Every finding on record at Galena Stauss Nursing Home

Based on observation, interview, and record review the facility failed to treat a resident with dignity by taking a resident's phone. This applies to 1 of 3 residents (R1) reviewed for dignity in the sample of 4.The findings include:R1's admission Record (Face Sheet) showed diagnoses to include but not limited to Alzheimer's disease (dementia), schizotypal disorder (distorted thinking, magical beliefs, eccentric behavior), and depression.R1's 6/26/26 Behavior Note from 10:06 AM showed, sitting at nurses' station berating another resident about 'masturbating' at the nurses' station.Attempted to remove her from the nurses' station but she began screaming and yelling at staff.R1's 6/27/26 Behavior Note from 12:44 PM showed, After Lunch, [R1] demanded her phone and to call the Sheriff's department. I told her once again her phone is locked up and I am unable to get it for her. We assisted her in calling the Sheriff's department.On 8/7/26 at 10:01 AM, V4 (Registered Nurse) stated R1 is challenging resident due to her behaviors. V4 stated a couple of months prior, R1 was at the nurses' station accusing another resident of masturbating at the nurses' station. V4 said, .she was disruptive, talking loudly, and talking inappropriately, so we asked her to go to her room. It's not appropriate to say these things in a common area. She would not let us take her back to her room. She had her cell phone, so I took it from her and told her if you go back to her room I will give it back to you . (V4's statement regarding taking phone was repeated back to V4 for clarification.) V4 said, I took the cell phone that day and I kept it in the med (medication) room. Right now, she has a land line and she is okay with that. I don't know if she ever got the phone back; I don't know the status of the phone.That's correct I took the phone to encourage her to go back to her room and did not give it back to her.On 8/7/26 at 9:12 AM, V2 (Director of Nursing) stated R1's phone was taken from her a couple of months ago. V2 stated R1's phone was taken from her due to R1 using the phone to dial 911, take photographs of residents, and playing loud music on her phone in the dining room.On 8/7/26 at 11:28 AM, V3 (Social Services) stated R1's phone was taken from her on 6/26/26 and her phone has not been returned to her. V3 stated she believed the phone was taken from R1 because R1 was inappropriate with her phone. V3 stated she was not aware R1's phone was taken as described by V4. V3 said, She [V4] should not have taken her [R1] phone from her as a bargaining tool to get her to go back to her room. That was not okay.On 8/7/26 at 12:59 PM, V1 (Administrator) stated, We do still have [R1's] phone. V1 located R1's phone in V2's office next to V2's desk.On 8/7/26 at 2:25 PM, R1 stated she believed her phone was taken away because she did not use headphones and she was taking pictures. R1 stated she wanted her cell phone returned.The State of Illinois Residents' Rights for People in Long-Term Care Facilities showed, Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on interview and record review the facility failed to transport a resident in a wheelchair in a safe manner for 1 of 4 residents (R2) reviewed for transport in the sample of 7. This failure resulted in R2 falling forward from the wheelchair and sustaining a femur fracture. The findings include:R2's Care Plan shows R2 is alert and oriented with activities of daily life self-care performance deficits related to osteoarthritis to bilateral knees, chronic pain, weakness, edema, activity intolerance, and osteoporosis. On 6/29/26 at 10:42 AM, V6 Activity CNA said she was with several residents on an outing to a local superstore. V6 said R2 had finished her shopping and V6 was pushing R2 in her wheelchair out of the threshold of the door of the store. V6 said she was looking straight ahead of R2 at some other residents that were in front, when she heard V7 Auxiliary Volunteer said Oh! V6 said when she looked down R6 was falling forward out of the wheelchair. V6 said she was unable to stop R2 from falling. V6 said R2 did not have footrests on her wheelchair. V6 said R2 landed on her stomach, and she knew right away that it was bad. V6 said V7 called 911. V6 said they have since been trained on no pedals, no push. On 6/29/26 at 12:00 PM, V7 said she was in the entry way of the superstore with a resident when she saw V6 and R2 come through the doors. V7 said R2 fell forward out of the wheelchair and landed on her knees and then her face. V7 said it all happened so quickly she could not recall if there were footrests or not on R2's wheelchair but there is supposed to be. On 6/29/26 at 9:40 AM, V3 and V4 Certified Nursing Assistants (CNA) said there has to be footrests on the resident's wheelchairs in order to push them. They both stated, No pedals, No push. On 6/29/26 at 12:21 PM, V1 Administrator said no pedals no push has always been the policy of the facility and R2's footrests had just been forgotten that day. On 6/29/26 at 12:42 PM, V9 Physician said R2 had a mechanical fall from her wheelchair and had sustained a fracture. V9 said R2 was still in the hospital so he did not have the details of the fracture yet. V9 said footrests should be on the wheelchairs when residents are being propelled. R2's Progress Note dated 6/23/26 shows resident is being transferred to a larger hospital via ambulance due to left femur fracture. R2's Hospital emergency room Notes dated 6/23/26 shows Chief Complaint: fell from wheelchair face first coming out of store. Assessment: left femur fracture. The facility's undated No Pedals, No Push Policy shows Footrests for wheelchairs shall be applied to wheelchair regardless of who is aiding with transport.

Based on observation, interview and record review the facility failed to ensure residents were treated with respect for 4 of 6 residents (R1, R3, R4, R7) reviewed for respect in the sample of 7. The findings include: On 6/29/26 at 9:45 AM, R1 was sitting in her wheelchair at the nurse's station. R1 said she has problems with the night Certified Nursing Assistant (CNA) V10. R1 said V10 acts like she is mad at her. R1 said she had her call light on to be changed and V10 came in and said she would be back and then never came back to help her. On 6/29/26 at 11:02 AM, R4 was sitting in her wheelchair in her room. R4 said V10 has turned off her call light saying she would come back and then never did. R4 said she thinks V10 went home and forgot about her. On 6/29/26 at 11:20 AM, R3 was sitting in her recliner in her room. R3 said she needs help transferring to the wheelchair and help with incontinence care. R3 said V10 has a cocky attitude and is lazy. R3 said V10 does half the job and leaves a mess for the other CNA. R3 said V10 has come in and turned her light off saying she would be back and then never comes back. On 6/29/26 at 11:43 AM, R7 said she has issues with V10. R7 said she has asked V10 for a box of tissues and V10 told her to use wet wipes. R7 said V10 has said to her you called me in here for that? and What do you want me to do about it! R7 said V10 is mouthy. On 6/29/26 at 10:17 AM, V4 CNA said R1 has complained to her about V10 not taking care of her and R3 and R4 had also complained to her about V10 not being nice. V4 said R1, R3 and R4 are alert and oriented. On 6/29/26 at 12:21 PM, V1 Administrator said there have been issues with V10's attitude in the past with another resident and R1 has complained about V10 as well. On 6/29/26 at 2:09 PM, V1 Administrator said residents have the right to be treated with respect. The facility's May 2026 Grievances shows Nightshift CNA at times has a bad attitude. The facility's Resident Council Minutes dated 5/21/26 shows Nursing: One resident reports an issue with a nightshift CNA. She says that the CNA often times has a poor attitude. The facility's Resident Council Minutes dated 6/18/26 shows Nursing: Residents stated that the nightshift CNA is still not always kind to them. The facility's undated Resident's Rights Policy shows Residents shall be treated with consideration, respect and absence of abuse.

Based on interview and record review, the facility failed to report a resident's (R1) allegation of sexual abuse to Illinois Department of Public Health (IDPH) and local law enforcement. This applies to 1 of 3 residents reviewed for abuse reporting in the sample of 3.The findings include:R1's electronic face sheet printed on 3/26/26 showed R1 has diagnoses including but not limited to congestive heart failure, type 2 diabetes, Alzheimer's disease, dementia with behaviors, major depressive disorder, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 refused to have her cognitive status assessed. During interview with R1 on 3/26/26, surveyor determined R1 is alert and oriented to person, place, and time.R1's care plan dated 12/18/25 showed, (R1) does have an Alzheimer's dementia diagnosis and does report experiencing visual hallucinations as well as long held delusions. (R1) does experience agitation and has displayed combative behaviors; however, her behaviors have improved greatly over the past quarter.R1's progress notes dated 3/19/26 showed, A few minutes after 0600-CNA came up to this nurse to report what (R1) had told her just now. (R1) said she only got changed once during the night. This is untrue, nurse knows she was changed at least twice by night shift CNA (Certified Nursing Assistant). (R1) then stated that (V9-CNA) isn't allowed in her room because she molested me .On 3/26/26 at 9:40AM, R1 stated, There was a girl who didn't want to answer my call light but she's fine now. I'm not going to tell you who it was because she has been really good and taking care of me. It wasn't a big deal; I just wanted you guys to know when it was happening. She molested me too . Surveyor attempted to talk to resident about including Ombudsman with her concerns but resident declined further discussion.On 3/26/26 at 10:41AM, V6 (Social Services) stated, From what I was told, (V9) and the other aide were toileting (R1) and when she was getting up from being cleaned up (V9) pinned her against the wall and was looking at her while cleaning her up. We did do an investigation and there were no findings. It depends on the day with (R1) and if she is getting along with us or not if she is going to make any accusations or not.The facility's investigation dated 3/19/26 showed, Accusation: (V9) molested (R1). This was voiced by the resident. Actions Taken: Spoke with (V9) and (V8-CNA) who are the aides on that shift. They gave their statements/reports. Based off of this, the claims made against (V9) have been unfounded and non-credible . No documentation was present in the facility's investigation showing that local police or IDPH were notified of R1's allegations.On 3/26/26 at 12:14PM, V9 stated, The first time (R1) alleged I did something was in February, I think. I made a statement and the facility has it. I was just told I shouldn't take care of her anymore. I don't think there was any investigation or anything like that. I haven't had contact with (R1) since that time. I do not go in her room even with other staff.On 3/26/26 at 12:49PM, V1 (Administrator) stated, I am the abuse coordinator for the facility. Normally this would be something I would report but this has been an ongoing situation that we weren't sure was a new allegation or something from her previous allegations she made. (R1) initially made the allegations back in January but then she said something again last week, so we weren't sure if this was a new allegation or still something from before. We did not report anything in January either. If we reported everything (R1) alleged against staff, you guys would be here all the time.The facility's undated policy titled, Abuse Prevention Policy & Procedure showed, It is the policy of the facility that all residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. It is our mission to ensure the maximum safety, sense of security, and quality of life for each of our residents. The abuse coordinator and abuse prevention committee members are responsible for the implementation of this policy to ensure the safety of each of our residents .Reporting of Abuse: It is our policy to report all incidents of abuse. If the reporter is unsure an incident meets the definition of abuse, our policy is to report .All abuse incidents shall be reported to the state no later than 24 hours after the incident occurs .A full completed investigation shall be reported within 5 days of the incident .Sexually Based Incidents: All sexually based abuse incidents shall be investigated. If the resident lacks decision making or the committee suspects lack of decision-making ability, the incident shall be investigated as an abuse incident to determine the victim and alleged perpetrator .

Based on interview and record review, the facility failed to schedule a follow up dental visit for a resident (R1) experiencing oral pain. This applies to 1 of 3 residents reviewed for quality of care in the sample of 6. The findings include:R1's electronic face sheet printed on 3/11/26 showed R1 has diagnoses including but not limited to congestive heart failure, Type 2 diabetes, Alzheimer's disease, major depressive disorder, hypertension, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and experiences delusions.On 3/10/26 at 12:56PM, R1 stated, I went to the dentist last month and they said I need 4 teeth extracted on the top of my mouth. They didn't do any x-rays or cleaning. Ibuprofen helps with the pain and takes it all away. When I went to the hospital they gave me antibiotics but I had a reaction to it. They said maybe I had an infection and that's why it was hurting so they ordered an antibiotic to cover it. I had a follow up appointment scheduled last week, but the facility turned the transportation away because I didn't have anyone to go with me. I don't feel like I need anyone to go with me. I don't know what the plan is to get me to the dentist.R1's medication administration notes dated 2/1/26-3/11/26 showed R1 utilized Ibuprofen and Tylenol 15 times for oral pain. 10 of the 15 occurrences were between 2/20/26 and 3/11/26.R1's dental visit note dated 2/19/26 showed, Patient presents for limited exam for upper anterior tooth pain. Took PA (periapical) for #10 per doctor. Doctor noted #10 all surface decay with PARL (Periapical Radiolucency). Doctor recommends #10 be extracted with oral surgeon. Patient noted she would like sedation and referred to (local oral surgeon). Patient accepted referral. Doctor recommends to return for full exam as other teeth need to be addressed .Advised patient seek comprehensive care and return for evaluation of other areas as soon as possible .On 3/10/26 at 10:13AM, V5 and V6 (Registered Nurses) stated, We use (local transportation company) if a resident doesn't have family to escort them to appointments. The company requires either family or staff to ride to all appointments so if there isn't family or a staff member to escort the resident, we have to reschedule the appointment. That has happened a few times but nothing major. (R1) does not currently have any follow up dental appointments. V5 stated, I worked last week and nobody told me (R1) had an appointment. The morning of her appointment we asked (V4-Transportation) who was riding with her. She said nobody could go with her alone because she accuses staff of things. I asked why 2 people couldn't ride with her but in the meantime, someone said her appointment was cancelled. (R1) was looking for transportation and ended up calling 911 to see if the ambulance can take her. She can't ride alone because she has Dementia. The ambulance ended up showing up and taking her and (V1-Administrator) said she was being sent out for a psychiatric evaluation, but the hospital didn't do one. They just gave her an antibiotic because of her mouth pain.On 3/10/26 at 10:47AM, V4 (Transportation) stated, I get notified by the nurses or family or whoever makes the appointments that a resident either needs transportation or if family is taking them. If they come back with any follow up appointments I set up transportation and sometimes family will cancel transportation and take the resident on their own. (Transportation company) requires someone to ride with the resident and that can be a struggle if family can't ride with. I do a lot of ride alongs with residents. From what I understand, (R1) called and set up a dental appointment and set up transportation on her own. The day of the appointment we didn't have anyone that could ride along with her. We had to cancel but the week prior she went to an appointment with a friend. I had set up transportation for her and then her friend was going to ride with, but when they showed up she had already left with her friend in her personal car. We called the dentist because she had been gone all day and didn't return until about 4pm. She did make it to the appointment. Last week would have been a follow up from that prior appointment. They were going to follow up on her sore tooth and have a cleaning. Last week she called 911 to take her to the dentist but they took her to the hospital. They wanted a psychiatric evaluation done because they said she shouldn't be calling 911. I don't remember who said it but it was someone in administration here. There is no plan to reschedule that visit because she didn't give us any paperwork when she came back from the 2/19 appointment, so we aren't sure what even really needs to be done.On 3/10/26 at 12:46PM, V3 (Social Service Director) stated, (R1) was supposed to take arranged transportation to her dentist appointment on 2/19 but left with her friend without taking any paperwork and then came back with nothing. We don't know what was done or what follow up was needed because she refused to take the paperwork. I'm not aware of any further appointments that she has.On 3/10/26 at 1:32PM, V1 (Administrator) stated, I'm not sure what is happening with (R1's) dental appointment. I think it was just for a cleaning so I don't think it needs to be rescheduled. She left with her friend and came back with no paperwork on the 19th and then all of a sudden transportation showed up here on the 4th to transport her, but we had no staff members to ride with her. The appointment has not been rescheduled and to my knowledge it won't be.On 3/10/26 at 3:25PM, V7 (Dentist office scheduler) stated, (R1) came in on February 19th for an urgent care appointment. We did tell her she needed oral surgery. We took a PAN (Panoramic x-ray) of the tooth and the dentist noted decay. We gave her a referral for oral surgery because the teeth need to come out. She was a no-show for her appointment on March 4th and we haven't heard anything from her or the facility about rescheduling.On 3/11/26 at 11:12AM, V2 (Director of Nursing) stated, If a resident returns to the facility after an appointment without paperwork, I would expect the nurses to call and follow up on the appointment and see if there were any orders or follow up appointments needed. If (R1) had a follow up appointment scheduled and we weren't able to get her transported there then we should have rescheduled that appointment.The facility's undated policy titled, Resident Appointments showed no guidance on what staff members should be doing if a resident returns from an appointment without paperwork.

Based on observation, interview and record review the facility failed to obtain and monitor weights for a resident (R6) with recent significant weight loss. The facility failed to inform the dietician of a decreased oral intake for a resident (R6) with recent significant weight loss. The facility also failed to notify the dietician that a resident's (R7) nutritional supplement was discontinued. These failures contributed to R6 and R7's continued weight loss. This applies to 2 of 3 residents (R6, R7) reviewed for weight loss in the sample of 17.The findings include: 1.R6's care plan revised on 7/21/24 showed R6 was at risk for weight loss related to her diagnosis of Multiple Sclerosis. The plan showed R6 required staff assistance to complete all activities of daily living. R6 was cognitively intact. R6's Weight Summary report showed R6 weighed 237.5 lbs (pounds) on 8/12/25, 218.9 lbs on 9/24/25 and 206 lbs on 11/5/25. The report showed no documented weight in October 2025 for R6. The report showed R6 sustained a significant weight loss of 13.3% from August 2025 to November 2025. The report showed no documented weights for R6 after 11/5/25. A Dietary Progress Note dated 11/12/25 showed R6 was seen and assessed by V7 Dietician. The note showed R6 had a 13% weight loss in 3 months related to her diagnosis of MS (Multiple Sclerosis) and consuming less than 50% of meals and skipping meals. R6 also had slow healing wounds to both buttocks. The note showed, Nutrition interventions. Recommend start 2 Cal (liquid protein supplement) three times a day, weights to be monitored weekly. monitor oral intake. On 12/1/25 at 9:52 AM, R6 was in bed. R6 stated she had been losing weight. R6 stated, No my weight loss wasn't something I was trying to do. I haven't been hungry. When V6 was asked when she was last weighed, V6 stated, It's been a little awhile. R6's Nutrition/Meal Intake report dated 11/12/25-12/2/25 showed R6 primarily consumed only 0-25% of her meals during that time. The report showed R6 refused to eat 12 meals during that time. On 12/2/25 at 10:37 AM, R6 was weighed by V6 Certified Nursing Assistant (CNA) with this surveyor present. The scale showed R6's weight was 199 lbs. This showed R6 had sustained an additional 3.4% weight loss from 11/5/25-12/2/25. On 12/2/25 at 9:55 AM, V4 Registered Nurse (RN) stated staff monitor residents for weight loss by weighing residents and monitoring how much residents eat. V4 stated staff are to notify the dietician as soon as possible, via note or phone call, if a resident is losing weight and/or not eating. On 12/2/25 at 11:35 AM, V7 Dietician stated she monitors residents for weight loss by monitoring residents' weights and their oral intake. V7 stated, I expect staff would notify me if a resident, with a history of weight loss, continued to lose weight and/or if that resident wasn't eating. V7 stated she assessed R6 on 11/12/25 after she had sustained a significant weight loss. V7 stated, I recommended starting her on a protein supplement for the weight loss. I also requested (R6) be weighed weekly and staff were to monitor her oral intake. V7 stated she was not aware R6 had not been weighed since 11/5/25. V7 stated, She was to be weighed once a week starting November 12, 2025. R6's meal intake record dated 11/2/25-12/2/25 was reviewed with V7. V7 stated she had not been notified by facility staff that R6's oral intake had continued to be poor from 11/2/25-12/2/25. V7 stated, The expectation was that (R6) was weighed as I had recommended. If she had continued to not eat or continued to have a poor appetite, I should have been notified. 2. R7's admission Record shows she was admitted to the facility on [DATE], with diagnoses including paraplegia, dementia, and dysphagia. R7's Weights and Vitals Summary dated 12/2/25, shows R7 weighed 166.1 on 3/2/25. R7 weighed 145.5 on 9/3/25. This was a 12.4% weight loss over six months. V7's Dietitian Note dated 9/12/25, shows, Resident with fair to good oral intakes; has been noted to be eating less at meals by staff. Significant weight loss per minimum data set. Recommend starting 60ml Two Cal (liquid nutritional supplement) three times per day and monitoring weekly weights. Recommendations to be faxed to primary care provider. Goal for weight to remain within 5 pounds of 145 pounds. R7's Medication Administration Record (MAR) dated 9/1/25-9/30/25, shows an order for nutritional supplement 60 ml three times per day. R7's MAR shows she received the supplement 15 out of 18 times. R7's MAR dated 10/1/25-10/31/25, shows she received the supplement 13 out of 16 times. R7's MAR shows the nutritional supplement was discontinued on 10/6/25. R7's Progress Note dated 10/6/25, entered by V3 Licensed Practical Nurse (LPN) shows that R7 disliked the nutritional supplement, refused to drink it, and the order was discontinued. R7's Weights and Vitals Summary dated 12/2/25, shows R7 weighed 161.4 pounds on 6/3/25. On 12/1/25, R7 weighed 135 pounds with is a 16% weight loss in six months. R7 weighed 145 pounds on 11/4/25, and on 12/1/25, R7 weighed 135 pounds which is a 6.9% weight loss in one month. On 12/2/25, at 11:34 AM, V7 Dietitian said she started the nutritional supplement in September 2025 due to her weight loss. On 12/3/25, at 9:40 AM, V3 LPN said when residents refuse nutritional supplements, it is documented in the residents' MAR. V3 said the dietitian should be notified if residents are refusing nutritional supplements so the dietitian can try something else. V3 said if residents do not take their nutritional supplements, then the resident can continue to lose weight and not get the nutritional value that they need. V3 said that V7 Dietitian was aware that R7 was not taking her supplement and did not know if V7 tried any other dietary supplement. On 12/3/25, at 10:20 AM, V7 Dietitian said she was not aware that R7's nutritional supplement was discontinued in October. V7 said if she had known that R7's nutritional supplement was discontinued, then V7 would have implemented other interventions to prevent further weight loss. V7 said R7 likes chocolate, so chocolate could have been added to the nutritional supplement. V7 said there are other options for nutritional supplements. V7 said she would want to know if a resident if refusing their nutritional supplement. The facility's Dietary Policy: Obtaining Accurate Height/Weight revised 1/6/11, shows, All weekly weight will be completed on Monday of each week. Registered Dietitian and Physician will be notified of any significant weight change. The facility's Significant Weight Loss policy implemented 10/1/07, shows, The goal of medical nutrition therapy is to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem.

Based on observation, interview and record review the facility failed to provide a restorative program for a resident with limited mobility. This failure resulted in R22 experiencing a decline in mobility. This applies to 1 of 6 residents (R22) reviewed for range of motion/mobility in the sample of 17. The findings include: R22's admission Record dated 12/2/25, shows she was admitted to the facility on [DATE], with diagnoses including osteoarthritis, abnormalities of gait and mobility, morbid obesity, pain in right knee, localized edema, and anxiety disorder. An order for physical therapy was entered on June 25, 2025. On 12/1/25, at 10:57 AM, R22 was observed sitting in her wheelchair. R22 said she is not able to stand. R22 said she does exercises when the exercise room is opened, but it's not opened every day. R22 said when the exercise room is opened, she does exercise to her right leg which is her weaker leg. R22 said no one walks her in the facility. R22 said facility staff have to use the stand lift in order for her to use the bathroom. R22 said she wanted to do enough exercises to allow her to go back home.On 12/3/25, at 9:10 AM, V10 Certified Nursing Assistant (CNA) said when residents get restorative therapy, the minutes are documented in the facility's computer charting program. At 9:12 AM, V11 Restorative CNA said she is working the floor today as a certified nursing assistant. V11 said R22 goes to the exercise room and does exercises with her right leg. V11 said the exercise room is opened at various times. V11 said the exercise room is only opened if there is enough staff because staff has to stay in the exercise room when residents are in there. V11 said the last day the exercise room was opened was on 11/26/25. V11 said she mostly works Monday Friday and every third weekend. V11 said she is usually able to do restorative exercises with the residents 1-2 days per week and the rest of the time she is working on the floor as a CNA because there is not enough staff to allow her to do restorative therapy. At 9:40 AM, V3 Licensed Practical Nurse (LPN) said the facility has a restorative nurse. V3 said the restorative nurse works the floor at times so she is unable to do restorative exercises with the residents. V3 said there is an exercise room that residents can use, but it's not always opened because staff have to be in there, and there are not always staff available to be there. V3 said the purpose of restorative therapy is to keep residents stabilized in their movements, keep their health and weight stable. R22's Minimum Data Set, dated [DATE], shows that she was using a walker and a wheelchair. R22's Minimum Data Set, dated [DATE], shows she was only using the wheelchair. R22's Rehab Form dated 6/30/25, shows, Presents to outpatient physical therapy with generalized weakness and impaired functional mobility which is not impairing her ability to transfer from her reclining lift chair and also to mobilize with use of her four-wheeled walker and use of the wheelchair. It is patient's desire to return to home alone in her single-story home. R22's Outpatient Therapy discharge note dated 7/25/25, shows, R22 performed all of her exercises with physical therapy and was discharged from physical therapy. Education provided for home exercise program and continued work on transfers and mobility with restorative therapy. She will continue to work with restorative therapy on strengthening and sit to stand transfers from her wheelchair within the parallel bars or with use of her front wheel walker. She has progressed with transfers from transferring with maximum assistance of one to transferring with minimum to moderate assistance of one with use of front wheel walker. She is able to stand approximately 60 seconds with standby assistance with use of the front wheel walker and is standing more upright without assistance. She is independent with her home exercise program and will continue with strengthening with restorative therapy. R22's Restorative documentation group exercises shows R22 has received 195 minutes of restorative therapy in the last 30 days. There was five days where R22 did not receive any restorative therapy. On 12/3/25, the facility said they did not have a policy in regard to Restorative Therapy.

Based on interview and record review the facility failed to provide a facility assessment. This applies to all 34 residents residing in the facility. The findings include:The long-term care facility application for Medicare and Medicaid dated 12/1/25 shows, there are 34 residents residing in the facility. On 12/3/25 at 11:40 AM, V1 Administrator stated she could not find her completed facility assessment. V1 did provide a facility assessment tool kit that did not have any facility information in it. The facility provided paper on 12/3/25 shows, Facility Assessment: Completed: 11/28/2024 however, there was no completed assessment. On 12/3/25 at 2:25 PM, V1 Administrator stated, she did not have a facility assessment policy. The facility did not provide a policy on the facility assessment.

Based on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 17 residents (R6, R16) reviewed for infection control in the sample of 17.The findings include:A facility list dated 12/1/25 showed R6 was on Enhanced Barrier Precautions due to her having wounds to her buttocks and having a urinary catheter in place. The list showed R16 was also on EBP due to her having a urinary catheter in place.1.On 12/1/25 at 11:50 AM, R6 was in bed. An Enhanced Barrier Precautions (EBP) sign was noted on the door to R6's room. The sign showed staff were to wear a protective gown, gloves, and mask when providing high contact cares to R6. An isolation cart containing PPE (personal protective equipment) was noted in the hallway by the entrance to R6's room. At 11:52 AM, V5 Certified Nursing Assistant (CNA) entered R6's room to provide cares. V5 donned a mask and gloves upon entering R6's room but did not don a gown. From 11:52 AM-12:32 PM, V5 CNA provided a bed bath to R6, without donning a protective gown, which included cleansing the wounds to R6's buttocks and handling R6's urinary catheter. 2. On 12/1/25 at 9:37 AM, R16 was seated in a recliner in her room. R16's urinary catheter bag hung off the recliner. No EBP signage was noted on or around the doorway to R16's room. No PPE cart was noted in the hallway by R16's door. When R16 was asked if staff wore a gown and gloves when they provided cares to her, R16 stated, They used too but don't anymore.On 12/2/25 at 8:56 AM, R16 was again seated in the recliner in her room with her urinary catheter bag hanging off the recliner. No EBP sign was noted on the door to her room. No isolation cart was noted in the hallway by her door. On 12/3/25 at 10:17 AM, V12 Infection Preventionist (IP) stated both R6 and R16 are to be on EBP. V12 stated residents on EBP are to have an EBP sign on the door to their rooms and an isolation cart containing PPE out in the hallway near their rooms. V12 stated a bed bath or shower are both considered high contact care activities which would require staff to wear a gown, gloves and mask when providing cares to residents with wounds and/or urinary catheters.On 12/3/25 at 11:52 AM, V12 IP stated she was unable to find a facility policy on Enhanced Barrier Precautions.

Based on observation, interview and record review the facility failed to supervise residents during medication administration to prevent a medication administration error. The facility failed to ensure a resident was transferred in a safe manner. This applies to 2 of 17 residents (R3, R28) reviewed for safety and supervision in the sample of 17.The findings include:1.R3's current care plan showed R3 was severely cognitively impaired related to her diagnosis of dementia.R3's Incident Notes dated 10/31/25 showed, While giving medication to tablemate (R17), resident (R3) grabbed the pills and water and started taking the other residents pills. The notes showed R3 ingested R17's medications which included Bumex (diuretic medication) 1 mg (milligram), Entresto 24/25 mg (blood pressure medication), Rexulti 0.5mg (antipsychotic), Rosuvastatin 10 mg (cholesterol medication), and Spironolactone 25 mg (diuretic). The notes showed R3's physician was notified of the incident. R3 was monitored by facility staff. R3 had no adverse outcome from the medication ingestion. On 12/1/25 at 11:29 AM, V3 Licensed Practical Nurse (LPN) stated on 10/31/25, I was passing medications in the dining room. I set (R17's) pills in a cup on the table by her. (R3) was also seated at the table. When I turned away to give (R17) her insulin shot, (R3) reached over and swallowed (R17's) pills. I tried to get her to spit them out. V3 stated, I should have watched (R17) take her pills first. I should have given (R17's) insulin shot to her in her room.The facility's Medication Administration/Control of Medications policy (undated) showed the facility will establish safe and accurate nursing procedures for dispensing medications to residents.2.R28's admission Record dated 11/14/25 showed she was admitted to the facility with diagnoses of repeated falls and unsteadiness related to leg weakness.R28's Baseline Care Plan dated 11/14/25 showed R28 required assistance from one staff member for toileting and transfers. On 12/1/25 at 9:12 AM, R28 was seated on the toilet in her room with her call light on and flashing. A wheelchair was positioned in front of R28, with the handles of the wheelchair facing R28. At 9:14 AM, V8 Certified Nursing Assistant (CNA) entered R28's room to provide cares. A gait belt was secured around V8's waist. Without placing a gait belt on R28, V8 asked R28 to stand from the toilet by holding onto the handles of the wheelchair located in front of her. R28 slowly stood, slightly bent over, resting her upper body on the wheelchair, without any physical assistance from V8. V8 wiped R28's buttocks and pulled up her pants. V8 then held onto R28's right arm and used her other arm to rotate R28's wheelchair. Once the wheelchair was in place, R28 sat down on the chair. On 12/1/25 at 11:45 AM, V9 Physical Therapist stated staff need to use a gait belt when transferring R28 for R28's safety. The facility's Transfer/Gait Belt policy (undated) showed, To promote resident comfort and safety and to prevent employee injuries, transfer belts shall be used. All nursing staff and the rehabilitation team shall utilize a transfer belt for resident mobility when the resident requires one or more to assist him/her during a transfer or ambulation.

Based on observation, interview and record review the facility failed to ensure a dressing was in place to an open wound. This applies to 1 of 17 residents (R22) reviewed for quality of care in the sample of 17.The findings include: R22's admission Record shows she was admitted to the facility on [DATE], with diagnoses including osteoarthritis, diabetes mellitus, morbid obesity, localized edema, and venous insufficiency. R22's Order Summary Report dated 12/3/25 shows an order was entered 6/25/25 for, Sodium chloride external solution. Apply to bilateral lower extremities two times a day. Cleanse bilateral lower extremities venous stasis ulcers with 50/50 vinegar and normal saline. Apply nonadherent gauze, abdominal dressing (as needed for drainage), and kerlix wrap. On 12/1/25 at 10:57 AM, R22 was observed sitting in her wheelchair. There was a large open wound to R22's left knee area that was about two inches by two inches. The wound had a yellowish wound bed. There was no dressing in place to this wound. R22 said facility staff do not put a dressing to the wound to her left knee area. On 12/3/25 at 10:26 AM, V12 Infection Preventionist/Registered Nurse said R22's left knee wound is cleaned with a cleanser, but no dressing is placed. V12 was unsure how they were preventing infection from getting into R22's knee wound. V12 said she was going to clarify R22's dressing orders with R22's doctor. (No clarification was provided to the team by the end of this survey). On 12/3/25 at 9:12 AM, V11 Certified Nursing Assistant (CNA) said sometimes R22 has a dressing to her left knee and sometimes she does not.

Based on observation, interview and record review the facility failed ensure a resident's cannabidiol (CBD) medication was securely stored and inaccessible to a resident for 1 of 17 residents (R2) reviewed for medication storage in the sample of 17.The findings include:On 12/1/25 at 9:50 AM, R2 was seated in bed. A small silver tin container, covered with a lid labeled Extra Strength 1500 mg (milligram) CBD Balm, was noted on R2's bedside table. R2 pointed to the CBD balm and stated, I put that on my back and knees when they hurt. When R2 was asked how much balm does she apply with each application, R2 stated, However much I want. On 12/2/25 at 9:56 AM, R2 was asleep in bed. R2's tin of CBD balm remained on her bedside table.On 12/2/25 at 9:08 AM, V4 Registered Nurse (RN) stated R2 cannot self-administer any of her medications because R2 is confused on and off.On 12/2/25 at 11:59 AM, V1 Administrator stated, We do allow residents to receive CBD products here if they are prescribed. A resident will need a physician order for the CBD for us to be able to administer it.On 12/3/25 at 10:24 AM, V12 RN stated all CBD products require a physician order to be used in the facility. V12 stated, All CBD products must be stored in a secure med room or med cart. A resident must be cognitively intact to be able to keep these products in their room. (R2's) cognition is not high enough to allow her to keep CBD at her bedside.R2's November 2025 and current December 2025 Medication Review Reports showed no physician orders for R2's CBD balm. On 12/3/25 at 10:50 AM, V1 Administrator stated the facility had no policy on resident use of CBD products.The facility's Medication Administration/Control of Medications policy (undated) showed, Self-administration of medication is permitted only upon written order from the attending physician. Topical medications can be kept at the resident's bedside if specified in the physician orders.The facility's Storage of Medications policy (undated) showed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample 3. The findings include: The facility's Incident Report dated 10/13/24 documents R1 was groping R2's breast. V7 (Agency CNA-Certified Nursing Assistant) witnessed R1 groping R2's breast in the dining room. R1's face sheet shows he is an [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, atrial fibrillation, major depressive disorder and metabolic encephalopathy. R2's face sheet shows she is a [AGE] year-old female with diagnoses including ischemia cardiomyopathy, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, heart failure, aphasia, and dementia. On 10/16/24 at 9:38 AM, R1 was observed in his room lying in bed. He was alert to self, he was confused to the month and year. R1 could not recall the incident with R2. On 10/16/24 at 10:07 AM, R2 was observed in the sunroom sitting in her wheelchair with a flat affect. She responded to her name but could not answer questions. On 10/16/24 at 2:55 PM, V7 said she was entering the dining room. R1 and R2 were both in their wheelchair's sitting next to each other. R1's hand was groping R2's right breast, he was touching and squeezing her breast. R2 sat there and did not say anything. R2 was not wearing a bra under her shirt and is well endowed. R1 was definitely foundling R2's breast. She told R1 not to touch other residents and removed him from the table. She reported the incident to V4 (LPN-Licensed Practical Nurse). On 10/16/24 at 12:15 PM, V4 (LPN) said she was in the dining room preparing medications around 4:30 PM to 5:00 PM. R1 was in the dining room in his wheelchair. She saw R1 using both feet self-propelling towards R2 with a purpose. R2's back was facing her and R1 was positioned next to R2. She continued to prepare her medications and saw V7 leaning towards R1 and removing him from the table. V7 then reported R1 was groping R2's breast. R1 and R2 knew each other from the community and knows R1 recognizes R2. R1 is alert to self, forgetful, he had a stroke and has limitations to his left side. He is on hospice and has declined. R2 is aphasic and does not communicate her needs, she seemed hesitant after the incident. On 10/16/24 at 10:30 AM, V10 (CNA) said R1 is forgetful and normally has no issues. She has seen R1 sit next to R2 talking to her in the past. They are both from this area and not sure if they know each other from the community. On 0/16/24 at 12:05 PM, V1 (Administrator) said she was notified about the incident that evening. V7 witnessed R1 groping R2's breast and reported the incident. She was surprised because it was unusual behavior for R1, none the less it was inexcusable. I don't think it's intentional abuse. R2's care plan dated April 2024 shows she has impaired cognitive function, has difficulty making decisions, following direction, has expressive aphasia related to a stroke. R2 is dependent on staff for meeting her emotional, intellectual, physical and social needs related cognitive deficits and physical limitations. The facility's Abuse Prevention Policy states, It is the policy of this facility that all residents will be free from abuse, neglect .sexual abuse of a resident by a staff member, another resident, or a visitor. Sexual abuse includes but is not limited to sexual penetration, intentional sexual touching without permission or ability to consent .

Based on interview and record review, the facility failed to implement their policy regarding Legionella management. This failure has the potential to affect all residents in the building. The findings include: The resident census report dated 10/1/24 showed 44 residents currently residing in the building. On 10/3/24 at 9:38AM, V1 (Administrator) stated, I have been working with (hospital infection preventionist) on our policy but we don't have any plan set yet. We don't have any of the water management program done yet, just the hospital one. We have no diagrams, surveillance process, or testing process completed or initiated yet. If we had a Legionella outbreak, we would probably not have any idea of where to even start looking as we haven't implemented anything yet. On 10/3/24 at 10:37AM, V3 (Infection Preventionist) stated, We have not done anything with legionella that I am aware of. I believe the plan is in process, but we haven't implemented anything yet. The facility's undated policy titled, Legionella and Waterborne Pathogens Policy showed, Objective: I. To establish a water management program which reduces the risk of Legionnaire's Disease, Pontiac Fever, and other infections due to waterborne pathogens associated with the hospital water system. II. To establish a surveillance process and criteria for defining hospital acquired Legionella and other infections due to waterborne pathogens.

Based on interview and record review, the facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ). This failure has the potential to affect all residents in the facility. The findings include: The facility's roster dated 10/1/24 showed 44 residents residing in the building. The facility's PBJ report dated April 1-June 30, 2024 showed, Failed to submit data for the quarter. On 10/2/24 at 10:03AM, V1 (Administrator) stated, I was made aware that this data was not submitted and there is no reason why. Our corporate staff usually submit it but for some reason they just didn't. We have already received our notification in the mail from IDPH (Illinois Department of Public Health) regarding this so I already knew about the issue. We don't have any policy regarding the PBJ reporting.

Based on interview and record review the facility failed to assess non-pressure wounds, failed to have treatments in place for wounds, and failed to notify the physician of new wounds. This applies to 2 of 2 residents (R10 & R41) reviewed for wound care in the sample of 13. The findings include: 1. R10's Admission Record (Face Sheet) showed he was admitted to the facility on [DATE]. R10's 7/11/24 Skin/Wound Note from 6:45 PM showed, Dime size areas noted on coccyx (tail bone area) with cares. Area cleansed and [protective ointment] applied for MASD (Moisture Associated Skin Damage). (The note does not document a wound bed description, measurements, or if any notifications made.) R10's 7/16/24 Skin/Wound Note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam bandage]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. (Five days after wound was first identified.) R10's 7/20/24 Skin/Wound Note from 6:49 PM showed the wound was closed. R10's 7/21/24 Skin note from 8:00 PM showed, Resident with open area in the crease of buttock. R10's July, August, and September 2024 Medication Administration Record and Treatment Administration Record showed no treatment orders for his buttock/coccyx area until 9/27/24. On 10/02/24 at 2:07 PM, V2 Interim Director of Nursing stated when wounds are identified, the floor nurse will assess the wound, which includes measurements of the wound, drainage description, and wound bed description. V2 said the floor nurse will then apply a treatment and notify the resident's provider and family. V2 said the nurse should inform them of what was identified and request orders from the provider. V2 said the purpose of assessments are to track the progression of the wound to determine if the wound is improving or declining. V2 said the purpose of wound treatments is to prevent infection and promote healing. V2 said R10's wound charting is poor and difficult to follow. V2 said the provider was notified of the wound on 7/16/24; however, he/she did not respond, and the nurse did not follow up. V2 said the provider should have been notified on 7/11/24. V2 said R10 did not have treatment orders until 9/27/24. The facility's undated Prevention and Intervention of Skin Breakdown policy showed, .3. If a skin tear or breakdown occurs, an assessment shall be completed under symptom assessment in [the electronic charting]; notification of physician and family, along with any treatment order/s and monitor wound in Treatment Book until healed .5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up . 2. R41's 7/13/24 Skin/Wound Note from 9:00 PM showed, A 2 cm (centimeter) x 2 cm open area showing the dermis (inner layer of skin) of the skin on the right buttock and there is a 1 cm x 1 cm open area showing the dermis of the skin on the left buttock. These areas show no signs of infection. [foam dressing] dressings applied for protection to these areas. Resident and staff instructed to reposition resident at least 2 hours to prevent future skin breakdown. This writer will notify the day nurse on 7-13-24 to notify [the physician] to obtain an order for dressing changes to buttocks and to notify resident's healthcare POA (Power of Attorney) of the information in this note. R41's 8/3/24 Skin/Wound Note from 1:29 PM, showed, .The [foam dressing] is not intact to the bottom of the area .The area is completely healed, inspected his buttocks and could not find an open wound. I did replace the [foam dressing] and placed zinc oxide cream to the rest of the buttocks. R41's electronic health records showed no documented assessments on or before 7/20/24 and 7/27/24. On 10/02/24 at 2:07 PM, V2 Interim Director of Nursing stated wound assessments are important for tracking the progression of wounds. V2 said assessments will allow the nursing staff to identify if current treatments are effective. V2 said nursing staff should have assessed R41's wound on or before 7/20/24 and 7/27/24. V2 stated there were no documented assessments during this time period.

Based on observation, interview, and record review, the facility failed to protect a resident (R40) from a significant medication error. This applies to 1 of 8 residents observed in the medication pass. The findings include: R40's electronic face sheet printed on 10/2/24 showed R40 has diagnoses including but not limited to type 2 diabetes, venous insufficiency, chronic kidney disease, and acute embolism and thrombosis of left lower extremity. R40's facility assessment dated [DATE] showed R40 has no cognitive impairment, has diabetes, and receives insulin. R40's care plan dated 6/11/24 showed, (R40) does have a diagnosis of diabetes mellitus. Diabetes medications as ordered by doctor. R40's physician's orders dated 9/21/24 showed, Lantus Subcutaneous Solution (Insulin Glargine) Inject as per sliding scale: If 100-280= 10 units morning and bedtime; 281-500= 25 units morning and bedtime. Follow same orders for noon and evening blood sugar. On 10/1/24 at 11:56AM, V5 (Licensed Practical Nurse-LPN) stated, (R40's) blood sugar is 238 so she has asked me to give her 15 units of her Lantus insulin. She chooses what amount of insulin she gets; she always has when she has been in the facility. We have an order for sliding scale, but she won't follow it, so we allow her to choose her dose. (R40 should have received 10 units of insulin with this blood sugar reading). On 10/1/24 at 2:00PM, R40's MAR (medication administration record) had no documentation that R40 had received 15 units of insulin, nor was there any area for staff to be able to document the medication administration. On 10/1/24 at 2:04PM, V5 (LPN) stated, (R40) came from home & she's always done this where she decides what dose of insulin she gets. Under the order it doesn't give you the option to chart on the noon and evening dose so that isn't documented anywhere. The dose I gave earlier isn't documented, but I guess I should enter a progress note so that it's documented how many units she received. She used to have an order for her to be able to get a total of 20 units sliding scale every day, but the doctor discontinued that. We have still been working off the discontinued order, but we just don't have a spot to document it in. That is definitely a problem because she could get too much insulin if we don't keep track of how much she has had. She's pretty with it though so she would probably tell us. I called her physician last week and told him about her refusing to comply with the dose, but I don't call him every time to get approval to give her the dose she wants. On 10/2/24 at 12:32PM, V2 (Director of Nursing) stated, (R40's) physician knows her history and knows she refuses the sliding scale the way it's supposed to be given. I wouldn't expect the nurses to call the doctor every time she refuses the sliding scale, they should just give it the way she wants it. Technically, we should have an order but that's how she does it at home, so we let her do it the same way. If the nurse's give any medications and there is nowhere to document it on the medication administration record then they should at least enter a progress note. It is not my expectation for them to just not document anything because then we don't know how much insulin she is receiving. The facility's undated policy titled, Medication Administration/Control of Medications showed, Objectives: 2. To identify policies for storage, dispensing and disposal of medication and controlled substances. 3. To establish safe and accurate nursing procedures for dispensing medications to residents .Procedure: 1. The nursing facility will comply with federal and state laws and regulations relating to the procurement, storage, dispensing, administration, and disposal of medications .15. If for any reason a physician's medication order cannot be followed, a notation shall be made on the resident's record describing the circumstances. The physician shall be notified . The facility's undated policy titled, Insulin Injection Administration showed, Procedure: 1. Check prescriber's order .6. Prepare injection as follows: a. Determine correct amount of insulin to be withdrawn. b. Read MAR again and compare with label on medication .i. Check medication label with MAR a third time .17. Document administration on MAR. 18. If resident refuses medication, indicate on MAR by initialing in appropriate space and circling initial .

Based on observation, interview, and record review, the facility failed to ensure resident oxygen tubing was replaced monthly for 2 of 4 residents (R7, R24) reviewed for oxygen in the sample of 13. The findings include: 1. R7's face sheet showed an [AGE] year-old female with diagnosis of obstructive sleep apnea, osteoporosis, heart failure, chronic kidney disease stage 3, fibromyalgia, and hypertension. On 10/01/24 at 09:26 AM, R7 was seated in her room. R7 had an oxygen tubing in her nostrils. The oxygen was administered at 3 liters (l) per hour per nasal cannula (nc) via concentrator. There was no date on the tubing to indicate how long it was in use. On 10/1/24 at 9:26 AM, R7 said she wears her oxygen all the time. On 10/02/24 at 11:41 AM, V3 Infection Preventionist said it is important to change oxygen tubing monthly to avoid moisture and bacteria buildup. There should be a physician order on the care and maintenance of the tubing, so it populates to the resident treatment or administration record. We can't ensure the tubing was changed if there's no documentation. If oxygen tubing is not changed, you risk compromising equipment by overuse, can cause respiratory issues for the resident and other adverse effects. The facility's undated Oxygen Administration & Respiratory Therapy Equipment Policy showed nasal cannulas and masks are changed on the last day of the month of each month, sooner if soiled, clogged or defective. R7's September treatment administration record showed no documentation the oxygen tubing was changed. R7's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment. R7's POS showed a 9/4/23 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%. R7 had no oxygen use care plan. 2. R24's face sheet showed a [AGE] year-old female with diagnosis of obstructive sleep apnea, anxiety disorder, chronic kidney disease, heart failure, hypertension, type 2 diabetes, and atrial fibrillation. On 10/1/24 at 10:27 AM, R24 was seated in a recliner in her room. R24 had oxygen tubing in her nose and the concentrator was running at 2 liters per nasal cannula. There was no date on the tubing to indicate how long it was in use. On 10/01/24 at 10:27 AM, R24 said her oxygen is on all the time except when showering or toileting. R24's September 2024 treatment administration record (TAR) showed no documentation the oxygen tubing was changed. R24's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment. R24 's POS showed a 1/26/24 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%. R24 had no oxygen use care plan.

Based on interview and record review the facility failed to have licensed staff administer medicated powder. The applies to 1 of 1 residents (R10) reviewed for pharmacy services in the sample of 13. The findings include: R10's 7/11/24 Physician Communication note from 2:09 PM showed Situation: resident red/yeasty groin. R10's Order Summary Report (Physician Order Sheet) showed an order for Nystatin Powder, apply to groin topically as needed for excoriated areas in groin. The order was started 7/11/24. R10's 7/16/24 skin/wound note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam dressing]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. R10's 7/20/24 skin/wound note from 10:51 AM showed, AM CNA (Certified Nursing Assistant) put treatment powder to [R10's] buttocks. This RN (Registered Nurse) unable to view as he is in the recliner chair. Will attempt to look at it when he is toileted if I am not with another resident. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated nystatin powder is used to treat fungal infections. V2 stated the warm moist environments, such as the groin and skin folds are prone to fungal infections. V2 stated nystatin is a medication and only nurses are allowed to administer nystatin powders. V2 stated the fungal powder should not be used to treat MASD (Moisture Associated Skin Damage] or pressure injuries. V2 stated based on the note a CNA administered the medicated powder and applied it the buttock wound instead of the groin.

Based on observation, interview, and record review the facility failed to assess a pressure injury, failed to treat a pressure injury, and failed to notify the physician of a pressure injury. This applies to 1 of 2 residents (R10) reviewed for pressure injuries in the sample of 13. The findings include: On 10/02/24 at 10:15 AM, V4 Registered Nurse (RN) removed R10's adult brief exposing an approximately 1-centimeter (cm) round, non-draining, wound to his right, upper, inner buttock. The area surrounding the wound appeared friable and inflamed. V4 provided a wound treatment and covered the wound with a 4-inch foam dressing. R10's 8/6/24 Skin/Wound Note from 6:58 PM showed, New [foam dressing] placed on upper gluteal crease. Dated for today. Area of concern is clean, no drainage, looks to be a stage 2 [pressure injury]. R10's 8/6/24 Skin/Wound Note from 7:02 PM showed, Wound measures: 0.8cm x 0.4cm, depth is approximately 2mm (millimeter). R10's 8/9/24 Skin/Wound Note from 8:49 PM showed, [Foam dressing] changed to upper gluteal crease. One open area remains, 0.5cm in diameter, 0.2cm in depth. R10's next documented skin/wound note assessment with wound measurements showed on 8/20/24 at 1:17 PM, (11 days after 8/9/24 assessment) Assessed [R10's] pressure injury while he was laying on his right side in bed. Pressure injury to the top of the gluteal crease on the right side: Measurements: 4mm long, 3mm wide and 1mm deep. Scant amount of yellowish drainage on the [foam dressing] placed by [Licensed Practical Nurse] today 8/20. Wound bed with granulation tissue at the edges, is filling in nicely. Cleansed with sterile normal saline and placed a new [foam dressing] on; dated and initialed. I thanked [R10] for laying in bed. R10 8/23/24 Skin/wound note from 2:16 PM showed, With the patient lying on his right side in bed, I donned a gown and put gloves on after washing my hands. I undid his brief. The area of concern is on the right upper inner buttock just off the gluteal fold. The area is improved since the last time this writer has seen it. Wound Measurements: 1.0cm long, 0.4cm wide and 0.1cm deep. The edges appear to be macerated and I can see granulation tissue in the small wound bed. I cleansed it with sterile normal saline and placed a new dated/initialed [foam dressing] on the area. I left the resident on his right side and he said he was going to nap. (Documented wound improved despite wound size increasing.) R10's 8/26/24 skin/wound note from 2:14 PM showed, Had to encourage [R10] to lay down in bed on his side to offload from his pressure ulcer. I then was able to perform wound care/assessment. Wound to the right upper inner buttock about 3 centimeters above the anus: Wound now measures 1cm long x 0.4cm wide and about 0.1cm deep. The edges of the wound are macerated, the wound bed is granulation tissue. No drainage, no odor. Area cleansed with sterile normal saline. Then applied a larger [foam dressing] to the buttock and I dated/initialed it. Around this wound is several reddened areas 1cm round. No open areas. This [foam dressing] covers all the areas. R10's next documented wound assessment was on 9/4/24 a 1:20 PM (9 days later). The note showed the wound was completely healed and no new open areas. R10's August and September 2024 Medication Administration record, Treatment Administration Record, and physician orders sheet showed there were no physician prescribed treatments for R10 pressure injury and no documented treatments were applied. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated wound assessments should be done weekly and should include measurements, wound bed descriptions, and drainage descriptions. V2 said the purpose of wound assessments are to track the progression of a wound and to determine if treatments are effective. V2 said the purpose of physician prescribed treatments are to promote wound healing and prevent infection. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 said there were not documented wound treatments apart from foam gauze treatments in the R10's progress notes. V2 said R10's provider and family should have been notified of the wounds when they were identified. R10's Skin/wound note from 9/11/24 showed (A new wound following the 9/4/24 note when R10's wound was healed), Assessed [R10's] buttocks while on the sit-to-stand (mechanically assisted sit-to-stand lift) from the toilet. On the left upper inner buttock, he has 2 areas of concern: Wound measurements (rough measurement as I had little time to properly measure): Wound #1 0.3cm in diameter, depth approximately 0.1 cm, wound bed beefy red, shallow. Wound #2 is next to it and measures approximately 0.2cm, depth approximately 0.1cm, wound bed beefy red. Wound beds are clean, no drainage. Applied [a gauze foam] after cleansing the area with sterile saline, initialed and dated it. Discussed with the resident [R10] about getting off of his buttocks in the afternoon and laying in bed. He was not happy about that but does verbalize understanding. (No documented provider or family notification.) R10's 9/17/24 skin/wound note from 10:47 AM showed, I assessed [R10's] skin in the shower room. His wound on the right upper inner buttock is healing nicely. It is down to one area, approximate measurements (the resident was on the sit-to-stand) was: 0.4cm in diameter and depth less than 0.1cm. The wound bed is almost healed over. [foam dressing] place, dated and initialed. R10's next documented wound assessment, following the 9/17/24, was documented on the 10/2/24 at 10:45 AM (17 days later). The skin/wound note showed, above observation, on 10/2/24 AM at. The skin/wound note showed, the wound care was observed by the state surveyor and R10's spouse. The note showed, .Wound: #1 Area measures 0.5cm in diameter and is approximately 0.1cm deep, . The wound bed was pink, no drainage. Just above this wound was unopened wounds #2 and #3, they are at the 11 o'clock position and at the 11:30 position and about 1cm from wound #1. These are healed over . R10's Order Summary Report (Physician Order Sheet) showed an order for [Foam] pad. Apply to coccyx/buttock topically as needed for MASD (Moisture Associated Skin Damage) to area on coccyx/buttock change every 2-3 days as needed. This was ordered and started on 9/27/24. R10's September 2024 Medication Administration Record (MAR) showed no documented wound care on 9/27/24, 9/28/24, 9/29/24, or 9/30/24. R10's MAR dressing change was listed only under the as needed section of the MAR. R10's progress notes from 9/27/24 through 10/1/24 showed no documented dressing changes. On 10/02/24 at 2:07 PM, V2 Director of Nursing stated there are no documented assessments for R10 following the 9/17/24 assessment and before the 10/2/24 assessment. V2 stated R10's pressure wound should have been assessed during this time period. V2 stated it is the floor nurses' responsibility to assess wounds and it appears as only one nurse was doing R10's assessments. V2 stated the physician and family should be notified whenever a wound develops, and orders should be obtained. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 stated R10's pressure ulcer dressing change order was poorly written and reads as if it should only be changed as needed instead of being completed every 2 to 3 days and as needed. V2 stated the order was listed under the as needed section of the MAR and there are not documented dressing changes from 9/27/24 until 10/2/24. The facility's undated Prevention and Intervention of Skin Breakdown policy showed, .3. If the resident has a pressure ulcer, the nurse shall complete the Wound Assessment initially in [the electronic charting]; notification of physician and family, along with treatment order/s and monitor wound in Treatment Book until healed. 4. The treatment of a pressure ulcer or wound should be determined by stage, size, location, drainage, presence of necrotic tissue, and infection status based on facility's wound care protocol and physician approval. 5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up .

Based on observation, interview, and record review the facility failed to safely transfer a resident with a hoist mechanical lift, which resulted in the resident falling from the hoist and sustaining a cervical spine (neck) fracture. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of the 3. The findings include: R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include partial left and right leg amputation; 2 diabetes; and mild cognitive impairment. R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS showed R1 was depenedent upon staff for transfers from the bed to chair. On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain. On 9/3/24 at 9:05 AM, R1 was in her geri-chair with a cervical (neck) brace in place. R1's left temple had a faint blue/purple color similar to a nearly faded bruise. R1's Serious Injury Incident Report submitted on 8/21/24 showed, CNA (Certified Nursing Assistant) report (V3) 8/12/24 - When transferring resident to the chair from bed with mechanical lift, resident leaned too far to the left and started to slip out. This CNA tried to brace the fall, but she still fell down .physician (V6 R1's physician) here to assess resident, 8/21/24, ordered x-ray at [local area hospital] hospital confirmed fx (fracture) of neck . R1's 8/12/24 Fall During Staff Assist form (Authored by V7 Registered Nurse) from 11:22 AM showed, CNA [V3] came out of [R1's] room to have me come in. I found [R1] laying on her back on the floor. The floor was dry, her geri-chair (high-back reclining chair) was upright with the cushion in it. R1's 8/13/22 Incident Note from 3:22 AM showed, .Resident states her neck was stiff. PRN (As needed) pain medication administered with HS (evening) pills. (Pills administered the evening of 8/12/24) . On 9/3/24 at 1:06 PM, V3 CNA stated herself and V9 CNA were transferring R1 from the bed to her geri-chair on 8/12/24. V3 stated she was monitoring/handling R1 during the transfer and V9 was operating the hoist mechanical lift. V3 said R1 was partially suspended over the seat of her geri-chair and as she pulled R1 towards the back of the chair R1 fell out the left side sling and hit her head, neck, and shoulder on the floor. V3 said the mechanical lift sling has a strap at each of the four corners of the sling; two at the head and two at the legs, which are the attachment points for the sling to the hoist. V3 said R1 fell out the left side of the sling between the head and leg straps. V3 said, Nothing like this has happened before .I don't know if the sling was not positioned correctly. I don't know if she was leaning to the left because the sling was not positioned well. I don't think she was trying to lean and grab something . V3 said R1 began complaining of pain the next day after the fall. On 9/3/24 at 11:30 AM, V9 CNA stated she was controlling the hoist mechanical lift for R1 on 8/12/24.She fell over the left arm rest and on to the floor. She went through the gap between the head strap and the leg strap, through that hole, over the left arm rest and onto the floor. She hit her head, shoulder, and neck area first . V9 said she did not work with R1 for a couple of days after the fall. V9 said the next time she worked with R1 she was complaining of neck pain with movement. R1's 8/13/24 Incident Note from 11:08 AM showed R1 was reporting neck pain. R1's 8/14/24 Incident note from 12:41 PM, showed R1 was reporting a sore neck. R1's 8/18/24 Health Status Note showed R1 continued to experience neck pain with her hoist mechanical lift. R1's 8/21/24 Leave of Absence note from 9:30 AM showed R1 left the facility for a neck X-ray. R1's CT cervical spine scan from 8/21/24 showed, Impression: Acute (recent onset) nondisplaced fracture of the odontoid process (a specific appendage of the cervical spine) . On 9/3/24 at 2:20 PM, V6 R1's Physician stated, Cervical fractures present as pain. I was concerned about a fracture, which is why I shot over there right away. They said the pain was moderate in nature .My concern with the neck pain, was that she had a cervical fracture as a result of her fall, which was the reason I had her sent out. She did have a cervical fracture . V3 said his expectation is the facility should be able to perform safe mechanical transfers. V3 said R1 has no diagnoses that would prevent her from being safely transferred with a hoist mechanical lift. On 9/3/24 at 2:00 PM, V8 CNA stated R1 is a stable and safe transfer resident. V8 stated she could not think of any reason, other than improper sling placement, which would cause R1 to fall out of the sling. On 9/3/24 at 3:05 PM, V5 Registered Nurse (RN)/MDS/Falls Program stated, regarding R1's fall on 8/12/24, .My understanding is she (V3) was assisting with a transfer, and she (R1) was not properly placed in the sling If the [hoist mechanical lift] is used correctly it is our safest way to transfer her. If all the policies and procedures were followed correctly and she was positioned correctly, she (R1) should be able to be transferred without falling out of the [hoist mechanical lift]. The fall from the [hoist mechanical lift] caused the cervical fracture . On 9/3/24 at 2:45 PM, V2 Director of Nursing stated, .If the CNAs are doing are everything correctly, there is no reason that [R1] should have fallen out of the sling. The only thing I can think of is that she was not positioned correctly. They way she fell out of the sling, as you describe it, is she was not positioned correctly in the sling. I have assisted with her transfers before, and she is generally very good during transfers and will follow our commands. Some days she may be more a little more confused. The sling and lift should be able to accommodate any movements she might make during the transfer The facility's undated Safe Resident Handling and Transfer policy showed, .Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training .The sling is placed under the patient appropriately and the straps are hooked upon the spreader bar

Based on observation, interview, and record review, the facility failed to have an Infection Control program and system in place to track or trend illnesses, failed to have a process to identify contagious residents, and failed to implement transmission based precautions for residents exhibiting infectious illness. This applies to all residents residing in the facility. These failures resulted in 19 residents (R1,R3,R5,R6,R8,R9,R11,R13,R14,R16,R18,R21,R23,R25,R29,R30, R35,R39,R42) experiencing gastrointestinal and respiratory illness. The Immediate Jeopardy began on 12/26/22 when R13 and R14 began having symptoms of being tired and rundown, and sore throat, congestion, and cough with green sputum. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/5/23 at 1:32PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/6/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: A review of electronic medical records showed: On 12/26/22, R13 reported being very tired and rundown and R14 experienced increased sore throat, congestion, and cough with green sputum. On 12/28/22, R23 experienced nausea and vomiting. On 12/31/22, R1, R3, R25, and R42 experienced nausea and vomiting while R18 and R35 experienced cough, sore throat, and congestion. On 1/1/23, R6 experienced coughing and wheezing. R21 experienced vomiting and R30 experienced a sore throat and cough. On 1/2/23, R5 experienced loose stools and R39 experienced sore throat and congested cough. R13 began experiencing a sore throat, green sputum, and congestion. On 1/3/23, R11 and R16 experienced several episodes of diarrhea. On 1/4/23, R29 experienced fatigue, cough, and congestion. On 1/4/23 at 1:19PM, V2 (Director of Nursing) stated, There were several residents over the weekend with a gastrointestinal illness but I would have to look at every single resident's progress notes to figure out who they were. I didn't track them because it was the weekend. At 1:30PM, V2 then provided the facility's document titled, Respiratory Symptom Pursuit for 9 residents in the building. V2 stated these were all of the residents who have been ill and no new residents have displayed any symptoms. At this time, surveyors had identified 17 residents who had become ill with respiratory or gastrointestinal symptoms. On 1/4/23 at 3:05PM, V1 (Administrator) stated, We don't exactly have an infection control program. I know (V2) looks at infections but we don't do anything with the documentation. We just don't have the resources to dedicate someone to just look at infections. I'm not sure how often our policies are updated and reviewed but I know they are current with the standard of practice. I heard about the illnesses over the weekend but to my knowledge everyone is doing fine and better. We don't have a contact at the local health department and we did not reach out to them about this outbreak. I guess I didn't realize we had to or should have. As of 1/4/23 at 3:15PM, none of the above residents had been placed on transmission-based precautions for their symptoms, no contact had been made between the facility and the local health department regarding an illness outbreak, and no infection tracking had been initiated for an outbreak of a potentially contagious illness. On 1/5/23, R9 experienced congestion, productive cough with yellow and green sputum. R8 began experiencing a cough with yellow sputum. On 1/5/23, R9 was sent to a local hospital due to her respiratory symptoms. R9's medical records showed, Patient here with complaint of shortness of breath, cough, generalized weakness and fatigue, increasing lethargy over the past 2 days. Patient was noted to be hypoxic to the high 80s on room air at facility, sent to the emergency room for further evaluation. She is on 3 liters nasal cannula. She does sound wheezy on lung exam, crackles to bilateral bases, my concern is for infectious process including pneumonia R9's diagnostic radiology report dated 1/5/23 showed, Impression: 1. Small bilateral pleural effusions with nonspecific bibasilar opacity, which can be seen with atelectasis or consolidation. Infection is not excluded if there is clinical suspicion. On 1/5/23 at 10:22AM. V2 stated, I have a book of other infections other than COVID. I print a spreadsheet and put it in the book but we don't do anything with it really. We discuss COVID in our Quality Assurance Performance Improvement (QAPI) meetings but don't necessarily discuss any other infections. We don't have an actual infection control program but we are working on it. Over this past weekend I was called for two residents that were sick with diarrhea and vomiting and there were a few that had respiratory symptoms. I told the staff just to try and keep those residents in their rooms and bring meal trays to them. I didn't see it as an outbreak necessarily because we didn't have a large group of residents that were ill. None of the residents that have been experiencing symptoms have been placed on transmission based precautions. We had one resident (R13) that has been tested for influenza but it was negative. No other residents were tested for influenza. I'm guessing we would report all illnesses to the health department. We did not call the health department for this illness. I didn't really think about it. It was the weekend and nobody was there so I don't even know who I would call. We have not identified any new residents other than the 9 resident symptom pursuit sheets I gave you. There are no new residents other than the initial 9 I gave you. It's like nothing ever happened. The only symptoms the residents had were vomiting and diarrhea so I don't even know what we do for them besides keep them comfortable, hydrated, and give an antiemetic if needed. The symptom tracker sheet is the main way we keep track of these illnesses. Residents are assessed every shift for 72 hours or until symptom free. If a resident is not getting better after 72 hours or the resident has increased symptoms then we would reach out to the physician again for further orders. I did have the nurses start a symptom pursuit form for the 9 residents to keep track of their illness. It is more of a visual aide and reminder for them to check on the residents. At this time, the facility had only identified symptoms for R1,R11,R13,R16,R18,R21,R25,R30, and R35. On 1/5/23 at 11:05AM, V21 (Director of Clinical Services-Health Department) stated, If there is an outbreak within a facility I am usually in contact with the Director of Nursing or the Administrator. Each facility should have a list of illnesses or symptoms that should be reported to the health department and when they should be reported. I have not received any communication from the facility regarding any recent outbreak of illnesses. If the facility is having any outbreak of a potentially infectious disease I would say 2 or more residents is an outbreak that should be reported to us. The facility has access to my phone number and I am available 24/7 so I can be reached any time. If the facility would have contacted me I would have asked for further information regarding what is going on and ask as many questions as I can. I would go through the Illinois Department of Public Health (IDPH) for specific pathogen guidance if we know the organism. It's on the IDPH web portal for them also but I would go over that and share the guidance with them. I would link them up with people at the state if it was more than I could handle. If the cases seem like they are all linked, I would wonder if its food borne or viral illness. I would have suggested they contact the physician and get an order to do stool testing done to see if we could find exactly what we were dealing with. If we suspected it was food borne illness we would go one route and viral another route. If it was something we thought could be food borne we would get our environmental health on board and get a kitchen inspection going, contact IDPH and go from there to determine what the pathogen is. There are so many avenues to this and so much tracking and documentation I would need to see to start making recommendations. They should have jumped into action within the first few cases to prevent an outbreak of this illness. Now they are behind on testing residents stool and testing for possible influenza. If it was a foodborne illness then it may be too late to try to get that information because they did not report it to me immediately. The purpose of the facility reaching out to us is so we can provide them guidance for infection control, find out what is going on, and stop it as soon as possible. They should contact us early when there is a small amount of cases and we could help them determine the cause and prevent further exposure and spread. On 1/6/23 at 11:33AM, V2 stated, In the residents electronic medical record program there is an infection control section that you can monitor infections. It's called a symptom pursuit and that's similar to what we use on paper and document in the system. The symptom pursuits go on the communication board on the dash board within the electronic charting program. I go over that every day. I guess I didn't see the new symptom pursuits for the additional residents you identified. I use the [NAME] Criteria for Infection Surveillance. The facility's undated policy titled, Communicable Disease Reporting showed, Objective: To establish policy in compliance with Illinois law for mandatory reporting of communicable diseases; as indicated per the IDPH rule and guidelines for reporting of communicable diseases .4. Suspected clusters of diseases, which may not be reportable at the time, may also be recorded on a log, and shall be reviewed and monitored per infection control officer, or designee .11. Per IDPH: Certain infectious disease with public health significance shall be reportable by phone, as soon as possible within 3 hours, to the appropriate local health department .b. Any unusual case or cluster of cases that may indicate a public health hazard. On 1/5/23, V2 provided surveyors with the Revised McGeer Criteria for Infection Surveillance Checklist that she uses for guidance on monitoring and reporting purposes. The undated criteria showed, Gastroenteritis: In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens. The facility's undated policy titled, Infection Control and Standard/Isolation Precautions showed, Objectives: To protect residents, visitors, students, and staff from communicable diseases and healthcare-associated infections .5. The nurse or physician shall institute and maintain isolation techniques as required by .suspicion of disease or as recommended by infection control officer. The Immediate Jeopardy that began on 12/26/22 was removed on 1/6/2023 when the facility took the following actions to remove the Immediacy. Administrative staff consisting of DON, and Administrator, completed a review of the current resident roster of 45 residents to determine any unidentified cases of illness presented on 1/5/23. No new residents were identified with GI or respiratory symptoms as of this date. The 19 residents identified who presented with GI/respiratory symptoms beginning 12/26/22 thru 1/5/23 were assessed for ongoing symptoms effective 1/5/23. Of those 19 residents, 1 resident identified will have a stool specimen collected as soon as possible. Primary care provider was notified and order obtained for GI panel. 8 of the 19 residents identified currently are exhibiting respiratory symptoms. Of these 8 residents, 1 resident was hospitalized [DATE] and tested for influenza and COVID, results were negative for both influenza and COVID. 1 resident is currently being treated for aspiration pneumonia and PCP declines need for respiratory panel. The remaining 6 residents have had nasal swabs obtained for an expanded respiratory panel on 1/5/23 as orders were obtained from primary care providers. R25 was moved to a private room for isolation effective 1/5/23. R29 was moved to a private room for isolation effective 1/5/23. R11 was isolated in his room as his roommate was moved to another room. He will remain in another room for the duration of the isolation effective 1/5/23. The Medical Director, was notified of GI/respiratory symptoms outbreak on 1/5/23. The Local Health Department Communicable Disease Nurse was notified by of the GI/respiratory symptom outbreak in the residents. Discussion took place regarding resident surveillance of symptoms, isolation, testing of residents, and appropriate cleaning measures. The DON has identified a surveillance tracking tool within the Point Click Care documentation system. The DON is completing the surveilling tracking within Point Click Care. This tool has been completed effective 1/5/23 for the current 8 residents that are exhibiting GI/respiratory symptoms. The surveillance tracking tool will be utilized when any resident develops symptoms which could be considered to be communicable or transmissible to others. The nursing staff will be educated by the DON RN, by 1/10/23. The Infection Control Coordinator will audit to ensure nursing staff is using the surveillance tracking log as part of her daily assignment. This data will be utilized to help identify when 2 or more residents have similar symptoms within 72 hours and the Local Health Department needs to be notified. Maintenance staff completed a deep clean of the facility to include high touch surfaces with use of an EPA registered appropriate cleaning product. High touch areas within the facility will be cleaned three times a day beginning 1/6/23 until symptoms resolve. Quality Assurance will be completed by the administrator with staff completing a daily log to ensure this is done three times per day when two or more residents have similar symptoms within 72 hours. This log will be reviewed daily. Administrative staff and the Infection Control Coordinator were trained on facility response to illness outbreak by the Local Hospital Infection Control Nurse and the Local Health Department Public Health Communicable Disease Nurse. This training included a review of Appendix A Type and Duration of Precautions found on the CDC website and the need to contact the local county health department at any time when there are 2 or more residents identified with similar symptoms within 72 hours of onset. Staff training took place on 1/5/23 at 4:30PM with all staff currently on shift. Training was completed by the local hospital Assistant DON. This training included the importance of hand hygiene, increased frequency of cleaning/disinfecting including high touch areas, reporting of resident symptoms to the shift nurse, and isolation protocols. The Administrator, returned to educate 3rd shift and arrived at 7AM to educate first shift. Please see sign-in sheet. As of 1/6/23 at 7:00AM, 26 employees received this education and the remainder of staff will be educated at their next scheduled shift up and until mandatory meetings that are scheduled for 1/10/23 for all staff. 3 different meeting times are scheduled for 1/10/23 which will include this education and it will be an opportunity for some staff to hear it twice. The Hospital CEO, will touch base with the administrator five days per week for the next three months to ensure that these plan of correction measures are being carried out. The Infection Preventionist, will be responsible for the new infection control program. An infection control program/committee will consist of the administrator, DON, a designated floor nurse, a designated CNA and a designated housekeeper and/or designated maintenance member. This committee will meet on a monthly basis. The Infection Preventionist will provide an infection control report at the quarterly quality assurance meetings. The Hospital CEO will attend the quarterly quality assurance meetings. On 1/6/23 at 12:00PM, a review of the facility's in-service record showed all staff working the remainder of the day on 1/5/23 and staff working on 1/6/23 were in-serviced on infection control procedures consisting of identifying and monitoring residents for symptoms, notification to nurse for residents identified as having new symptoms, isolation of potentially contagious residents, hand hygiene, and disinfection of high touch surfaces. As of this time, 44% of the entire staff had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift and/or on scheduled in-services on 1/10/23.

Based on observation, interview and record review, the facility failed to follow recommended guidelines from the Centers for Disease Control (CDC) by not wearing proper Personal Protective Equipment (PPE) for a new admission resident on transmission-based precautions (contact/droplet precautions). These failures have the potential to infect high risk residents with COVID-19 and spread COVID-19 to negative residents. This applies to all 32 residents residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 3/16/21 when staff failed to wear proper PPE when entering a new admission room and failed to remove PPE when exiting the new admission room who was on contact/droplet isolation. The Immediate Jeopardy was identified on 3/16/21. V1 (Administrator) was notified of the Immediate Jeopardy on 3/22/21 at 10:03 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/22/21, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The CMS 672 (Resident Census and Conditions of Residents report) dated 3/16/21 shows there are 32 residents in the facility. R133's computerized face sheet shows an admission date of [DATE] (8 days ago) from an acute care hospital. R133's base line care plan shows a focus area, Isolation/quarantine for COVID- admission isolation. On 3/16/21, signage was posted outside of R133's room stating, Contact/Droplet Precautions. Isolation precautions. Required upon entry: N95 mask, gown, gloves, face shield or goggles. On 3/16/21 at 11:45 AM, V5 (Licensed Practical Nurse) entered R133's room wearing a surgical mask over a N95 mask, gown, gloves, and eye protection. V5 administered the noon medications and exited the room. V5 continued wearing the surgical mask over the N95 mask and walked down the hallway to the nurse station. On 3/17/21 at 7:55 AM, V6 (Certified Nurse Aide) entered R133's room wearing a cloth rainbow colored mask over a N95 mask. V6 stated a fresh mask is needed over both masks before entering the isolation room. V6 alerted a passing housekeeper and asked for fresh surgical masks to be placed in R133's PPE supply bin. The housekeeper returned with the surgical masks and handed them to V6. V6 donned a gown, gloves, and eye protection to transfer R133 on and off the toilet. V6 did not wear a fresh surgical mask over the cloth and N95 masks. V6 removed the gown, gloves, and eye protection. V6 exited the room still wearing the rainbow-colored cloth mask over the N95 and continued down the hallway. On 3/17/21 at 11:45 AM, V4 (Speech Therapist) was in R133's room wearing a gown, gloves, eye protection, and a surgical mask. V4 was directly next to R133's chair and speaking one on one with R133. At 12:00 PM, V4 exited the room and was still wearing the surgical mask. V4 stated he does have a N95 mask to use while in the facility. V4 said he was told, it was not necessary, to wear it anymore while in the new admission isolation rooms. V4 stated he only needs to wear a surgical mask, gown, gloves, and eye protection in those rooms. V4 left the area and continued wearing the surgical mask down the hall. On 3/18/21 at 8:00 AM, V7 (Housekeeper) was standing inside R133's doorway wearing a pink butterfly surgical mask, gown, gloves, and eye protection. V7 said she wears the same surgical mask the entire day and in every resident room. V7 said she does not wear a N95 mask in the isolation rooms. At 8:08 AM, V7 exited R133's room still wearing the pink butterfly mask and pushed the cleaning cart down the hallway. On 3/18/21 at 9:08 AM, V3 (Infection Control Preventionist) stated new admission residents require isolation for 14 days to observe for signs and symptoms of COVID-19. V3 said they are PUI residents (persons under investigation). V3 stated anyone entering the room must wear a gown, gloves, eye protection, and a surgical mask. V3 said a N95 mask is not necessary in those rooms and staff can wear the same surgical mask throughout the entire building. V3 said it is not necessary to change masks after exiting a PUI room. V3 said all staff are required to wear the correct PPE in isolation rooms. At 9:15 AM, V3 stated she did not know why the PUI resident rooms had signage on the doors showing N95 masks are required before entering the room. On 3/18/21 at 11:11 AM, V2 (Director of Nurses) stated new admission residents are placed on contact/droplet precautions for 14 days. V2 said staff must wear a surgical mask, gown, gloves, and eye protection in those rooms. V2 said staff are only required to wear a N95 mask in the room if the resident displays signs or symptoms of COVID-19. V2 said the facility is not in a crisis capacity strategy and there have been no issues getting a good supply of N95 masks. V2 said staff have only been wearing a N95 mask if they enter a known positive COVID-19 room and not in the PUI rooms. V2 said it is important for all staff to wear proper PPE to stop the spread of COVID-19 and limit the risk of transmission to other areas in the building. The facility's Coronavirus Disease (COVID-19) policy dated 4/2020 states under the Procedures for Accepting Admissions from Hospitals: b. place in COVID-19 Admission Isolation (contact & droplet with door closed) for 14 days and wear recommended PPE when caring for the resident, The facility's COVID-19 PPE for Healthcare Personnel policy dated 12/2020 shows the PPE recommendations include a face shield or goggles, gloves, gown, and a N95 mask. The policy also states under the recommendations when caring for a patient with suspected or confirmed COVID-19: Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area .unless implementing extended use or reuse. The CDC (Center for Disease Control) website guidance under the Preparing for COVID-19 in Nursing Homes updated 11/20/20 states: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .HCP (Healthcare Personnel) should wear a N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. The Immediate Jeopardy that began on 3/16/21 was removed on 3/22/21 when the facility took the following actions to remove the immediacy: 1. In-service on ensuring proper PPE is worn in isolation rooms which include: gowns, gloves, goggles/face shield and N95. Education start date 3-22-2021/end date 3-26-2021. 2. Re-education on the use of N95's in PUI isolation rooms. Education start date 3-22-2021/end date 3/26/2021 3. Restocking of supplies reviewed & addressed and DON/Administrator/Infection Control Nurse along with our Medical Records clerk shall ensure all supplies are available and stocked appropriately in isolation carts. Education start date 3-22-2021/end date 3/26/2021 4. Compliance audits shall be conducted at minimum of 3xs per shift by Administrator, DON, Infection Control Nurse or Charge nurse. Compliance auditing includes proper donning and doffing of all PPE and review of supplies available in isolation carts. Compliance audit start date 3-22-2021 5. QA Committee shall review and monitor for compliance on an ongoing basis. Meetings will be held once a month x 6 months. Start date 3-22-2021