V11 stated he had just recently discussed with V2 (DON) how they were going to document the MRR's. V11 stated that he used to chart in the resident's medical record before they started using this new program for electronic medical records. V11 stated when they switched, he started using a paper form. V11 stated he ran out of the paper form and was unable to order more because they had been discontinued. A facility document titled (Name of Facility) Monthly Summary September 2024 signed by V11 (Consultant Pharmacist) states that all charts were reviewed and signed on September 25, 2024 and that all charts were in order. The facility was unable to produce any resident specific documentation by V11, to show that the medications were reviewed, or charts were signed in June, July, August and September 2024. The undated Facility Policy titled Pharmacy Provider documents under Section II, titled Consultant Pharmacist that it is the responsibility of the consultant pharmacist to maintain a log of all visits and activities within the facility and to submit written reports to the LTC (Long Term Care) manager on a monthly basis. It further documents that it is the responsibility of the consultant pharmacist to review the drug regimen of each resident on a monthly basis and report any irregularities to the medical director, LTC manager, and the resident's personal physician. Under Section III, titled Resident Drug Regimen Reviews it documents that the consultant Pharmacist shall provide the facility with documentation that he/she has reviewed each resident's drug regimen at least monthly. If the Consultant Pharmacist determines that there are no irregularities, he/she shall record in the resident medical record that he has performed the review and shall sign and date the entry.

Based on interview and record review, the facility failed to implement new fall interventions to aid in fall prevention for 1 (R10) of 3 residents reviewed for falls in the sample of 22. Findings include: R10's Face Sheet documented an admitted [DATE] and included diagnoses of legal blindness, hallucinations, delusional disorders, major depressive disorder, restlessness and agitation, anxiety disorder, overactive bladder, and pain in thoracic spine. R10's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. This MDS also documented R10 needs substantial to maximal assistance for sit to stand. R10's Long Term Care Fall Log dated 08/26/24 documented a fall on 08/26/24 on the 2:00 PM to 10:00 PM shift. The summary of the incident documents: Certified Nurse Aide (CNA) had been in R10's room to ask about a shower and resident refused. CNA stepped out of room to notify nurse of refusal and heard alarm sounding. R10 was on the floor in front of the recliner. R10 stated, that she did not fall, but stood up and then laid down on the floor. The intervention for this fall is documented as: R10 has chair alarm and is on hourly rounds. CNA had just been in R10's room. Continue current interventions. R10's Long Term Care Fall Log dated 09/10/24 documented a fall during the 6:00 AM to 6:00 PM shift. The summary of the incident documents: resident (R10) slid out of recliner and was found sitting on the floor. The intervention for this fall is documented as: R10 has safety alarm and is on hourly rounds, checked 15 minutes prior to the incident. R10 has behaviors and no safety awareness. R10's Long Term Care Fall Log dated 09/24/24 documents a fall on 09/24/24 on the 6:00 AM - 6:00 PM shift. The summary of incident documents: CNA had just been in R10's room, no needs were voiced, three minutes later R10 was found sitting on her buttocks on the floor. R10 stated she stretched and slid to foot of recliner and slid to floor. R10's intervention for this fall is documented as: has an alarm, a low bed, soft mats and hourly rounds. R10 has behaviors, no safety awareness, no acute illness, and no environmental factors. R10 is in the safest environment possible. R10's Care Plan documents under Focus Area fall risk, had previous fall on 08/02/24 resulted in fracture to her left distal radial arm. She recently was in the hospital and returned to the Long Term Care on 08/15/24. Resident slid from her recliner to the floor on 08/17/24 with no new injuries noted. Resident is experiencing hallucinations and delusions. She is not aware of her physical limitations, with poor balance, unsteady gait. Family have declined surgery to repair the fracture. Often tries to remove splint from left arm. She has pain to her left arm at times. She had another fall on 08/26/24, but she stated, she did not fall, she got on the floor to rest. No injury noted. 09/13/24 found on the floor. (The two open areas on the left thumb are healed on 09/23/24.) 10/21/24 resident has been picking at a reddened area on her mid forehead. The care plan's revision date is documented as 10/21/2024. There were no new fall interventions documented on R10's Care Plan following the falls on 8/26/24 and 9/24/24. On 10/24/24 at 12:45 PM, V2 (Director of Nursing) stated they do not have a new intervention for the fall on 8/26/24 or the other fall on 9/24/24, it is just to continue the interventions that are currently in place. On 10/24/24 at 12:50 PM, V1 (Administrator) stated it is hard to come up with new interventions for her, but they will talk to her son and see if they can figure some out. R10's Care Plan documents under Focus Area fall risk, had previous fall on 08/02/24 resulted in fracture to her left distal radial arm. She recently was in the hospital and returned to the Long Term Care on 08/15/24. Resident slid from her recliner to the floor on 08/17/24 with no new injuries noted. Resident is experiencing hallucinations and delusions. She is not aware of her physical limitations, with poor balance, unsteady gait. Family have declined surgery to repair the fracture. Often tries to remove splint from left arm. She has pain to her left arm at times. She had another fall on 08/26/24, but she stated, she did not fall, she got on the floor to rest. No injury noted. 09/13/24 found on the floor. (The two open areas on the left thumb are healed on 09/23/24.) 10/21/24 resident has been picking at a reddened area on her mid forehead. The care plan's revision date is documented as 10/21/2024. There were no new fall interventions documented on R10's Care Plan following the falls on 8/26/24 and 9/24/24. The undated facility policy titled, Fall Prevention Program documents in part: Post-fall management: Post fall assessment includes, but not limited to: what happened, how it happened, why did it happened, (vital signs, blood glucose level, neuro checks at the time of the fall), were appropriate interventions in place Specific considerations as to why the fall might have occurred, including, but not limited to: .How similar outcomes can be avoided. How the care plan will change.

Based on interview and record review, the facility failed to conduct pain assessments in accordance with professional standards of practice for 1 of 1 (R27) resident reviewed for pain management in a sample of 23. This failure resulted in R27 experiencing unrelieved pain for potentially 5 days due to an unknown left hip fracture. Findings include: R27's Face Sheet documents admission to the facility on [DATE] with diagnoses of dementia, urinary tract infection, seizures, vitamin D deficiency, and hypokalemia. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Section G, Functional Status, documents R27 requires Extensive Assistance with physical assist x (times) 2 with bed mobility, Total Dependence with dressing, toilet use, personal hygiene, and eating. Section J100 for Pain Management documents R27 receives scheduled pain medication; J200, Pain Assessment Interview should not be conducted due to R27 is rarely/never understood; J800, Indicators of Pain or Possible Pain (non-verbal sounds, vocal complaints of pain, facial expressions (grimacing, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), protective body movements or postures (bracing, guarding, rubbing or massaging a body part, clutching or holding a body part during movement); J850, Frequency of Indicator of Pain or Possible Pain documented possible pain observed 3-4 days in the last 5 days. R27's Physician's Order, dated 7/15/2023 documents Tylenol 650mg by mouth every four hours for pain as needed. The orginal start date is not listed. A facility final investigation report submitted to IDPH on 7/28/23 documented the following, in part .On 7/10/2023, R27 was sitting up in wheelchair . started having a seizure . frothy drool came from mouth and became unresponsive .sent to the emergency room and was admitted to a local hospital with a diagnosis of seizures, hypokalemia, and aspiration pneumonia .returned back to the facility on [DATE]. R27 experienced continual pain in her left leg/groin area from her return from the hospital and on 7/22/2023 an x-ray was obtained that resulted with a left hip fracture. On 9/13/2023 at 3:00 PM, V17 (Registered Nurse/RN) stated that he worked the evening shift on July 15, 2023, and received report from the previous nurse that R27 had returned from a hospital stay on this same date. V17 stated that he did a skin assessment on R27 that evening and noticed that she had a healing bruise on her top, left thigh. V17 stated that he did not assess range of motion or pain when R27 returned back from the hospital on 7/15/2023. A written statement as part of the facility's investigation regarding R27's hip fracture, by V16 (Certified Nurse Aide/CNA) documents Based on what I noticed since R27's return last week, she has been grabbing at her leg when we go in to change her. I noticed this on date 7/17/2023. R27 would grab at it and say ouch when rolling her to change brief. On 9/12/2023 at 12:50 PM, V10 (Certified Nurse Aide/CNA) stated that she works the day shift 6:00 AM - 2:00 PM and remembers taking care of R27 when she returned from the hospital in July 2023. V10 stated that one morning, she could not recall exact date, she and V11 (CNA) were getting ready to transfer R27 from her bed to her wheelchair with the mechanical lift. R27 was moaning out while they were rolling her and before her heel got off the bed, R27 grabbed her left hip, crying out. V10 stated she reported R27's pain to her left hip to V13 (Licensed Practical Nurse/LPN). V10 stated she worked the next day and R27 still appeared to have a lot of pain while trying to transfer her. V10 stated that R27 was grabbing more to her left side/buttock area and her face showed grimacing. V10 stated that she then reported R27's pain to V9 (LPN) and V9 stated to her that she would check on R27 and do an assessment on her. V10's (CNA) written statement from the facility's investigation regarding R27's hip fracture dated 7/22/2023 documents, On Thursday, 7/20/2023, during AM care with R27, observed R27 repeatedly grabbing at her left hip/groin area when being changed. R27 does this every time when being changed but on this morning, she was grimacing and holding onto the hip, upper thigh area and when being turned to get brief on, she reached behind her to grasp her left buttock. Reported this to my nurse, V13 (LPN). Same behavior occurred when laying her back down and changing her after lunch. Reported again to V13 that R27 was continuing this behavior and yelling out. At the end of shift, report was given to oncoming shift, and they said they had noticed R27 doing that as well. On Friday 7/21/2023, during AM report from V20 (CNA) about R27, there was no discomfort of R27 reported. When doing AM care on this date, I noticed R27 doing the same as the day before and reported her discomfort to V9 (LPN), informing V9 that she had been doing this the day before and that I had reported it to (V13). On 9/12/2023 at 1:05 PM, V11 (CNA) stated she worked 6:00 AM - 2:00 PM on July 20, 21, & 22, 2023. V11 stated that on July 20, 2023, she noticed R27 grimacing hard and grabbing her left hip/leg area while she was being rolled and during transfers. V11 stated that she reported R27's left hip/leg pain to V13 (LPN) on Thursday, July 20, 2023. V11 stated that she worked the following two days and R27 was still experiencing pain while being rolled and during transfers. V11 stated that she then reported R27's pain to V9 (LPN). V11 stated that V9 went down to assess R27. V11 stated that she did not notice any bruising to R27's left leg and there was no report that R27 had fallen. V11 stated that she noticed that R27 was a lot more tearful more frequently since she returned from the hospital. V11's (CNA) written statement dated 7/24/2023 documents On Thursday, 7/20/2023, I had noticed R27 being in a lot of pain during care. R27 would grab her left hip area and holler out. During transfers, R27 would cry out as well. Reported to nurse of what I had observed. On Friday, 7/21/2023, R27 was having same reactions during care and transfers. Reported to nurse again and also put it on our CNA communication papers and informed the 2:00 PM - 10:00 PM shift about her being in pain and to be careful with her left hip area. Saturday, 7/22/2023, R27 was still having very obvious pain. Still grabbing her hip area and yelling out and crying. Reported to nurse again, put it on our CNA communication papers and passed to the 2:00 PM - 10:00 PM shift during report. On 9/12/2023, at 1:25 PM, V9 (LPN) stated that when R27's pain was reported to her on 7/21/23, she went down to assess R27 and there were no complaints of pain to R27's left hip/leg. V9 stated that R27 pointed to her right thigh when asked if she was in pain but there were no abnormalities noted to either leg. V9 stated that she did not perform range of motion and did not ask V10 (CNA) & V11 (CNA) to perform range of motion. V9 stated that R27 was getting pain medication routinely twice a day. V9 stated that when a resident is experiencing pain, it is documented in the progress notes and reported to the following nurse on our report sheet. V9 stated that there was no fall reported on R27. V9 stated that she did not document R27's pain in the progress notes. V9 stated that she forgot to add her assessment to the progress notes on 7/21/2023. V9 (LPN's) written statement from the facility's investigation regarding R27's hip fracture documents I had taken care of R27 on 7/21/2023 and V11 (CNA) told me she thought R27 was hurting. On assessment, noted that R27 was holding her right thigh and grimaced. Pain medication was given as ordered. R27 had not fallen or any other incident. No further signs of pain or discomfort after giving pain medication. On 9/13/2023 at 11:45 AM, V13 (LPN) stated that she remembers working one day and taking care of R27 after she had returned from the hospital, later that week. V13 stated V10 (CNA) had reported to her that R27 was experiencing pain in her left groin area. V13 stated that she went down to assess R27 and noticed that her peri-area was reddened. V13 stated that she did not perform any range of motion on R27's extremities at that time and did not ask V10 (CNA) to help perform range of motion. V13 stated she contacted the primary physician to notify the physician that R27 had redness in her peri-area and an antifungal powder was ordered. V13 stated that she did not document R27's pain in the progress notes. V13 (LPN's) written statement from the facility's investigation regarding R27's hip fracture dated 7/23/2023, documents On 7/20/2023, V11 (CNA) reported that R27 acted like she was hurting in her hips or legs. Pain medication given as needed. Received new order for antifungal powder and was applied to groin area. I thought maybe that is what was hurting. No further complaints after pain medication given. V18's (former CNA) written statement from the facility's investigation regarding R27's hip fracture dated 7/24/2023, documents in part . On 7/21/2023, 8:00 PM, rolled R27 towards the closet and that is when R27 started to cry and grimace .asked R27 if she was having any pain .R27 did not respond .repositioned R27 onto her back and went down the hall to report R27's pain to V17 (RN). On 9/13/2023, at 3:00 PM, V17 (RN) stated that he worked that week after R27 returned from the hospital and took care of R27 and there was nothing reported to him of R27 experiencing any signs of pain until Friday, [DATE]. V17 stated that V18 (CNA) reported to him that R27 was holding her left hip when being turned and repositioned. V17 stated that he went down and assessed R27 on 7/21/2023, in the evening time around 8:00 p.m. V17 stated that he performed range of motion on R27, and she did not grimace or moan out in pain. V17 stated that he asked R27 if she was any pain and he stated R27 said, No. V17 stated that he did not fill out a pain assessment at this time because R27 did not complain of any pain at this time. On 9/13/2023 at 3:15 PM, V2 (Director of Nursing/DON) stated that she worked on the evening of July 22, 2023, and received in report that R27 had been uncooperative with her care and was experiencing pain in left hip. V2 stated that she went down to assess R27 and was unable to perform range of motion to R27's left leg. V2 stated that R27 kept her left leg stiff and moaned out when palpated. V2 stated that she told the nursing staff to not move R27 and she sent a concern sheet over to the emergency room and received an order to get an x-ray of R27's left side. V2 stated that R27's x-ray results showed a fracture to her left hip. V2 stated that during the week of July 15-July 22, 2023, she did not receive any reports of R27 experiencing any pain. R27's Xray report dated 7/22/2023 documents under findings: There is an acute subcapital fracture of the left femoral neck with varus angulation. On 9/13/2023 at 2:00 PM, V3 (Infection Preventionist/Risk Manager) stated that the facility does not have a pain policy. R27's Medication Administration Record dated 7/01/2023 - 7/31/2023 documents Tylenol 650mg by mouth twice a day for pain. No diagnosis given was documented. R27's Medication Administration Record nor the Treatment Administration Record dated 07/01/2023 - 7/31/2023 has any pain monitoring for either document. On 9/13/2023 at 3:15 PM, V2 (DON) stated that the facility does not have a pain policy and the only time that nurses complete a pain assessment is when an as needed pain medication is given. V2 stated in the electronic medication administration record, a pain assessment sheet will trigger when an as needed pain medication is given. V2 stated that the only pain assessment that was filled out for R27 in the month of July 2023 is dated for 7/16/2023 by V9 (LPN). V2 stated that there is a section on the pain assessment that can be completed for non-verbal residents or residents that are unable to answer. V2 stated that she would expect the nurses to fill this out when they give a PRN pain medication or document their pain assessment in the progress notes. The only pain assessment that was completed on R27 was dated 7/16/2023 by V9 (LPN) when Tylenol was given as a PRN. This was after R27 came back from the hospital. R27's pain assessment dated [DATE] documents under Pain Pain Intensity (non-verbal), (grimacing/wincing) checked, under Res pain interview: frequency, (unable to answer) checked, under Exacerbating Factors, (movement) checked, under Alleviating Factors, (lying down) checked, under Currently on scheduled pain med, (Yes, effective scheduled pain treatment in place) checked, under Currently on PRN pain med, (Yes, PRN treatment is effective) checked, under Pain Med Type, (non narcotic analgesic) checked.

Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS (Minimum Data Set) data to the CMS (Center for Medicare/Medicaid Services) System after a resident death for 1 (R10) of 1 residents reviewed for timely MDS transmittals. Findings Include: R10's facility Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses of Anxiety, Hypertension, Paroxysmal Atrial Fibrillation, Constipation, Atherosclerosis, Gastro-esophageal Reflux Disease (GERD), History of Transient Ischemic Attack (TIA), Iron Deficiency Anemia, and Urinary Tract Infection, and documents a discharge date of [DATE]. R10's Progress Note dated [DATE] documents in part .R10 continued on Hospice .expired at the facility at 10:15 PM .R10's body released to (name of funeral home). R10's medical record documents the Minimum Data Set (MDS) dated [DATE] as a Significant Change in Status assessment, and as the last assessment completed for R10. On [DATE] at 10:30 AM, V8 (MDS Coordinator) stated that she forgot to input R10's discharge date in her MDS. V8 stated that R10's last MDS was dated [DATE] and R10 expired at the facility on [DATE].

Based on record review and interview, the facility failed to provide a safe transfer for one resident of three residents (R1) reviewed for falls in the sample of three. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Anxiety Disorder, Gout, Restlessness and Agitation, and Atrial Fibrillation. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 had no deficits in cognitive function and that R1 required extensive assistance from at least one staff member for transfers and ambulation, utilized either a walker or wheelchair as an assistive device, and was unsteady while walking and transferring from a sitting to a standing position. R1's Fall Risk assessment dated [DATE] documented a score of 40, indicating that R1 was at moderate risk for falls. R1's Care Plan with a review date of 5/11/23 listed a problem area of, I have a history of falls , with a corresponding goal,I will be free from fall related injuries, and intervention,Transfer/Ambulate with gait belt, walker, and one (staff) assist. R1's Nursing Progress Notes documented the following: 6/11/23 at 12:15am: CNA(Certified Nursing Assistant) alerted nurse to resident room, resident on floor by bed, against the wall, CNA stated that she was getting ready to walk (resident) to the bathroom and resident was up with walker, CNA went to turn to shut off (pad) alarm and resident lost her balance and fell back onto floor, did bump back of her head against the wall and bump her head with walker, small bump noted to the back of her head in the middle, and small bump to right forehead Range of motion per usual .No pain, just where she had bumped her head .Changed her from her house slippers that are a little slick and put on her tennis shoes and assisted to toilet Neuro(logical) checks started and are WNL(Within Normal Limits) 6/11/23 at 1:30am: Concern sheet sent to ER (emergency room ) to notify MD (Medical Doctor), concern sheet was returned with NNO (No New Orders). Neuros and vital signs continue to be WNL. A Final Report submitted to IDPH (Illinois Department of Public Health) dated 6/26/23 documented, On June 11th at approximately 12:15am, (R1) was being assisted to the bathroom. (R1) ambulates with a walker and assist of one (staff member). She has a safety alarm because she gets up at night and ambulates to the bathroom without assist. As the CNA (Certified Nursing Assistant) who was assisting her turned to shut off the alarm, (R1) lost her balance and fell , hitting the back of her head against the wall and pulling her walker down and hitting the front of her head with the walker. (R1) was noted to have a small bump on the back of her head, and a small bump to the right forehead with a small abrasion across it. She was able to move all extremities and had no complaints of pain except where she had bumped her head The Physician acknowledged the fall report and no new orders were received. A Fall Investigation Report dated 6/11/23 documented, (V3), Certified Nursing Assistant, (CNA) was helping (R1) up to the bathroom, (V3) thought (R1) had her balance and went to shut off alarm, (R1) lost her balance and fell beside her bed against the wall. Did bump back of head on wall and her right forehead on her walker, (causing a) small bump and scrape. This Fall Investigation did not document a root cause analysis of the fall. On 7/11/23 at 8:20am,V3, Certified Nursing Assistant, stated that on 6/11/23 around midnight, V3 was assisting R1 to the bathroom. V3 stated she had been employed at the facility about three weeks at that time. V3 stated V3 was under the impression that R1, who was alert and oriented and utilized a walker for ambulation, required stand by assistance for transfers. V3 stated she had never used a gait belt to transfer R1 and she did not utilize one on this occasion either. V3 stated she assisted R1 in sitting up to the side of the bed, putting on her house slippers and placing her walker in front of her. V3 stated R1's slippers were in good condition and not slippery. V3 stated if the slippers had been slick on the bottom, she would have put different footwear on R1. V3 stated she assisted R1 to a standing position and R1 appeared to be steady. V3 stated R1's bed pressure pad alarm was sounding, and the control box was sitting on top of the sharps container on the wall. V3 stated she turned her body away from R1 to retrieve the box, and at that moment R1 lost her balance and fell backward, with her head hitting the wall and the walker falling onto her right forehead. V3 stated V4, Licensed Practical Nurse (LPN) was immediately notified of the fall. V3 stated after the incident she found out that R1 required the assistance of at least one staff and a gait belt for transfers. V3 stated she should not have turned away from R1 and that she should have used a gait belt. V3 stated she has since been re-educated on the appropriate usage of gait belts. On 7/11/23 at 9:05am, V7, (R1's Physician) stated he was notified of R1's 6/11/23 fall. V7 stated he was aware that a gait belt had not been utilized during the transfer and that it should have been. On 7/11/23 at 10:05am, V4 stated she assessed R1 immediately after the fall. V4 stated R1's vital signs and neurological checks on 6/11/23 from the time of the fall around midnight until 6:00am at the end of her shift were within normal limits. V4 stated R1 had small bumps to the right forehead and the back of the head. V4 stated she noted R1's house slippers seemed to be slick, so she put V1's tennis shoes on her and ambulated R1 to the bathroom. V4 stated R1 had no complaints of pain, and when V4 staffed R1 with the emergency room (ER) physician he did not believe R1 needed to be seen in the ER. V4 stated V3 told V4 that V3 had turned away from R1 for a few seconds to turn off her pad alarm, and that V3 had not used a gait belt during the transfer. On 7/11/23 at 2:50pm, V2, Director of Nurses, stated the root cause analysis of the fall was that V3 should not have turned away from R1 and that V3 should have used a gait belt. V2 stated that if R1's house slippers were slick on the bottom, they should have been replaced. V2 stated CNAs will now be required to document on each shift that resident's personal alarm boxes are sitting on the residents dresser, not on the wall mounted sharps container. V2 confirmed that R1 should have been transferred using a gait belt. V2 stated she is in process of re-educating all nursing staff on the proper use of gait belts. An undated Gait Belt Policy documented in part, Employees will be educated in the use of gait belts and gait belts will be used to ensure the safety and well being of all long term care residents with an assessed need. An undated Fall Prevention Program Policy documented in part, .Ambulatory residents shall wear proper foot gear; nonskid shoes or well-fitting nonskid slippers .Encourage use of ambulation aids at all times .

Based on interview, observation and record review, the facility failed to secure a foot strap during a sit to stand mechanical lift transfer for 1 of 10 (R23) residents reviewed for falls in a sample of 27. This failure resulted in R23 receiving 4 sutures to the left 3rd and 4th toes. Findings Include: R23's Face Sheet documents R23 is a male resident with a date of birth of [DATE] and an admitted [DATE]. R23's Face Sheet documents diagnoses including: Type 2 diabetes Mellitus, Chronic Diastolic heart failure, Unspecified [CONDITION(S)], [CONDITION(S)] with behavioral Disturbance and [CONDITION(S)]. R23's Minimum Data Set (MDS) dated [DATE] Section C documents a Brief Interview For Mental Status (BIMS) score of 13, indicating R23 is cognitively intact. Section G documents: Extensive assistance with a one-person physical assist for transfers. A final report sent to the Department on [DATE] documents in part, On Friday [DATE] at 4PM, R23 was being assisted up from the bed using a Sit to Stand mechanical lift. His foot slipped and he received lacerations under the third, fourth, and fifth toes of the left foot. He was transported to the E.D (Emergency Department) for treatment. He received dissolvable sutures to third and fourth toe. R23's Emergency Department Summary of Care printed [DATE] documents in part, 79 y/o (year old) M (male) presents with lac (lacerated) plantar 3rd and 4th toes from sit to stand device Repair #1, Wound closed with: Sutures; Number Sutures/Staples Placed: 4 R23's Departmental Notes dated [DATE] at 9:27 PM document: sent resident to emergency room at approximately 4:15 PM. Resident's foot slipped while CNA (Certified Nurse Aide) was getting him up on the sit to stand. There is a laceration to left 3rd, 4th, and 5th underneath the toes. Two sutures to the 3rd, an 4th toes that will dissolve on their own were administered. On [DATE] at 10:10 AM during the demonstration of the use of the sit to stand, while securing the leg strap, R23 stated to V8 (Certified Nursing Assistant/CNA), Is this new? On [DATE] at 3:57 PM, V4 (Certified Nurse Aide/CNA) stated, during the incident with R23 she did not utilize the leg strap when she was lifting him. She went to set him back down and his foot slid off of the foot plate. V4 (CNA) stated, after she set him down she noticed blood on his foot and went and got the nurse. R23 did have non-skid socks on when the incident occurred. V4 (CNA) stated, the leg strap is supposed to be used, she does use it now, but she did not then. On [DATE] at 4:40 PM, V5 (Certified Nurse Aide/CNA) stated, when she utilizes the sit to stand she has the resident sit on the side of the bed, she will already have the sit to stand there, she will put the harness on the resident, bend down to belt the legs down, attach the harness to the sit to stand and then begin the lift. V5 (CNA) stated, she would always use the foot strap, it would help them from stepping back. The sit to stands usually take one person to utilize it however, if the person is really shaky she may have another person assist her. The facility usually goes over one topic a month for training. The facility keeps a paper on each resident at the nurse's station that will give any needed information or any changes to a resident that is updated daily and there is a space to document if there was something with that resident on that shift. On [DATE] at 5:03 PM, V6 (Certified Nurse Aide/CNA) stated, when using the sit to stand you place the resident's feet on the foot plate and put the leg strap on, put the harness on, and make sure they hold on. She was trained at the facility on how to use the sit to stand. She always uses the leg strap. On [DATE] at 1:05 PM, V2 (Director of Nursing /DON)) stated, they do competencies every year, in fact they are going on right now. Newly hired Certified Nurse Aides (CNAs) are trained by senior CNAs that have been deemed trainers. The trainers will go through a check list with the new CNAs and sign off when a skill has been completed. They have 90 days to get through the checklist. If there is an item they still feel uncomfortable with or a resident they feel uncomfortable with individually, they are encouraged to have another CNA assist them. V2 (DON) stated, she is the one that is in charge of the training and does train CNAs. V2 (DON) stated, when the CNAs are trained to use the sit to stand, they are always trained to utilize the leg strap and footwear or gripper socks to help secure their feet. They are instructed to use the leg strap in every situation. They do not have a CNA competency checklist for V4 (CNA). V2 stated V4 started at the facility as a Nurse Aide and became a CNA then left shortly after due to not being vaccinated, she was then vaccinated and was rehired at the facility. During this timeframe, her 90 had expired and her 90 days have not passed since her rehire. On [DATE] at 1:30 PM, V1 (Administrator) stated, all CNAs are trained to secure the leg strap when utilizing the sit to stand. V1 (Administrator) stated, V4 has been trained on the sit to stand and if she felt uncomfortable with utilizing the sit to stand she should have had another CNA assist her. We are in-servicing all CNAs on utilizing the sit to stand. On [DATE] at 1:42 PM, V7 (CNA) stated, she is a CNA trainer for the facility. She trains the new CNAs to utilize the leg strap on the sit to stand every time. The leg strap is supposed to be secured on the resident with the sit to stand before lifting the resident. R23's Care Plan dated [DATE] for [DATE] under the heading Risk for Pressure Ulcers (handwritten in) documents: My foot slipped off the sit to stand lift platform when staff were transferring me. I have laceration to the under side of my left 3rd, 4th, and 5th toes. I went to the emergency room and have some stitches that will dissolve on their own. The interventions listed include: Treatment to laceration under the left 3rd, 4th, and 5th toes as ordered per doctor. Monitor for healing of the lacerations under my left 3rd, 4th, and 5th toes. Notify medical doctor with updates as needed. [DATE] Continue to use sit to stand for transfers. Ensure proper staff training of foot placement, sling placement, and preventing total weight left of device. [DATE] Treatment to top of left great toe nail area. Monitor top of left great toenail for healing. Notify medical doctor with updates as needed. Notify podiatrist with updates as needed. The undated facility document titled, Safe Patient Handling and Movement states: Purpose: This policy is intended to ensure that employees use safe patient handling and movement techniques to reduce patient and employee injury. Statement of policy: #301 Direct care staff will be trained in patient handling and movement techniques, and identification of the safest methods to employ based on patient assessment and categorization. Additionally, mechanical lifting equipment and/or other approved patient handling aids should be utilized to prevent the lifting and handling of patients/resident except when absolutely necessary, such as a medical emergency. Zero-lift Policy: III. Staff Competency A. All direct care staff will receive education/training on this policy and proper use of the associated equipment upon hire and then, annually to ensure competency.

Based on record review, and interview, the facility failed to ensure residents were free of unnecessary [CONDITION(S)] medications for 2 (R13 and R28) of 5 residents reviewed for unnecessary medications in the sample of 19. The Findings Include: 1. R13's face sheet lists an admitted [DATE] and includes the following diagnoses: anxiety disorder, major depressive disorder, and Alzheimer's disease. Current physician orders list [MEDICATION(S)] 25mg (Millimgram) tablet, give half a tablet to equal 12.5mg by mouth every evening with a start date of 3/17/20. R13's behavior tracking for the past 6 months track the following behavior: Anxiety (restlessness/fidgeting) monitored for medication [MEDICATION(S)]. R13 only exhibited two instances of anxiety in March, one in April and once in May. On 6/3/21 at 11:24AM, V2 (Director of Nursing) stated that there are no other diagnosis besides anxiety and Alzheimer's listed in the medical record for the anti-psychotic medication [MEDICATION(S)]. V2 went on to state that R13 at times exhibits behaviors where he attempts to self injure by pounding on his chest, but he has not done this is quite sometime. There is no record of this type of behavior being tracked, nor diagnosed in the medical record. On 6/3/21 at 11:24 AM, V2 stated that she as attempted to fax V3 (Physician) regarding gradual dose reductions on [MEDICATION(S)] on 5/12/21 and has not received a reply yet. V2 went on to state that this is not uncommon with V3 to have a delayed response to faxes, no medication changes have been made at this time. 2. R28's face sheet has an admitted [DATE] and includes the following diagnoses: dementia with behavioral disturbance, hallucinations, restlessness and agitation and major depressive disorder. R28's current month Physician Order Sheet includes an order for [MEDICATION(S)] 0.5mg tablet take one tablet twice daily' as needed' for anxiety with a start date of 3/3/21 with no end date, and an order for [MEDICATION(S)] 0.5 mg one tab by mouth daily at noon. V2 stated on 6/2/21 at 2:00 PM that R28 has not received any 'as needed' anxiety medication since March, but the order is still active. R28 has behavior tracking for [MEDICATION(S)] in regards to physical aggression exhibited by hitting, slapping, and or grabbing. R28 had one aggressive behavior tracked in December 2020, two aggressive behaviors in January 2021, 4 behaviors tracked in March 2021, 7 behaviors tracked in April 2021, and 3 aggressive behaviors tracked in May 2021. V2 faxed a request for discontinuation or rationale for extension of the 'as needed' [MEDICATION(S)] order on 5/13/21 to V3 and has not received communication back on what to do with the medication order.

Based on interview and record review the facility failed to ensure care plan meetings were scheduled to accommodate and include the resident representative for 1 of 3 (R3) residents reviewed for resident rights in the sample of 10. Findings Include: R3's facility face sheet dated 10/27/2020 documents R3 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R3's MDS (Minimum Data Set) dated 10/01/2020 documents R3 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R3 is cognitively intact. R3's resident care conference signature sheet dated 8/12/2020 documents R3 attended the meeting and R3's family was invited but did not attend. On 10/28/2020 at 1:58 PM R3 stated she wanted V19 involved in her care plan meetings. When asked if she was notified of the meetings R3 stated, Oh yes I am, (R3 laughed) and usually at the last minute. On 10/23/2020 at 3:22 PM V19 (family member) stated she received a letter from the facility with a date in August or September for a care plan meeting. V19 stated she informed the facility she was unable to attend the meeting at that time and would need to reschedule it. V19 stated the facility did not respond with a new date and called her on the day the meeting was originally scheduled to do the care plan meeting. On 10/27/2020 at 12:18 PM V3 (Care Plan Coordinator) stated she sends out letters to family prior to the care plan meetings with a date and time for the meeting. V3 stated if the family cannot attend she attempts to accommodate them with a different time. V3 stated R3 had care plan meetings on 3/4/2020 and 5/13/2020 and R3's family did attend those meetings. V3 stated the last care plan meeting for R3 was on 8/12/2020 and R3's family did not attend. V3 stated when she attempted to call V19 (family member) for R3's meeting V19 was unable to talk. When asked if she had sent a letter prior to 8/12/2020 to R3's family informing them of the meeting date and time, V3 stated, Probably not. When asked if R3's family was aware of the care plan meeting scheduled for 8/12/2020 prior to 8/12/2020 V3 stated, I don't know. On 10/28/2020 at 1:05 PM V3 (Care Plan Coordinator) stated she had no documentation showing she had notified V19 of R3's care plan meeting prior to 8/12/2020. V3 stated when she spoke with V19 (family member) on 8/12/2020 V19 stated she could meet on 8/20/2020 to review the care plan. V3 stated I was supposed to call her at 10:00 AM on 8/20/2020 and was unable to. V3 stated she sent V19 a text at 11:36 AM and V19 was unable to talk. V3 stated I then sent out a letter for a meeting on 9/30/2020. When asked how far in advance the letters are sent to the family members regarding a scheduled care plan meeting V3 stated two-four weeks. When asked if two weeks was enough time for a family to receive a letter and send it back to the facility letting them know if they would be able to attend or needed to reschedule, V3 stated there are occasionally issues with that being enough time. V3 stated she normally tries to call them the day of the care plan meeting and usually they have gotten the letter, but just haven't returned it to the facility. V3 confirmed she has not spoken with R3's family regarding her plan of care discussed at the 8/12/2020 care plan meeting. V3 provided copies of the text messages from/to V19 that document; On 8/3/2020 V3 contacted V19 to see if she could attend a care plan meeting scheduled for 8/21/2020 at 10:30 AM. V19 responded that she was booked for the month of August and would have to get back with V3. On 8/12/2020 V3 scheduled a meeting for 8/20/2020 at 10:00 AM with V19. On 8/19/2020 V19 confirmed the meeting time of 8/20/2020 at 10:00 AM. On 8/20/2020 at 11:36 AM V3 contacted V19 asking if she could talk then because V3 had been unable to call V19 at the scheduled time of 10:00 AM. On 10/28/2020 at 1:21 PM V1 (Administrator) states the facility does not have a policy on scheduling of care plan meetings. V1 stated she would expect families to be notified of a meeting prior to the day of the meeting.

Based on interview, and record review, the facility failed to administer a medication as ordered for 1 of 3 residents (R3) reviewed for medication errors in the sample of seven. Findings include: On 10/01/20 at 9:24am,V8, Family Member of R3, stated that R3 had an appointment with V7, Medical Doctor, on Friday 06/19/20, late in the afternoon. V8 stated she had accompanied R3 to the appointment, and V7 had prescribed [MEDICATION NAME] to be started. V8 stated the following day, she was told by R3 that the [MEDICATION NAME] had not been started. V8 stated she called the facility and was told by nursing staff that they had received the [MEDICATION NAME] from the pharmacy, but they had not received the orders for administration from V7. V8 stated she asked staff to contact the pharmacy to clarify the order, and was told it would have to wait until Monday 06/22/20, when V7's office could be contacted. V8 stated she subsequently filed a grievance with the facility related to the medication omission. An Office Clinic Note authored by V7 dated 06/19/20 documented, Assessment/Plan: Prescribed [MEDICATION NAME], 5 mcg(micrograms) inh(inhale) 2 sprays daily in each nostril. A Grievance Form dated 07/13/20 documented, Medication([MEDICATION NAME]) sat for four days and no one knew anything until family called pharmacy and doctor. Grievance was investigated. (R3) saw (V7) on June 19th. (V7) did not write new orders. Medication ([MEDICATION NAME]) was delivered, but staff did not have an order, and due to it being the weekend, staff could not reach (V7) to receive an order. (V8) spoke with the nurse on Saturday June 20th and stated to the nurse that (V7) told (V8) that he was writing an order for [REDACTED]. Grievance confirmed. On 10/01/20 at 2:30pm, V1, Director of Nursing, stated nursing staff have since been educated that if issues regarding new medication orders arise on weekends, staff are to either call the pharmacy or the prescribing physician to clarify the order rather than letting it wait until Monday. V1 stated a Medication Error Report and Nurses Notes regarding the error could not be located. An undated Medication Event Policy documented, A medication event is any preventable event which may cause or lead to inappropriate medication use or or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, health care products labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

Based on observation, record review, and interview, the facility failed to prevent cross contamination during resident care for 6 of 8 residents (R3, R5, R19, R23, R28, R33) reviewed for infection control in the sample of 33. Findings include: 1. On 08/19/19 at 10:50am, V8 (Registered Nurse/RN) performed a blood glucose test on R19 and then on R28 without disinfecting the blood glucose testing machine after use on R19, and before use on R28. When asked, V8 stated the facility uses Sani-Cloth brand disinfecting wipes to disinfect the meter (blood glucose testing machine) and the meter is to be wiped for 2 minutes per the instructions on the Sani-Cloth container. V8 then returned to the medication cart, removed a germicidal disposable sanitizing cloth from a container labeled Sani-Cloth and wiped the blood glucose testing machine for only 45 seconds. V8 then entered R23's room at 11:11am to perform a blood glucose test on R23 using the same blood glucose testing machine as used earlier on R19 and R28. After the test, V8 wiped the blood glucose testing machine with a Sani-Cloth for only 60 seconds. On 08/21/19 at 3:00pm, V4 (Infection Preventionist/Nursing Supervisor) stated Sani-Cloth germicidal wipes are to be used to disinfect the blood glucose meters with a two minute wet surface contact time. V4 said 45 seconds and 60 seconds wet surface contact time would not properly disinfect the blood glucose testing machine, and would not be in accordance with the facility's policy. The bottle of Super Sani-Cloth label shows the manufacturer's instructions for the germicidal disposable wipe usage as: To disinfect and deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two minutes. Let air dry. An undated facility policy titled Accu-Chek Inform II Blood Glucose Monitoring System under the heading of Cleaning the Meter it states .Clean the meter with .Sani-Cloth chemical disposable wipes . 2. On 8/19/19 at 10:40 am, V9 (Licensed Practical Nurse/LPN) and on 8/20/19 at 1:00pm, V10 (LPN) were each observed providing wound care for R33. During each separate observation, both V9 and V10 were noted to remove R33's dirty bandage with bloody drainage, open and handle a tube of Triple Antibiotic Ointment, apply the ointment to R33's wound and then cover the wound with a clean bandage all while wearing the same pair of gloves. 3. On 08/20/19 at 8:42am, V10 (Licensed Practical Nurse/LPN) removed a plastic scoop from inside a stock container powdered medication (Questran) with unwashed or non-gloved hands and placed one scoop of the powder into a cup of water for R3. V10 then replaced the plastic scoop back inside the container and shoved it down into the powder. 4. On 08/19/19 at 9:45am, V11 and V12 (both Certified Nurse Assistants) utilized a patient lifting machine to place R5 on the toilet. When R5 was finished, V11 applied gloves and used a wet wash cloth to cleanse R5's genital area. While wearing the same contaminated gloves, V11 then re-dressed R5, transferred her back to her wheel chair and grabbed the wheel chair handles to roll R5 from the bathroom. On 8/19/19 at 11:55am, V12 was observed toileting R5, in which V12 also cleansed R5's genital area, re-dressed R5, returned R5 to her wheel chair, and then grabbed the wheel chair's handles to wheel R5 out of the bathroom, all while wearing the same pair of gloves throughout the procedure. A facility policy titled Perineal/Catheter Care (revised 6/30/2014) under the section labeled Procedure: at the 7th bulletin point states for the care giver to Remove soiled gloves and put on clean gloves before touching any items . to avoid contamination with soiled gloves. On 08/21/19 at 3:00pm, V4 (Infection Preventionist/Nursing Supervisor) stated during resident care, staff are to remove contaminated gloves followed by hand washing when going from a dirty procedure to a clean procedure. V4 said examples of dirty to clean procedures that require glove changing and hand hygiene would include removing dirty bandages and applying clean bandages or cleansing a patients genital area and then re-dressing the patient.

Based on observation, record review, and interview, the facility failed to safely store medication in the presence of two cognitively impaired residents, and allowed access to unattended, unsecure medications on top of the medication cart for 2 of 2 residents (R3, R29) reviewed for safe medication storage practices in the sample of 33. Findings include: On 08/20/19 begining at 8:28am through 9:00am, R3 and R29 were continuously observed sitting in their wheel chairs next to the medication cart utilized by V10 (Licensed Practical Nurse) to administer medications on the 400 Hall. During this time frame, V10 entered 3 seperate resident rooms to administer medications and left a small clear plastic cup with 4 unidentifiable pills unattended and openly sitting on top of the medication cart within the reach of R3 and R29. When asked, V10 said earlier a resident refused to take their medications, so V10 saved the resident's four pills and did not intend to leave the pills unattended on top of the medication cart. On 08/19/19 begining at10:50am through 11:28am, R3 and R29 were again continuously observed sitting in their wheel chairs next to the medication cart utilized by V8 (Registered Nurse) to administer prescribed medications to residents in their rooms on the 400 Hall. During this time frame, V8 left the medication cart in the hallway to administer medication to a resident inside their room and left a pill unattended in a medication card on top of the medication cart, and within the reach of R3 and R29. On 8/21/19 at 3:00pm, V4 (Infection Preventionist/Nursing Supervisor) stated medications should never be left open and unattended where confused residents or unauthorized persons could freely access them. V4 also said medications should always be kept securley locked up when a nurse is not able to attend them. An undated facility policy titled Pharmacy Provider, category IX. Storage of Drugs (page 8), section D states .All medications and other drugs shall be stored in a locked cabinet .inaccessible to residents and visitors and an undated facility policy titled Medication Administration Record [REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE], states R3 has a Brief Interview for Mental Status (BIMS) of an 8, which indicates R3 has moderate cognitive impairment; and R29's MDS dated [DATE], states R29 has a BIMS of an 8, which indicates R29 has moderate cognitive impairment.

Based on record review and interview, the facility failed to follow physician's orders for one of eleven residents (R6) reviewed for following physicians orders in the sample of 11. R6's Medication Chart documents R6 received [MEDICATION NAME] 10mg by mouth every morning from 4/1/17 - 4/11/17 and documents R6 also received [MEDICATION NAME] 10mg by mouth every morning during this time. The Nursing Home Notification, form sent to E3 (Medical Director / R6's Physician) on 4/11/17 from the facility, states:Pharmacy called and brought to our attention that resident (R6) is on both [MEDICATION NAME] and [MEDICATION NAME] and they feel she does not need both - please advise. E3 responded on this form by stating, We discharged her 3/31/17 on [MEDICATION NAME] 10mg but no [MEDICATION NAME]. R6's physician's order written on 4/11/17 documents to discontinue [MEDICATION NAME] 10mg by mouth daily for R6. R6's Discharge / Transfer Report dated 3/31/17 for R6 verifies [MEDICATION NAME] was not ordered at the time of R6's discharge back to the facility. On 6/21/17 at 9:05 AM, E2 (Director of Nursing) verified that [MEDICATION NAME] being ordered and given was a transcription error and R6 should not have received [MEDICATION NAME] after her 3/31/17 re-admit to the facility from the hospital.

Based on observation, record interview and interview, the facility failed to ensure that a [MEDICAL CONDITION] medication prescribed on an as needed basis is only given when there are adequate indications for its use for one of four residents (R3) reviewed for [MEDICAL CONDITION] medication use in the sample of 11. The findings include: R3's June 2017 Medication Administration Record [REDACTED]. R3's June 2017 Physician order [REDACTED]. R3's Care Plan dated 4-5-2017 includes a [DIAGNOSES REDACTED]. Interventions listed on a blank Behavior Observed Monthly Flow Sheet, which is included as part of the Care Plan, include speaking calmly to R3, provide a warm blanket, soft music, and check for overstimulation. The Care Plan states that behavior monitoring and tracking are to be completed and offer non - medication interventions as appropriate. R3's May 2017 MAR indicated [REDACTED]. R3's June 2017 (1st thru 20th) MAR indicated [REDACTED]. It is noted that the time of day that the PRN [MEDICATION NAME] is given is always during day shift anywhere between 6:43 am and 8:34 am. R3's May and June 2017 Psychoactive Monthly Flow Records, which includes Target Behavioral Symptoms on which staff are to document the number of episodes of a targeted behavior per shift, do not document any behaviors. The only behavior documentation noted on R3's May 2017 Nurses Note is of combativeness on May 11 and 12. R3's June 2017 Nurses Notes do not include any documentation of behaviors. R3's May 2017 Behavior Observed Monthly Flow Chart, documents behaviors occurring on day shift on the 12th, 24th, and 25th. R3's June 2017 sheets do not document any observed behaviors. On 6-20-17 during morning hours R3 was observed during a transfer lift procedure, incontinence care and passive range of motion and during that time there were no behaviors observed. On 6-22-17 at 2:00 PM, E2, Director of Nurses, provided the behavior tracking forms noted above and stated that was all the documentation related to behaviors in R3's record that was found.

Based on observation, record review, and interview, the facility failed to utilize personal protective equipment (PPE) and prevent contamination of common equipment in isolation rooms for two of four residents (R1, R2) reviewed for infections in the sample of eleven. Findings include: On 06/20/17 at 8am, a sign was observed on the door of R1's room which read Contact Precautions. On 06/20/17 at 8:10am, a sign was observed on the door of R2's room which read Contact Precautions. On 06/21/17 at 8:45am, E5, Licensed Practical Nurse, was observed preparing to do wound care treatment for [REDACTED]. Without wearing gown or gloves, E5 entered the room and set up dressing supplies on the over bed table and placed an isolation linen disposal bag on the bed. E5 then walked back to the entrance of the room where the PPE supplies are kept and donned gown and gloves, without re-washing her hands. On 06/21/17 at 9:10am, E5 was observed preparing to do wound care for R2. Without wearing gown or gloves, E5 entered the room and picked up the fall mat lying on the floor beside the bed and propped it up against the wall. E5 then walked to R2's bathroom, washed her hands, and donned gown and gloves. After completing R2's treatment, E5 placed her personal bandage scissors and marker, which had been used in the treatment, on R2's bedside table with no barrier. E5 went to R2's bathroom, removed the gown and gloves, and washed her hands. E5 then re-entered the room, picked up the marker and bandage scissors, and placed them in her pocket without disinfecting the items. E5 then left the room without re-washing her hands. R1's Care Plan with a review date of 04/20/17 documents a problem of, Contact isolation related to coccyx pressure wound. R2's Care Plan with a review date of 05/25/17 documents a problem of, MRSA (Methicillin-resistant Staphylococcus aureus) in wounds. An undated Contact Isolation Policy documents in part, Specific Isolation Requirements .B) Gloves must be worn to enter the room. C) Gowns must be worn to enter the room. D) .Care must be taken after gown removal and handwashing to avoid touching potentially contaminated items or surfaces. E) .If use of common equipment or items is unavoidable, vigorously clean and disinfect them before use on another patient. This is the responsibility of the nurse, the transporter, or any other employee who used the common equipment. On 06/21/17 at 3pm, E6, Registered Nurse/Infection Control Nurse, confirmed that E5 had not followed infection control policy in the above referenced observations.

Based on record review, observation, and interview, the facility failed to provide all required range of motion exercises for two (R3, R6) of nine residents reviewed for range of motion in the sample of twelve. Findings include: 1. R3's Minimum Data Set((MDS) dated [DATE] showed that R3 has [DIAGNOSES REDACTED]. This same MDS indicated R3 is totally dependent on staff for transfers and is impaired on one side in her upper extremities and both sides in her lower extremities. On 08/17/16 at 8:45 am, E3, Restorative Aid, was observed performing range of motion exercises on R3. R3's lower extremities were spastic and moderately contracted. E3 did not exercise the wrists on either side of the body. 2. R6's MDS dated [DATE] showed that R6 has [DIAGNOSES REDACTED]. This same MDS indicated R6 is totally dependent on staff for transfers and is impaired on both sides in her lower extremities. On 08/17/16 at 8:15 am, E4, Registered Nurse, was observed doing range of motion exercises on R6. R6's lower extremities were slightly contracted. E4 performed the exercises on the right side of R6's body and then asked the surveyor if she should do the left side as well. E4 did not exercise the thumb joints or the knee joints on either side of the body. On 08/18/16 at 2:30 pm, E2, Director of Nurses, stated that all joints are to be exercised in range of motion unless there is a doctors order stating otherwise and confirmed that R3 and R6 should have had all joints included in the observed range of motion. A Resident Census and Conditions of Residents document dated 08/16/16 indicates that of the nine residents in the facility who have contractures, only one of those residents had contractures on admission.

Based on observation, record review and interview the facility failed to follow the preplanned menu for service of the noon meal on 7/22/15. This has the potential to affect all 46 residents in the facility. The findings include: The facility's Resident Census and Conditions of Residents form, dated, 7/21/15 documented the facility had a census of 46 residents. 1. The menu for the noon meal of 7/22/15 called for the service of Beef Stroganoff and noodles as an entree. The spread sheet menu for each diet type documented the portion size: Residents with a regular diet order were to receive 3/4 cup of Stroganoff (3 ounces of protein) and 1/2 cup of noodles. Residents with a No Concentrated Sweets/Low Concentrated Sweets/ Consistent Carbohydrate Diet (LCS/NCS) order were to receive 3/4 cup of Stroganoff and 1/3 cup of noodles. 2. The residents were observed eating the noon meal on 7/22/15 in the dining room beginning at 11:45am with a mixture of beef stroganoff and noodles on their plates. At noon, E15 (Dietary, cook) was questioned about the food portions for this meal. E15 indicated she had put the noodles and stroganoff together because the residents seem to eat it better if it is mixed. E15 further stated the residents were given two number 8 scoops (1/2 cup each) of the mixture. At 12:20pm E15 stated that the server had given the residents with a NCS/LCS diet order the same 1 cup amount of stroganoff and noodles that was served to the residents with the regular diet order. With the food products mixed there was no way to determine the amount of protein and noodles available in the 1 cup serving.

Based on observation, interview and record review , the facility failed to dispose of expired medications. This failure has the potential to affect all 53 residents living in the facility. Findings include: 1. On 06/18/14 at 1:10 pm, the 600 hall medication cart was observed to contain a bottle of Ferrous Sulfate 325 milligram #1000 tablets with an expiration date of 09/13. On 06/19/14 at 8:00 am E1, Administrator/Director of Nurses,stated the expired Ferrous Sulfate was disposed of on 06/19/14. 2. On 6/18/14 at 3:00 pm, the 400/500 hall medication cart contained 1 opened bottle of stock Docusate Sodium capsules, with less than twenty-five percent capacity of the medication remaining, and an expiration date of 11/2013. E8, (Registered Nurse), acknowledged that the medication was currently being received by residents during medication administration. E8 removed the expired medication bottle and placed it into a bin for return to pharmacy. 3. On 6/18/14 at 3:10 pm, the medication refrigerator's locked narcotic compartment was found to contain (2) 30 millimeter sized bottles of Lorazepam 2 milligram per millimeter liquid medication for intermuscular injection; 1 bottle was opened and 1 bottle was unopened. Both bottles expired 4/2014. The medication was stored for 1 resident, R29, and ordered for use as needed - for seizures. E8 immediately removed the 2 expired bottles and called pharmacy to report that the medication was expired and needed to be replaced. An undated Medication Storage/Medication Security Policy stated , "Expired, damaged, and/or contaminated medications shall be removed from drug storage areas within the facility during the Pharmacy inspection and shall be returned to the Pharmacy/Provider Pharmacy for proper disposal." The Facility's Resident Census and Conditions of Residents form dated 06/17/14, documented the facility had a census of 53 residents.

Based on record review and interview the facility failed to notify the physician of high blood glucose readings for 1 of 2 residents (R8) reviewed for Insulin Dependent Diabetes Mellitus in the sample of 14. The findings include: 1. R8 's admission records and current physician's orders [REDACTED]. Current June physician's orders [REDACTED]. R8's current 6/5/14 care plan for Diabetes states "Notify MD of Accucheck over 401 or Accucheck below 50." 2. Review of nursing notes for R8 for the month of May 2014 found the following entries: 5/23/14 at 4:00pm, states "Sitting up per chair eating a snack. R- even nonlabored. . Accucheck --CR. Administered routine [MEDICATION NAME] 25 units, refused SSI at this time. Will continue to monitor." Phone interview with E16 ( Registered Nurse) on 6/19/14 at 12:15pm found the CR that she noted was a "Critical High" blood glucose value. 5/23/14 at 5:00pm, states "Sitting up per chair eating supper. Appetite fair. R even nonlabored. Rechecked BS at this time 464. Will continue to monitor. 5/23/14 at 8:00pm states "Sitting up per chair. C/O nausea and headache. Accucheck---465. Agreed to SSI at this time. Humalog 10 units administered. Tylenol and [MEDICATION NAME] given at this time. Will cont to monitor." The next nursing note available following the entries above from 5/23/14 was 6/12/14. There was no documentation to indicate that the physician was notified of the blood glucose values of critical high, 464 and 465.