Every finding on record at Greek American Rehab Care CTR

Based on observation, interview, and record review, the facility failed to ensure preventive measures were in place to prevent developing of new skin impairment and deterioration of current pressure ulcer, and failed to follow physician orders in wound management. These failures affect one (R144) residents in the sample of 31 reviewed for Pressure Ulcer/Wound Care Management, and resulted in R144 all developing a Stage 3 Sacral Pressure ulcer, with R144's wound needing debridement.Findings include:1.R144 was re-admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Dementia, History of falling, Pressure ulcer of sacral region stage 3.Active physician order sheet indicated: Bilateral heel suspension boots for offloading every shift. Low air loss mattress. Use one flat sheet only every shift. Moisture barrier for incontinence care as needed every shift for skin prophylaxis. (specialized) cushion when resident is up in chair to protect skin integrity. Sacrum- clean with normal saline solution, apply Medi honey, cover with island dressing every day shift and as needed for MASD (Moisture Associated Skin Damage). The order of Medi honey did not indicate if it is gel, paste, or cream. Braden scale for predicting pressure sore risk, dated 12/2/25, indicated at high risk.Comprehensive care plan, dated 1/13/26, indicated R144 has stage 3 pressure ulcer to sacrum. On 1/14/26 revised by V28, Care plan Coordinator, R144 has actual impairment to skin integrity related to fragile skin, incontinence, and impaired mobility. 1/13//25 noted with stage 3 pressure ulcer of the sacrum. See care plan for pressure ulcer. No care plan developed for prevention of skin impairment.R144's progress note, dated 12/31/25, indicated, upon assessment (R144) noted with MASD to the sacrum, wound measures1.5cm x 1.0cm x 0.1cm with small serous exudate. Cleansed with normal saline solution, applied Medi honey and covered with island gauze.R144's Wound care physician assessment note, dated 1/13/26, indicated: I have been asked to consult on this [AGE] year-old long term care who had MASD and today was found to have a stage 3 sacral pressure ulcer. Wound assessment indicated: Sacral is an acute stage 3 pressure injury ulcer acquired on 1/13/26 and has received a status of not healed. Initial encounter measurements are 0.7m x 0.6cm x 0.1cm. There is a small amount of serous drainage noted. Wound bed has 76-100% adherent yellow slough. Selective debridement with a total area debrided of 0.42sq cm was performed. Dermis and epidermis were removed along with devitalized tissue: biofilm and necrotic/eschar.On 1/13/26 at 11:00AM, V4, WCN (Wound Care Nurse), said R144 has an acquired stage 3 pressure ulcer on sacral area. On 1/14/26 at 9:58AM, V4, WCN, and V22, CNA (Certified Nurse Assistant), were preparing R144 for wound care. R144 was lying on an inflated mattress, not a low air loss mattress, as indicated in physician order sheet (POS). V4 said the mattress is a (specialized) mattress. The mattress is inflated, hard, and firm on the lower part, and soft, with an irregular indentation on upper part of the mattress. No bilateral heel suspension boots as indicated in POS. V22 repositioned R144 on his right side. V4 removed the dressing on sacral area. Observed minimal serous sanguineous drainage. V4 said R44 has a Stage 3 pressure ulcer with 25% yellow slough and 75% granulation tissue. V4 cleansed wound with normal saline solution (NSS) and apply Medi honey gel to sacrum and covered with bordered gauze dressing. On 1/14/26 at 11:00AM, review of R144's medical records showed the following: Physician order of low air loss mattress and bilateral heel boot were not implemented as ordered.No skin care plan was developed for prevention of skin impairment. No care plan was developed when R144 was identified with MASD on 12/31/25. Care plan was not initiated until after the MASD deteriorated to a Stage 3 pressure ulcer.No weekly wound monitoring and documentation was done from 12/31/25 when MASD was identified.On 1/14/26 at 11:00 AM, V4 stated she only develops skin care plans and does weekly skin assessment/monitoring for stage 2 and above pressure ulcers. V4 added V28, Care plan coordinator, initiates the skin care plan if she missed it. V4 said she informed the IDT (Interdisciplinary Team) during morning meeting when R144 was identified with MASD. On 1/14/26 at 12:44PM, V28, Care plan Coordinator, said he was not aware R144 had MASD on 12/31/25. V28 said any changes in skin condition such as MASD on sacral area must be addressed in care plan to develop new interventions to enhance healing and prevent deterioration.Facility unable to provide policy on following physician order.Facility's policy on Skin condition monitoring reviewed 2/5/25 indicated:Policy: Nurse will complete comprehensive skin assessment on admission/re-admission, quarterly, annually or for significant change. A weekly skin condition check is completed by a nurse in conjunction with the resident's shower/bath schedule. All documentation related to the skin condition assessments and check will be documented.Procedure:1. Skin condition check will be done by the nurse assigned to the resident on shower day. At a minimum of once a week.2. Observe entire body for any broken areas, rashes, bruises, dry flaky skin, redness, irritation, wounds, etc. document findings in the skin progress notes.3.Wounds will be measured weekly by the wound care nurse or an outside provider such as a wound physician.4. Any new open wound areas, skin breaks or skin discoloration must be communicated to the resident/responsible party and physician by the assigned nurse.11. All resident with wounds and residents at high risk of a wound are reviewed and discussed in weekly NAR meeting. Facility's policy on Care plan reviewed 8/19/25 indicated:Procedure:The care plan will be formulated in terms of problems, goals, and interventions.MDS, CAA and comprehensive assessments will be reviewed to identify possible problems, goals and interventions.Significant change in condition/readmission: within 7 days of completion of the resident assessment, a care plan will be reviewed and updated by IDT.Care plan will be updated in the computer.When a new approach is added to the care plan, the day it is initiated will be placed at the beginning and electronically signed.

Based on observation, interview, and record review, the facility failed to follow management of waste bins. This deficiency has the potential to affect all 156 residents receiving food from the kitchen. Findings Include:On 1/13/2026 at 9:38 AM during kitchen initial round, one garbage bin with more than half full of refuse was without a lid/cover. Garbage bin was by food preparation area and there was no staff currently working in the vicinity of immediate area. V5 (Food Service Director) stated if there is no staff currently working in the area, garbage bins should have the lid on.On 1/13/2026 at 10:14 AM, V1 (Administrator) stated he is not sure of the policy for garbage bins management in the kitchen. V1 said he is not sure if garbage bin should have a lid when not in use.On 1/14/2026 at 9:35 AM, V2 (Director of Nursing) stated garbage bins should have a lid on when not in use for infection control purposes. Policy and ProcedureSubject: Kitchen Waste Bins - trash cans, Effective date 1/13/2026Policy: It is the policy of the Greek American Rehabilitation and Care Centre to maintain trash cans and waste receptacles in accordance with Illinois Department of Public Health (IDPH) guidelines to reduce the risk of infection, contamination, pests, and odors. All waste receptacles used in food service and healthcare areas shall be properly designed, maintained, and managed to promote sanitation and infection prevention.Purpose:To prevent the accumulation of unwanted pests, odors, and physical contaminants: Trash cans shall be used and maintained as follows:Trash cans shall be kept closed when not in active use.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during medication administration. This deficiency affects all three (R49, R50 and R85) residents in the sample of 31 reviewed for Infection control prevention program.Findings include:1.On 1/13/26 at 9:31AM, V10, RN (Registered Nurse), took the portable Blood Pressure (BP) machine from the hallway without disinfecting it and brought to R50's room. V10 placed the BP cuff around R50's left wrist and checked the oxygen saturation on left finger. V10 obtained BP of 107/56mmHg, pulse rate of 69/minute and 90% oxygen saturation in room air. After obtaining her vital signs, she prepared her medications. She did not disinfect the medical equipment used. After she administered medication to R50, she is preparing to take vital signs of another resident without disinfecting the medical equipment.On 1/13/26 at 9:40AM, V10 said they usually disinfect medical equipment used for taking resident's vital signs before and after using it. V10 said she forgot to disinfect before and after each use.2.On 1/13/25 at 9:41AM, four students were wearing gloves and V13, Instructor, surrounding R49. As the surveyor entered the room, the instructor left the room, followed by her students in a hurry. The 3 students removed the gloves and performed hand hygiene by quickly rubbing hand sanitizer to their hands, but V12, student, removed her gloves and did not perform hand hygiene. V13, Instructor, said V12 should have performed hand hygiene after removing the gloves. V12, LPN (Licensed Practical Nurse) student, said she forgot to perform hand hygiene after removing the gloves. 3.On 1/13/26 at 11:32AM, V14, RN/Registered Nurse, performed blood sugar testing to R85 left little finger without using gloves. She obtained blood sugar of 209. She did not perform hand hygiene and proceeded to the medication cart located by the nursing station to prepare R85's sliding scale insulin. She did not disinfect the glucometer used. She prepared insulin Aspart 2 units from the vial without performing hand hygiene and without using gloves. At 11:41AM, V14, RN, prepared insulin medication to R85's left abdominal area without using gloves. She did not perform hand hygiene after insulin administration. V14 said she should have donned gloves when performing blood sugar testing, preparing insulin and administration of insulin to the resident. She said she should have performed hand hygiene before preparing medications and after administration of medication to resident. She said she should disinfect the glucometer after each resident use. Facility's policy on Hand Hygiene reviewed 1/8/26 indicated: Purpose: To promote effective hand hygiene practices, reduces the risk of healthcare-associated infections by preventing the spread of harmful germs. To ensure that staff, visitors and residents follow proper hand hygiene protocols to maintain clean environment. Policy: Examples of times/situations to perform hand hygiene are: *After contact with a patient's intact skin*After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient*After removing glovesProcedure Hand hygiene technique:Alcohol based hand rubAnti-microbial soap and waterFacility's policy on Cleaning and Disinfection reviewed 1/8/26 indicated: Purpose: To ensure the safety of our residents and staff by minimizing exposure to pathogensPolicy: it is the policy of the Greek American Rehabilitation and Care Centre to provide guidance on proper cleaning and disinfections techniques in accordance with applicable standards rules and regulations. Disinfection of common areas, medical equipment and devices. Guidelines for cleaning and disinfection: *All non-dedicated, non -disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies after use. Medical equipment disinfection: Using disinfectant wipes: hard surface disinfectants/disinfection wipes are used for routine decontamination of intermediate level of disinfection of semi critical items such as glucometers, thermometers, vital machines and other medical equipment

Based on observation, interview, and record review, the facility failed to assure resident's personal privacy for electronic medical records and during administration of insulin. This deficiency affects two (R85 and R132) of three residents in the sample of 31 reviewed for Resident Privacy.Findings include: 1.On 1/13/26 at 11:41AM, V14, RN/Registered Nurse, administered an insulin injection to R85's abdominal area without providing privacy. The door was widely open visible to residents and employees passing through the hallway. V14 said she should have closed the door to provide privacy to R85 when administering insulin injection to her abdomen.2.On 1/13/26 at 10:19AM, observed a laptop on top of the treatment cart outside the door with the screen exposed, displaying R132's list of physician orders, visible to employees and residents walking past in the hallway. V4, Wound Care Nurse/WCN said she should have closed the computer screen to provide privacy for the confidential records of R132.On 1/13/26 at 2:20PM, V2, DON (Director of Nursing), said they should provide privacy when administrating insulin to abdominal area, and protect resident resident's confidentiality of medical records.Facility's policy on Resident's Rights for people in Long Term Care (LTC) facilities from Illinois LTC Ombudsman Program indicated: Your rights to privacy and confidentiality:You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a PASSAR (Pre-admission Screening and Resident Review) level 2 screening for evaluation and determination of newly evident serious mental illness related condition and prescribed medication, for one of one resident (R108) reviewed for a PASSAR level 2 screening in a sample of 31.Findings Include.On 1/15/2026 at 10:30am, R108's admission record documented a new Diagnosis, dated 5/12/2025, for Delusional Disorder, and on 12/20/2025 for Major Depressive Disorder, with added medication of Venlafaxine HCI 75 mg one time per day for Depression.On 1/15/2026 at 10:45am, V1 (Administrator) said, I know that residents with a mental illness should have a PASSAR level 2 completed but not if they have dementia. I have social services requesting a PASARR level 2 now for all the resident's that you've requested. On 1/15/2026 at 10:50am, V2(Director of Nursing-DON) said, (R108) should have a PASARR level 2 completed if he has a new psychiatric diagnosis and prescribed medication for any symptoms, I will make sure a PASARR level 2 is completed as soon as possible.R108's admission record, dated 1/15/2026, indicated R108 has a new diagnosis, dated on 5/12/2025, for Delusional Disorder ,and on 12/20/2025 for Major Depressive Disorder; a order summary report dated 1/15/2026 for Venlafaxine HCI Extended release 75mg one time per day; a PASRR level 1, dated 6/5/2024, with an outcome of no level 2 required at this time there is no evidence of intellectual developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings a new screen must be submitted. A care plan, dated 1/15/2026, with major depressive disorder. Per V2, the facility is unable to present a facility policy.

Based on observation, interview, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 2 of 3 residents (R12, R45) reviewed for PASARR in a total sample of 31.Findings Include:Findings include: 1.R12 is an [AGE] year-old female who was admitted into the facility with an initial admission date of 9/20/2021. R12 was diagnosed with a major depressive disorder on 10/15/2021. On 1/15/2026 at 11:00 AM, R12's physician order documented R12 is on Sertraline HCL Tablet 75 mg by mouth at bedtime. On 1/15/2026 at 11:00 AM, surveyor was not able to find PASARR level I screen for R12. On 1/15/2026 at 12:25 PM, V2 (Director of Nursing) said R12's PASARR Level I screen should have been completed. 2.Review of R45's records indicate an initial admission of 5/6/2021. Current diagnoses include schizoaffective disorder (9/23/2023), depressive type, other specified anxiety disorders (5/4/2025), major depressive disorder, single episode, unspecified (5/6/2021). Order Summary, 7/23/2025, read Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) for mood stabilizer Dx: Schizoaffective Disorder depressive type and Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) for Schizoaffective Disorder, Anxiety Disorder. Care Plan report read, revision date 8/13/2025, Problem: PSYCHIATRIC ILLNESS R45 presents with a psychosis, schizophrenia. Her symptoms are manifested by depressed mood, excessive worry about health issues, excessive eating at times and extreme obsessive behavior. On 1/15/2026 at 9:25 AM, V1 (Administrator) and V2 (Director of Nursing) stated, There is no PASARR, Level I or Level II completed for (R45). PASARR Level I was requested and completed yesterday, 1/14/2026, with determination of Refer for Level II onsite. V2 stated PASARR should be completed for proper placement and appropriate services provided for residents. V2 stated the facility does not have policy for PASARR.

Based on observation, interview, and record review, the facility failed to implement care plan interventions and follow the recommendation of Occupational Therapy for residents with limited mobility. This affects two (R1 and R124) of three residents in the sample of 31 reviewed for Restorative Program.Findings include:1.R1 was re-admitted on [DATE] with diagnosis listed din part but not limited to Dementia, Type 2 Diabetes Mellitus, Osteoarthritis, Palliative care. Active physician order sheet indicated: reposition resident per turning schedule. Comprehensive care plan indicated she has ADL (Activity of daily living) self-care deficit. Intervention: Provide (specialized wheelchair) and assistance for mobility as needed. She has limited physical mobility due to weakness. Functional abilities and goals dated 12/29/25 indicated she is dependent with ADLs and transfers.On 1/13/26 at 10:57AM, R1 was sliding down in a high back chair in the dining room. R1 was confused, has facial grimacing, and appears uncomfortable. SV30, Activity Aide, who is monitoring the dining room, said she already observed R1 sliding but she cannot leave the dining room to ask the nursing staff to help her. She said she will wait until nursing staff comes to the dining room. V16, Registered Nurse/RN requested CNA to pull up and repositioned R1.On 1/13/26 at 11:56AM, R1 was sliding down again in a high back chair. V18, CNA, and V19, CNA, were standing in the dining room waiting for the lunch trays to come. Both CNAs observed R1 but did not help her. R1 had nonslip device for wheelchair underneath the wheelchair cushion. V19 said they usually applied another nonslip device on top of the wheelchair cushion to prevent her from sliding.On 1/13/26 at 12:42PM, V3, Restorative Nursing, said she was not aware R1 has issues with sliding down in her high back chair.On 1/14/26 at 12:34PM, V3, Restorative Nurse, was informed R1 has a care plan intervention for (specialized wheelchair) which helps with safe positioning/posture especially for resident who cannot sit comfortably or safely in a standard wheelchair. 2.R124 was re-admitted on [DATE], with diagnosis listed in part but not limited to hemiplegia and hemiparesis following cerebrovascular disease (CVA) affecting right dominant side, Aphasia, Dementia, stiffness of the right hand.Active physician order sheet indicated: Apply right resting hand splint to right wrist at night and off at am. Comprehensive care plan indicated he has an ADL self-care deficit related to hemiplegia. He is on right hand splint related to increase in right hand stiffness and recommended by Occupational Therapy (OT) due to history of CVA. Intervention: Perform AROM (active range of motion) to right hand before application of splint and after. R124's MAR (medication administration record) indicated application of right-hand splint at 8:00PM documented on MAR by nurses but no documentation of removal and providing of AROM before and after application as indicated in care plan.R124's Skilled therapy restorative program referral by Occupational therapist, dated 1/5/26, indicated: Brace/splints: Right half lap tray. (Right half lap tray is a wheelchair accessory that mounts on the right armrest to provide a support surface for the right arm. It is commonly used for positioning the arm. Extremity: right upper extremity. Wearing schedule: 4-5 hours/day. On 1/13/26 at 10:49AM, R124 was sitting in a wheelchair in front of the nursing station with a flexion contracture of right arm. V16, RN, was asked if R124 has splint for his right hand. V17 said it was discontinued when he was re-admitted .On 1/14/26 at 12:34PM, V3, Restorative Nurse, said she received the referral from OT for R124's restorative program. She said she did assess R124 but did not document. V3 said she incorporated the recommendation in the care plan. V3 was informed there are no updates in splint care plan and the last revision done was 12/20/23. No documentation was indicated in R124's medical records regarding OT's recommendations.On 1/15/26 at 10:01AM, V27, Restorative manager, said once they received recommendation from therapy for restorative program, they will screen the resident using restorative/functional assessment and care plan.On 1/15/26 at 10:49AM, V29, Therapy Director, said when a resident is discontinued for skilled therapy and will stay in the facility for long term care, they refer them to the Restorative nursing program. The restorative nursing will do assessment/screen if the resident is appropriate to the restorative program and see if there are discrepancy between their assessment. They also provide training for CNAs and restorative aide the use of the devices if needed. Most of the time the restorative nurse accepted their recommendation. Facility's policy on Positioning revised 2/5/25 indicated: Policy:The facility will position residents in a comfortable and appropriate way.Facility's policy on ADL/Function Assessment reviewed 8/5/25 indicated: Policy: In an effort to ensure all our residents received the highest level of care possible with specific attention to physical function and reduce (wherever possible) the functional decline of our residents the following standards and measures have been established.Facility's policy on Referrals to Therapy effective 3/1/25 indicated:Purpose: This policy outlines the procedure for Long Term referrals for therapy servicesPolicy: 9. Upon discharge from therapy services, updated referral will be made to restorative nursing program with up-to-date functional status and program recommendations.Facility's policy on Referrals to Restorative Department effective 3/1/25 indicated: Purpose: This policy outlines the procedure for referrals for restorative nursing maintenance. Policy: 2. Once referral received, restorative nurse will screen patient to determine if resident is appropriate for recommended services.4. Appropriate task will be entered or discontinued from HER. Updated information will be communicated to designated staff.Facility's policy on Splint/Appliance reviewed 2/20/25 indicated: Purpose: To provide resident with therapeutic devices as needed to prevent worsening or to improve functioning.Policy: Residents who have contractures and require further evaluation will be assessed by the Occupational Therapist for a splint/ appliance. Responsibility: It is the responsibility of the nurses, CNAs, and restorative aide for splint application unless otherwise indicated. Procedure: 2. OT to develop splint and recommend splint schedule3. Splint and schedule will be addressed on care plan

Based on observation, interview, and record review, the facility failed to implement oxygen equipment storage affecting 1 of 2 (R118) residents reviewed for oxygen administration in a sample of 31. Findings Include:On 1/13/2026 at 11:04 AM, R118's oxygen nasal cannula tubing was on top of the bed, without a visible date, tubing touching the floor, and not currently in use. V21 (Certified Nursing Assistant) said she was not sure if tubing should be stored in a bag when not in use but stated would loop tubing and placed on top of the concentrator. V21 then looped the tubing and placed on top of oxygen concentrator. On 1/13/2026 at 11:24 AM, V10 (Registered Nurse) stated R118 uses her oxygen as needed and when not in used, tubing should be stored in a (plastic) bag for infection control purposes.On 1/14/2026 at 9:35 AM, V2 (Director of Nursing) stated when oxygen is not in used tubing should be stored in a clear plastic bag and tubing should not be touching the floor to prevent cross-contamination. Review of Care Plan Report, revision on 1/13/2026, read Problem: The resident has oxygen therapy r/t Shortness of breath. Order Summary Report, order date 7/27/2023, order status active, read Respiratory - Nasal Cannula prn 2L to maintain O2 Sats above 92%. Policy and ProcedureTitle: Oxygen Administration, reviewed 1/20/20251. Purpose: 1.1 To safely administer oxygen to treat and prevent the symptoms of hypoxia.2. Policy 2.3 Infection Control2.3.1 All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are single patient use only.When not in use tubing, masks, and cannulas should be bagged in a clear bag.

Based on observation, interview, and record review, the facility failed to implement its hospice services agreement in provision of information for coordinated hospice care. This deficiency affects one (R87) of three residents in the sample of 31 reviewed for Hospice Care Management.Findings include:On 1/13/26 at 10:49AM, V17, LPN (Licensed Practical Nurse), said R87 is on hospice care. R87 was up in a wheelchair in the dining room.R87 was re-admitted on [DATE], with diagnosis listed in part but not limited to Dementia, Palliative care, Parkinson's disease, Type 2 Diabetes Mellitus, Pressure Ulcer of sacral region stage 3. Active Physician order sheet (POS) indicated admit or eval to hospice (other hospice name) hospice 6/18/25. Active comprehensive care plan indicated R87 has a terminal diagnosis and is presently connected to (hospice name) for hospice care services. She has co-morbid complexities and maybe fatigues and have decreased social interaction with her peers. She is unable to make decisions about her care revised 1/7/26.On 1/14/26 at 10:30AM, R87's hospice binder was reviewed with V17, LPN, and V24, ADON (Assistant Director of Nursing). Hospice binder indicated (hospice name) hospice services of Illinois. No hospice plan of care in hospice binder. Both V17 and V24 said that Social Services coordinates with the hospice services with R87's hospice documents.On 1/14/26 at 11:06AM, V25, SSD (Social Service Director), and V26, SW (Social Worker), said they coordinated hospice residents' documents with hospice services chosen by resident/family. They obtain resident hospice information from the hospice services, and they make sure it's in resident's hospice binder such as hospice plan of care, nurses, and CNAs visit notes, and other pertinent records needed for coordinated care. Unable to find hospice plan of care. V25 said they will reach out to hospice to provide the documents.On 1/15/26 at 9:55AM, V26, SW, said they just requested R87's plan of care yesterday. R87's hospice plan of care indicated benefit period from 12/17/25 to 2/14/26.On 1/15/25 at 10:00AM, V2, Director of Nursing (DON), was informed R87's active POS indicated R87 is on (other hospice name) hospice care, but the care plan and hospice binder indicated (hospice name) hospice services. V2 said (other hospice name) hospice and (hospice name) services are different provider of hospice services. R87 is on (hospice name) hospice service. They should have physician order for the provider of hospice service to R87. They will update R87's POS. Facility's agreement between Hospice services provider dated 2/3/2020 indicated: Responsibilities of Hospice Care:(e) Provision of Information. Hospice shall promote open and frequent communication with facility and shall provide facility with sufficient information to ensure that the provision of facility services under this agreement is in accordance with the hospice patient's plan of care, assessment, treatment, planning, and care coordination. At minimum, hospice shall provide the following information to facility for each hospice patient residing at the facility:1. Plan of care, medications and orders. The most recent plan of care, medication information and physician orders specific to each hospice patient residing at facility.

Based on interview and record review the facility failed to ensure a resident at risk for falls with a history of falls was supervised in the bathroom. This failure resulted in R1 falling from the toilet and sustaining a right hip fracture requiring surgical intervention. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 6. The findings include: R1's face sheet shows she is a [AGE] year old female and has diagnoses including: history of falls, unsteadiness on her feet, pain in right hip and a nondisplaced intertrochanteric right femur fracture. R1's 6/2/23 facility assessment shows she has a moderate cognitive impairment and requires staff assistance with toileting and transfers. R1's active fall risk care plan initiated on 12/29/2020 shows she is at high risk for falls and has had falls on the following dates: 12/14/18, 12/17/19, 1/20/20, 4/11/20, 4/29/20, 7/3/20, 2/14/21, 8/15/21, 10/18/21, 11/20/21, 12/25/21, 5/5/22, 11/16/22, 1/8/23, 5/14/23 and 7/7/23. The same care plan shows R1 has a history of attempting to self transfer and she is on the facility's fall prevention program. Fall interventions identified in the care plan include call light in reach at all times, prompt response to her call light, toileting every 2 hours and as needed, supervise when in her wheelchair, and the use of a bed/chair alarm for monitoring. R1's care plan identifies her as primarily Greek speaking. R1's 6/2/23 fall risk assessment shows she is at high risk for falls due to impaired mobility and limitations. R1's facility reported incident (not dated) completed by V27 (Assistant Director of Nursing/ADON) shows on 7/7/23 R1 who requires a 1 person staff assist, had a fall from the toilet seat while in the bathroom resulting in a right hip fracture. A nursing incident note completed by V7 (Licensed Practical Nurse/LPN) on 7/7/23 at 2:30 AM states, Around 2 AM in the morning CNA (Certified Nursing Assistant) transferred resident to restroom per facility protocol. Resident educated to use call light once done, call light placed within reach. Nursing staff heard the resident calling for help. Nursing staff immediately entered resident's restroom. Resident observed laying down on her right side with face leaning towards the floor. Bathroom's call light noted on off position. Resident noted with redness, bruising, and swelling to right cheek and to her brow bone. 911 was called and she was sent to the emergency room . A nursing progress note completed by V7 on 7/7/23 at 8:19 AM, shows R1 was admitted to the hospital and diagnosed with a right hip fracture and will be transferred to another facility for surgical repair. X-Ray results from a local community hospital dated 7/7/23 shows that R1 has a displaced, foreshorted right intertrochanteric femur fracture also described in the report as a right hip fracture. On 8/25/23 at 8:50 AM, R1 was interviewed (using a Greek speaking interpreter- V25 Social Worker). R1 said she had a fall in the bathroom when the CNA left her in the room alone and went out of the room. R1 said she slid off from the toilet onto the floor and threw a bootie she was wearing on her feet out into the room to try to get staff attention. R1 said she is [AGE] years old and sometimes forgets to about the call light. On 8/25/23 at 8:40 AM, V5 (LPN) said before her recent fall, R1 was a 1 person assist to the toilet. She said R1 tries to get up on her own and does not always use her call light. When she is in the bathroom staff should stay in the room with her. On 8/25/23 at 9:01 AM, V4 (LPN/Restorative Nurse) said R1 was a fall risk prior to her recent fall. She described R1 as having periods of forgetfulness and said generally CNA's stay in the bathroom with residents who are at risk for falls and she would not have left R1 in the bathroom alone. On 8/25/23 at 9:18 AM, V6 (CNA) said the staff should never ever leave a resident who is a fall risk alone in the bathroom. They should always stay with them or just outside the bathroom door where they can still see the residents if they request privacy. On 8/25/23 at 10:45 AM, V7 (LPN) said around 2 AM on 7/7/23 she heard a resident yelling for help and went to R1's room where she found her on the bathroom floor. No staff were in the room with R1 when she entered. She said in this instance, the CNA who had put R1 on the toilet left her there to go answer another resident's call light and R1 fell from the toilet. V7 said the CNA who left R1 was educated on never leaving residents at risk for falls alone in the bathrooms. On 8/25/23 at 11:00 AM, V2 (Director of Nursing) said this particular incident with R1's fall was an issue because the CNA left her alone in the bathroom. She said the CNA (V8) should have gotten another staff person to stay with R1 if she needed to leave the room but she did not do that. V2 said V8, in addition to other staff, were educated and in-serviced about not leaving residents alone in the bathroom. On 8/25/23 at 12:25 PM, V8 (CNA) said she had been in the bathroom with R1 for like 15 minutes when she heard another resident calling out, so she left the call light by R1 and left her alone in the bathroom. V8 said she did not go to let anyone know that R1 was in the bathroom alone. On 8/25/23 at 12:34 PM, V3 (R1's Primary Care Physician) He would think R1's hip fracture is consistent with her fall and if the facility has procedures in place to supervise residents at risk for falls then they should follow it. The facility provided Fall Prevention Program policy last revised on 2/4/22 says the facility should identify residents at high risk for falls and maintain as safe of an environment as possible and ongoing supervision will be provided by staff.

Based on observation, interview, and record review, the facility failed to implement an appropriate isolation precaution for one covid-19 positive resident (R73) out of two residents reviewed for covid-19 positive droplet/contact precautions in a sample of 29. This failure has the potential to affect all the ambulatory residents, and all the staff that walk pass R73's room. Findings Include: On 2/14/2023 at 11:07 AM, surveyor observed with V5 Licensed Practical Nurse (LPN) that R73's door was left wide open. R73 is a confirmed COVID-19 positive resident who has a signage on her door that says isolation: contact and droplets precautions. On 2/14/2023 at 11:07 AM, V5 said that the door should be closed. On 2/14/2023 at 11:15 AM, V2 (Director of Nursing), said that R73's door should be closed at all times. On 2/15/2023 at 11:50 AM, surveyor observed with V11 (Registered Nurse), that R73's door was left open. On 2/15/2023 at 11:50 AM, V11 said that the door should be closed, but added that R73 is non-compliant. On 2/15/2023 at 02:42 PM, V4 (Infection Preventionist) said R73's door should remain closed except if R73 is at risk for falls. R73 is an [AGE] year female with a diagnosis not limited to COVID-19, personal history of COVID-19, and congestive heart failure. Review of R73's diagnosis did not indicate that R73 is at risk for fall or has a history of falls to justify leaving R73's door open. Review of progress notes dated 2/9/2023 documents: Patient is ambulatory and walks with walker. R73's room is in the middle of resident's rooms on that wing of the facility. All the ambulatory residents whose rooms are beyond R73's room, and the staff, are exposed to the COVID-19 virus as they walk pass R73's door. Review of physician's orders dated 2/9/2023 documents, Isolation: Strict Contact & Droplet. Subject: Isolation (General Guidelines) - With COVID Last revised on 12/20/2022 Policy: It is the policy of this facility to provide guidelines in alliance with CDC, IDPH for the care of residents with infection to minimize transmission to others. Standard precautions shall be used to reduce risk of exposure. It is the policy to follow CDC, IDPH guidance. Procedure: Once a resident has been tested and identified as infected with a microorganism that may cause harm to others he/she will be placed on isolation precautions in accordance to the facility standards. Standard precautions are utilized on all residents regardless of infection to minimize risk of cross contamination. 1. A sign will be placed in view prior to entering a room indication what type of precaution resident has been placed. Droplet/Contact (for Covid-19) - Residents can isolate in a single room with appropriate Droplet/Contact signage if Covid Unit is not in place. When feasible and if safe to do so the resident door should remain shut.

Based on observation, interview and record review, the facility failed to collaborate with hospice for the development and implementation of the coordinated plan of care for one (R55) of two residents reviewed for hospice care in a sample of 29. Findings include: On 02/14/2023 at 11:55AM, hospice binder for R55 was reviewed and was observed with V2 (Director of Nursing) with no plan of care and historical hospice nurse visit notes on file, and the last documented hospice certified nursing assistant (CNA) visit was 10/17/2022. On 02/14/2023 at 11:55AM, V2 said that the hospice plan of care should be in the hospice binder and hospice CNAs should document their visit on the hospice binder. On 02/14/2023 at 12:00PM, V14 (hospice nurse) stated that hospice plan of care should be in the hospice binder as part of the medical records and hospice CNAs are expected to document their visit in the hospice binder in the facility. R55's care plan initiated on 7/25/2022 indicated R55 has a terminal diagnoses and presently connected to hospice. Order Summary Report dated indicated admitted [DATE], diagnoses of but not limited to chronic kidney disease stage 3b and diastolic (congestive) heart failure, and order for admitted to hospice with diagnosis (Dx) of congestive heart failure (CHF) with order date of 7/23/2022. Facility Policy and Documents: Title: Policy and Procedure - Hospice Care Effective: 06/21/2018 Purpose: .The goal is to make the resident as comfortable as possible, working closely with the attending and hospice physician or specialists to integrate this added layer of care into any care plan for patients facing serious terminal illness. Procedure: 3. Hospice Care consultants and the facility will communicate in a manner that will ensure collaboration of care. Routine/Inpatient/Respite Hospice Agreement Date: July 9, 2018 Hospice agrees to meet the following standards: 1.Hospice shall furnish facility with the most recent copy of the patient Plan of Care. 6. Hospice shall furnish facility a copy of the patient's Plan of Care and appropriate documentation, and update information as appropriate.

Based on observation, interview, and record review, the facility failed to follow the Pressure Ulcer Prevention Policy by using a flat sheet and draw sheet on an air mattress. This failure affected 1 resident (R85) of 6 residents reviewed for pressure sores in a total sample of 29. Findings include: On 02-14-23 at 12:00 PM, R85, V10 (LPN) and V11 (CNA) verified R85 was laying on air mattress with a flat sheet, draw sheet, and disposable brief. R85 is nonverbal and unable to make her needs known. On 2-16-23 at 10:27 AM, V2 (DON) said when using an air mattress, the facility uses a flat sheet only and may use incontinent briefs when residents' are incontinent with bowel and bladder. The facility uses one sheet per manufacturers recommendation to facilitate wound healing. The facility incorporated this in the pressure prevention policy. On 2-16-23 at 9:49 AM, V10 (Wound Care Nurse) said when using an air mattress, the facility should use only a flat sheet. You may also use a single diaper or incontinence pad. The more layers are more risk for potential skin breakdown. R85 has an unstageable wound and the facility should use minimal layers on the air mattress. On 02/14/23 at 12:00 PM, V10 (LPN) said a resident on an air mattress should be using only a flat sheet. On 02/14/23 at 12:20 PM, V11 (CNA) said the staff uses flat sheet and draw sheet for residents on an air mattress. The staff can use the draw sheet to help re-position residents on an air mattress. Pressure Ulcer Prevention Policy revised 1-17-23 documents: Fitted sheets should not be used on air loss mattresses, only a single flat sheet.

Based on observation, interview, and record review, the facility failed to apply hand splints on one resident (R12) out of 10 residents observed for hand splints in the sample of 29. Finding includes: On 02/14/23 at 02:56 PM, surveyor observed R12 sitting in the dining room with V9 Licensed Practical Nurse (LPN) assigned to R12. R12 was observed without a right resting hand split on. On 02/14/23 at 02:58 PM, said that R12 should have the right hand split on. On 2/15/23 at 09:54 AM, V2 (DON) said that the right hand split should be on at all times except when providing ADLs' care. R12 is a [AGE] year old female admitted with diagnosis not limited to scoliosis, unspecified, age-related osteoporosis without current pathological fracture, and polyosteoarthritis. Review of physician order dated 1/22/2023 documents, right resting hand palm protector to be worn at all times, except for exercises, hygiene, or functional activities. Review of R12 care plan dated 11/30/2022 document, Restorative program for splint: R resting hand splint to be worn at all times, except for exercises, hygiene, or functional activities with R hand 2/2 contracture of right hand 3rd, 4th, and 5th digit. Splint was recommended by OT. Facility Policy: Subject: Splint/Appliance Policy: Effective 02-01-2019 Department: Nursing: Reviewed: 02/01/2021 Purpose: To provide resident with therapeutic devices as needed to prevent or to improve functioning. Policy: Residents who have contractures and require further evaluation will be assessed by the Occupational Therapist for a splint/appliance. Procedure: 5. Apply Splint per determined schedule

Based on observation, interview and record review the facility failed to maintain dignity during dinner, by staff standing over a dependent resident while providing feeding assistance for 1 of 3 residents (R103) reviewed for dignity in a sample of 29. Findings include: On 2/14/2023 at 12:50pm V6(Restorative Nurse) was observed standing over R103 in the dining room providing spoon feeding assistance. On 2/14/2023 at 12:51pm V6 was asked should she be standing over a resident while providing spoon feeding assistance. V6 said I'd rather stand up. On 2/15/2023 at 12:30pm V2(Director of Nursing-DON) said I expect all staff to sit down at eye level and assist residents with feeding, R103 was sleepy and V6 assisted R103 whom usually can feed herself and does not need assistance. A care-plan that indicated a diagnosis of Dementia in other Diseases classified elsewhere, unspecified severity, with other behavioral disturbance. An intervention dated 1/30/2020 for eating: The resident requires (supervision) by (x1) staff to eat. A hospice care-plan intervention check food and fluid intake. Do not force food if the resident does not desire to eat. Facility Policy: Reviewed on 10/8/2022- Resident rights, respect and Dignity Policy It is the policy of the Greek American Rehabilitation and care Centre that all residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. Providing feeding assistance while seated, not standing over the resident and not engaging in other activities (example: talking to fell ow staff) while assisting the resident.

Based on interviews and record reviews, this facility failed to thoroughly assess and determine an acute change in condition leading to respiratory distress and failed to notify the physician immediately notify the physician of a fracture. These failures affected 2 of 3 residents (R4, R1) reviewed for quality of care. These failures resulted in R4 having a change in respiratory condition and not immediately transported to the hospital for over 90 minutes where R4 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R4: On [DATE] at 330pm, V16 (nurse supervisor) stated that V16 was called by the nurse in charge and informed that she was going to send R4 to the hospital. V16 stated that when V16 arrived at R4's bedside, V16 brought vital sign machine, nebulizer machine, and nebulizer medication. V16 stated that R4's oxygen saturation level was normal when he arrived. V16 does not remember any details of R4's respirations, but recalls R4 was congested. V16 stated that R4's blood pressure was quite elevated and R4 was responsive to name. V16 stated that R4's head of bed was elevated and a breathing treatment was administered. V16 stated that R4 was not in cardiac or respiratory distress. V16 stated that he was not aware R4's oxygen saturation level was 78% prior to V16 arriving at R4's bedside. V16 stated that he would have sent R4 out to hospital via EMS (emergency medical services) 911 if he had known that. On [DATE] at 3:45pm, V2 DON (director of nursing) stated that R4 was stablized with oxygen and did not require urgent transport to the hospital. V2 stated that R4 was not normally on oxygen therapy. When questioned regarding R4's breathing status (rapid, labored, or use of accessory muscles), additional vital signs, pulse oximetry results with and without oxygen, and lungs sounds, V2 did not respond. Review of R4's medical record notes the following: On ,d+[DATE] at 2:05pm, V20 LPN (licensed practical nurse) noted V20 was informed by R4's POA (power of attorney) that R4 was noted to be lethargic and sounded like he was struggling to breathe. R4 was assessed and blood pressure ,d+[DATE], oxygen saturation level 78% on room air, respirations 22/minute. R4 was put on 4 liters of oxygen and oxygen saturation level went up to 94% on oxygen. R4's physician was notified and new orders received to send to hospital for evaluation and treatment. R4 was put to bed and head of bed elevated 45 degrees. V16 (nurse supervisor) assessed R4 and nebulizer treatment was given. A private outside ambulance service was contacted for transport, estimated time of arrival 1 hour. Will continue to monitor R4's condition for any changes On ,d+[DATE] at 2:57pm, R4's chest x-ray results show heart is slightly enlarged with mild congestive heart failure and possible pnuemonic infiltrate in the right lung base. Results faxed to R4's physician, R4 remains with order to send to hospital. On ,d+[DATE] at 3:25pm, V20 noted private outside ambulance service arrived at 3:10pm to transport R4 to the hospital. Review of the private outside ambulance service run sheet, dated [DATE], notes dispatch was contacted at 1:43pm for transport to hospital for resident with high blood pressure. An ambulance was dispatched to this facility at 2:26pm. Paramedics were at R4's bedside at 3:09pm. The ambulance did not leave facility with R4 until 3:43pm. R4 arrived at the hospital at 4:02pm. The paramedics noted: chief complaint severe respiratory distress. Vital signs at 3:11pm, oxygen saturation 76% on room air, respirations 24/minute and labored. Narrative note: responded to this facility for a male resident (R4) complaining of lethargy and evaluation for high blood pressure. Assessment showed R4 was mouth breathing and had labored breathing. R4 was placed on a non-rebreather mask with 15 liters of oxygen and oxygen saturation 98%. R4 is less labored and less agitated on non-rebreather mask; R4 was receiving 3 liters of oxygen via nasal cannula upon paramedics arrival at R4's bedside. R4 was admitted to hospital with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R1: On [DATE] at 3:45pm, V2 DON (director of nursing) stated that R1 did not complain of pain in left hip so did not need to be transferred to the hospital urgently. When questioned if V2 assessed R1's leg for pain with slight movement, V2 did not respond. V2 was informed that V17 NP (nurse practioner) noted R1 grimaced with slight movement of left leg. Review of R1's medical record notes the following: On ,d+[DATE] at 3:35pm, V15 RN (registered nurse) noted: R1 was seen by V17 NP (nurse practitioner), new orders received; x-ray of left hip, left Femur, left knee, left lower leg,and left foot due to left foot swelling. Order placed with outside diagnostic imaging company. On ,d+[DATE] at 4:23pm, V17 NP noted: R1's family member reports that R1 has been guarding left leg. R1 was sleeping. R1 did grimace upon exam. Left lower extremity with 2+ non-pitting [CONDITION(S)] (swelling). Range of motion not performed as R1 grimaced upon slight movement. Left leg pain and swelling, x-rays of left hip, femur, tibial/fibula, ankle, and foot to be done. On ,d+[DATE] at 2:28am, V18 LPN (licensed practical nurse) received results from the outside diagnostic imaging company. Findings for left hip: Left inter-trochanteric fracture and superior subluxation and impaction. On ,d+[DATE] at 2:36am, V18 LPN noted: Faxed to V13 (attending physician) and will endorse to incoming shift. On ,d+[DATE] at 8:08am, V11 RN contacted V17 NP regarding X-ray results. Order received to send R1 out to the hospital for further evaluation. R1's family member notified. R1 was picked up by a private outside ambulance service at 9:15am. Review of R1's hospital record, dated [DATE], notes R1 presented to the emergency room at 9:51am. It notes reason for admission: left hip fracture, age-related [CONDITION(S)] without current pathological fracture. The emergency room physician noted R1's left leg is internally rotated, flexed at knee and hip, limited range of motion due to pain. Left leg x-rays noted evaluation of left lower leg is somewhat limited secondary to osteopenia. There is an intertrochanteric fracture, comminuted with impaction of the distal fracture fragment and medial angulation.

Based on interviews and record reviews, the facility failed to use the mechanical lift and safely transfer a resident one resident to prevent an avoidable accident. This failure affected one of three (R1) residents reviewed for safe transfer. This failure resulted in R1 being transferred without the use of the mechanical lift resulting in R1 sustaining an acute comminuted left [CONDITION(S)] with impaction requiring transport to the local hospital. Findings include: On 11/1/22 at 10:47am, V19 (R1's family member) stated that V19 was present on 8/26/22 when V21 CNA (certified nurse aide) transferred R1 from reclining wheelchair to bed. V19 stated that V21 CNA grabbed R1's arms, V19 asked about mechanical lift device, V21 CNA responded 'I can lift her myself'. V19 asked 'shouldn't you be grabbing R1 under armpits?' Before V19 could get to other side of bed to assist V21 CNA, V21 CNA threw R1 into bed, R1 was half on and half off the bed. V19 stated that V19 assists the CNAs with incontinence care of R1. V19 stated that R1 is essentially nonverbal, only speaks one or two words, but looked at V19 like she was scared. V19 stated that V21 spread R1's legs apart, like R1 was a wishbone. After R1's brief was changed, V21 CNA threw R1 back into the reclining wheelchair, again R1 was half on and half off chair. V19 stated that V19 saw another CNA in R1's doorway and called out for assistance. The other CNA, V9, stated that he would get the mechanical lift device to transfer resident to bed. V19 stated that she told V9 CNA that R1 did not need the device and asked his assistance with getting R1 positioned better in wheelchair. Stated that V21 CNA informed V9 CNA that R1 was fine like she was, V9 CNA assisted anyway. V19 stated that once R1 was positioned better in wheelchair, V19 took R1 to nurses' station to speak with V2 DON (director of nursing) regarding situation. V19 stated that family had to request x-rays of R1's left leg and inform staff of swelling to left foot. V19 stated that on 9/2 V19 requested further x-rays due to R1's grimacing with slight movement of left leg. V19 stated that R1's left hip was shattered. R1 had surgery on 9/3/22. On 11/2/22 at 11:55am, V2 DON stated that per this facility's transfer protocol R1 requires a mechanical lift device and two staff members for transfers. V2 stated that V21 CNA disregarded this facility's transfer protocol. V2 stated that on 8/26/22, V21 was sent home after the incident. V2 stated that V2 and V5 (human resources director) met with V21 on V21's next scheduled day to work. V2 stated that V21 informed V2 that she transferred R1 without a mechanical lift device. V21 informed V2 and V5 that V21 transferred R1 by herself because she thought R1 was light enough to transfer by herself. V2 stated that V21 was aware of the transfer codes that are on each resident's door and that all staff will follow a resident's transfer status as assessed by the restorative nurse. V2 stated that R1's transfer code was orange for mechanical lift device required. On 11/1/22 at 1:25pm, V6 (restorative nurse) stated that she is familiar with R1. V6 stated that R1 did not walk, unable to bear weight, unable to stand pivot, and required a mechanical lift for transfers. V6 stated that there is a color code with each resident's name on his/her door. V6 stated that R1 had an orange dot next to her name indicating mechanical lift device required. V6 stated that all staff receive color coding training and transfer technique upon hire and annually. V6 stated that staff have to provide return demonstration during competency. V6 stated that V6 is aware of V21. V6 stated that V21 received training upon hire in April 2022 On 11/1/22 at 2:05pm, V8 CNA stated that R1 was not able to walk, was totally dependent on staff for transfer, and required a mechanical lift device and two staff members for all transfers. V8 stated that both of R1's legs were stiff. V8 stated that all residents have color coded sticker dots on their door to indicate how they transfer and the number of staff needed. V8 stated that staff receive annual training on transfers, return demonstration required. V8 stated that V8 has assisted V21 with transfers a couple of times. V8 stated that V21 seemed unsure of herself. V8 stated that R1's family spoke with V8 the following day regarding V21's transferring R1 without the mechanical lift device. V8 stated that it was not safe to transfer R1 without lift device. On 11/1/22 at 2:15pm, V9 CNA stated that V9 did not assist with R1's care on 8/26. V9 stated that R1 requires a mechanical lift device for all transfers. V9 stated that there is a color coded dot beside the resident's name indicating how the resident transfers. V9 stated that he was bringing food to R1 when family member asked him for help. V9 stated that he thought family wanted to get R1 in bed so he went to utility room to get the mechanical lift device. V9 stated that the transfer had already been done before V9 went to R1's room. V9 stated that when he returned to R1's room with lift device, R1's family informed him that the family wanted assistance with positioning R1 better in wheelchair. On 11/2/22 at 1:24pm, V12 PA (physician assistant for R1's orthopedic surgeon) stated that V12 reviewed R1's hip x-ray. V12 stated that it looks like R1's left [CONDITION(S)] was caused by a combination of [CONDITION(S)] and rough transfer from wheelchair to bed and then back to wheelchair. Review of this facility's report notes on 8/26/22, all resident transfer status codes were in place on all resident rooms. V21 came into R1's room which was clearly labeled orange dot for mechanical lift required. V21 transferred R1 from wheelchair to bed to provide incontinence care. Instead of getting a co-worker to assist with mechanical lift, V21 scooped R1 up in her arms and placed R1 in bed. Once care provided, V21 again scooped up R1 and placed R1 back in wheelchair. On 8/29/22, V5 (human resources director) asked V21 if she knows the transfer codes and V21 responded she does. V21 stated that she thought R1 was light enough to carry by herself. V21 stated that R1 did not look too fragile and R1 didn't complain on transfer so no issue. V2 DON informed V21 that the restorative nurse makes recommendations on transfer staus and it is up to the CNA to follow the transfer status without making judgement calls. Review of this facility's resident transfer/lift procedures policy, reviewed 11/17/2021, notes initial screeningwill be performed on all our residents to assess transfer and ambulation status. Ongoing evaluation and updates will be conducted as needed. Transfer status will be designated for each resident. Residents transfer status will be identified by a color coded dot on the outside of the door next to resident's name.

Based on interviews and record reviews, the facility failed to follow its shower and bathing policy and procedures to ensure all residents received a bath/shower at least twice a week. This failure affected 1 resident (R1) out of 3 residents reviewed for activities of daily living assistance. Findings include: On 11/1/22 at 2:15pm, V9 CNA (certified nurse aide) stated that every resident is showered/bathed twice weekly, once a week on the evening shift and once a week on day shift. On 11/1/22 at 2:30pm, V19 (R1's family member) stated that there were three different occasions when R1 was not bathed for about10 days. V19 stated that V2 DON (director of nursing) was aware of this. On 11/2/22 at 3:45pm, V2 DON stated that R1 has refused shower/bed bath. Review of R1's medical record, dated 2/23/22, notes V2 DON had a phone conference with R1's family members regarding their concern for R1 missing showers. Review of R1's medical record notes R1 was scheduled to receive a shower/bed bath every Tuesday and Friday. Review of R1's shower/bathing documentation, dated 2/1/22 through 6/30/22, does not note R1 received a shower on 2/18, 3/4, 3/25, 4/1, 4/15, 4/29, 5/3, or 5/13. There is no documentation found in R1's medical record noting R1 refused any showers/bed baths. Review of this facility's shower and tub bath policy and procedure, reviewed 2/18/2020, notes the following information should be recorded in the resident's medical record: the date and time the shower/bath was provided,; the name and title of the person who assisted the resident;and if the resident refused the shower/bath, the reason why and the intervention taken. It also notes to notify the supervisor if the resident refuses shower/bath.

Based on interviews and record reviews, the facility failed to notify the attending physician immediately of an abnormal x-ray results. This affected 1 of 3 residents (R1) reviewed for notification of change. This failure resulted in a 5 hour delay in notification to the physician of a fracture and delay of treatment. Findings include: On 11/2/22 at 10:50am, V11 RN (registered nurse) stated that if the x-ray results note a fracture, the nurse should call physician immediately; never just fax results to the physician's office. V11 stated that the x-ray report can be faxed later. On 11/2/22 at 11:55am, V2 DON (director of nursing) stated that this facility's x-ray protocol is for the nurse to call the outside diagnostic imaging company of x-ray order. V2 stated that the nurse is expected to notify the resident's physician, V2, V1 (administrator), and the resident's power of attorney right away if the x-ray result is abnormal. On 11/2/22 at 2:34pm, V14 ADON (assistant director of nursing) stated that the nurse is expected to call the outside diagnostic imaging company after x-ray order entered into the computer to notify of order and also obtain time when x-ray will be performed. V14 stated that this facility also uses a second diagnostic imaging company if the first company cannot complete the x-ray within 24 hours. On 11/2/22 at 3:10pm, V13 (attending physician) stated that the expectation is for the nurse to call V13 immediately with abnormal x-ray results. On 11/2/22 at 3:15pm, V15 RN stated that the nurse enters the order for x-rays online and then calls the outside diagnostic company. V15 stated that if the x-rays are not ordered urgent, the outside diagnostic imaging company should perform x-ray(s) within 12 hours. V15 stated that if the x-ray results are abnormal, the nurse notifies the physician and the resident's family member immediately. On 11/2/22 at 3:45pm, V1 (administrator) acknowledged that the nurse should have called V13 immediately upon receiving abnormal x-ray results for R1. Review of R1's medical record, dated 9/1/22 at 3:35pm, V15 RN noted R1 was seen by V17 NP (nurse practitioner), new orders received; x-ray of left hip, left femur, left knee, left lower leg, and left foot due to left foot swelling. Order placed with the outside diagnostic imaging company. Review of R1's medical record, dated 9/2 at 2:28am, V18 LPN (licensed practical nurse) noted: received results of R1's left hip x-ray. Findings: left inter-trochanteric fracture and superior subluxation and impaction. On 9/2 at 2:36am, V18 LPN noted: Faxed to V13 and will endorse to incoming shift. On 9/2 at 8:08am, the nurse contacted V17 NP regarding X-ray results. Order received to send R1 out to the hospital for further evaluation.

Based on interviews and records reviewed, the facility failed to follow policy and procedures, failed to provide a safe transfer and failed to follow resident's Care Plan to prevent an avoidable accident. This affected 1 of 3 residents R1 reviewed for safety during care. This failure resulted in R1 falling to the floor suffering a left femoral intertrochanteric [CONDITION(S)]. Findings include: Facility incident report dated 7/30/2022 documents the following sent to IDPH and another received from facility: IDPH incident report: conclusion: resident attempted to self transfer from bed to wheelchair although she was aware that staff was on their way to assist her. Facility incident report: Conclusion: after investigation - wheelchair was placed next to the bed and resident decided to transfer herself to the wheelchair. She is normally a 2 person transfer. She was unable to sustain her balance and fell to the floor. Review of hospital records dated 7/30/2022 documents the following: page 17: Hospitalist History and Physical Chief Complaint: Fall, Hip Pain. HPI: R1 is a [AGE] year old female with history of [CONDITION(S)] accident, Hypertension, [CONDITION(S)], and Diabetes Mellitus who presented from nursing home after an unwitnessed fall. She was being changed in the bed by an aid who sat her on the edge of the bed, but then stepped out of the room to get something. When she returned, the patient was on the floor complaining of left hip pain. Family says there have been a few falls similar today in the course of her 4 years living here, but none this severe. Daughter notes that the patient has severe spinal stenosis and is unable to sit up unassisted, and therefore is frustrated that she was left alone sitting which caused the fall. The patient is complaining of moderate pain in the left hip, but denies any other symptoms. Page 20: Imaging/other studies: Xray Femur MIN 2 views LT. Result date 7/30/2022. Impression: Comminuted, angulated left femoral intertrochanteric fracture. Page 29 dated 7/31/2022 Ortho Consulted for further recommendations: Dr. has examined the patient and recommended surgery to repair the fracture. Review of R1's MDS section C dated 6/10/2022 documents R1 has severely impaired cognitive functions as evidenced by a BIMS of 7/10. R1's Care Plan dated 10/19/2020 documents: The resident is at high risk for falls r/t (related to) hearing impairment, poor safety awareness and history of falls. Interventions: 11/24/2018- Re-do of transfer competencies given to CNA giving showwr, 2 person transfer and gait belt to be used at all times. 12/9/2021 Staff educated on the facility's protocol and policy on transferring residents who require two-person assist. 12/30/2018- Resident was assessed for use of sit to stand lift for all transfers x 2 assists, resident was informed and will be referred for PT (physical therapy) evaluation due to repeated falls. 4/30/2019- Staff instructed to stay with resident in the washroom until done with grooming. On 8/30/2022 at 10:55 AM R1 is sitting at nurse's station in a wheelchair. Appears clean and comfortable. R1 is very hard of hearing. Points to her ear and mumbles something as if she does not hear surveyor. R1 is unable to be interviewed. R1 has unclear speech. On 8/30/22 at 12:23 V3 (LPN) states R1 is alert and oriented times 2, hard of hearing, complaint with care. V3 states she has been taking care of R1 for a few years here. V3 states R1 does not ambulate and is a two-person assist. V3 states she was the nurse on duty the morning R1 fell on [DATE]. V3 states she was passing medications in the dining room when V4 (agency CNA) came to her. V3 states that V4 (CNA) said R1 had fallen. V3 states, V4 said she was getting R1 dressed. V3 states that V4 stated she left R1 sitting at the side of the bed to go get help and when she came back she was on the floor. V3 states the CNA put R1 in a wheelchair and brought R1 to me. V3 states, I told the CNA who found her that it is not protocol for them to put her in a chair. She should have called the nurse immediately. V3 states R1 requires one person assist for dressing and for Toileting and shower is 2 person assist. V3 states, V4 (CNA) and another CNA V5 helped R1 into the wheelchair. V3 states, the standard protocol is bed low position, call light at bedside everything in reach. R1 did not have pads on the floor. V3 states I learned that on 7/29/22 a CNA took R1 to restroom R1 couldn't balance and CNA placed her on the floor and R1 had no injury. V3 states, they don't normally sit R1 at the side of bed and leave because R1 has poor trunk control. On 8/30/2022 at 12:52 PM V6 (LPN) states when leaving a resident who is high fall risk in her room, she would leave them in bed, with the call light, and bed low position. V6 states, she would make sure the bed alarm or pads on. V6 states, they should never leave the patient sitting at the side of the bed if high fall risk. V6 states, CNA's are not supposed move resident's post fall. V6 states, CNA's should call the nurse right away because we don't know if the patient had any fractures. On 8/30/2022 2:12 pm in first floor conference room. V4 (CNA) states, R1 does not walk. V4 states R1 talks, tells what she wants, and alert to person. V4 states R1 is a fall risk. V4 states R1 is Wheelchair bound. V4 states she believes R1 is a fall risk and up with two-person assist. V4 states, She [R1] is 2-person assist with transfers. V4 states R1 has always been a 2- person assist. V4 states she remembers the incident of 7/30/22. V4 states, in the morning R1 was her last resident to get up. V4 states, when she got to R1's room R1 had had a bowel movement. V4 states, by then breakfast was being served. I changed her. I told her to wait for me to get someone to help her into the wheelchair. I lowered the bed before I left. I brought the wheelchair nearby and left her at the side of the bed. Surveyor asked V4 to clarify where R1's feet were. V4 states, She [R1] was sitting at the side of the bed feet on the floor. I had just finished dressing her. V4 states, yes, She had her shoes on and everything. I had just finished dressing her. V4 states she put R1's bedside table in front of her so she didn't move and the wheelchair to her left that was locked to box her in so she didn't move. V4 states, I did it that way to make sure she didn't move. V4 states she was gone not even 2 minutes. V4 states, she saw V5 (CNA) waved to her to help her and went back to the room. V4 states, when she came back the table was moved forward away from the where she left it and R1 was between the table and the bed. V4 stated, she figured R1 wanted to go with everyone else to eat. V4 states, I didn't pull the call light because I thought no one would come because they were passing food. V4 states, I would press the call light and would stand by the door so she could see me. V4 states, she puts them flat on bed and put wedges if have them and put the alarm on. V4 states, I think she [R1] lost confidence I was coming back. I don't remember if R1 had an alarm. V4 states she definitely did not have a wedge. V4 states she has had R1 in her care before. V4 states, V5 came and they lifted R1 to the wheelchair after they found her on the floor. V4 states, after that I was taught that I should not have done that. If possible should use the hoyer. V4 states, she was told don't lift residents until the nurse assesses them. On 8/30/2022 2:51 pm V7 (Restorative Nurse) investigated R1 fall on Monday after fall. V7 states, the nurse said it was an unwitnessed fall. V7 states, R1 has never gotten out of bed previously. V7 states R1 does not walk. V7 states, R1 requires 2 person assist for bed mobility and transfers. On 8/30/22 3:15PM V2 (DON) states V2 states, I don't expect someone who is high fall risk to be at the side of the bed for any amount of time. With R1 everything done correctly, except leaving her at side of the bed. V4 stepped away to call someone to help. V2 states. In retrospect, V4 would have laid her down. V2 states, V4 was gone only a short time. V2 states, after a fall the Protocol is that a resident should stay on floor until nurse assesses them in case there is an injury, you don't want to move them and make injury worst. On 8/31/2022 at 1:07 PM V5 (CNA) states she usually works on 1st floor. She is not too familiar with the R1 because don't work on 2nd floor. V5 states she remembers the incident. They were getting everyone ready for breakfast. V5 states V4 (CNA) came to her and she said to help her transfer someone. V5 states, I immediately followed V4 and when we got there we saw R1 on the floor on the side of her bed. V5 states the resident kept saying we should get her up. We got her up and put her in wheelchair with a gait belt. V5 states, she is not sure if R1 said she was in pain. V5 states, she just looked like she was in pain and said get her up in the chair. V5 states it is policy that we are supposed to call the nurse so she can assess the scene and figure out what happened before we get a resident up who has fallen. V5 states, I didn't do it because the patient kept saying we should get her up. V5 states, because there might be an injury or something that we may not know. V5 states, first I make sure they are dressed and ask for help to get them up. I put the resident in the bed, bed low, and call for help. I make sure they don't sit on the bed, they lie down on the bed. V5 states, I make sure they are not in the sitting position. V5 states, because maybe they are at fall risk. On 9/1/2022 at 9:16 AM V2 states, she submitted the conclusion on the incident report. V2 states R1 had an unwitnessed fall on 7/30/2022. V2 states that, V4 said she was just gone for a couple minutes and when she came back the bedside table was pushed forward. V2 states, in her experience when resident's see a wheelchair near they try to get into it. V2 states, It is possible R1 had fallen forward. Review of R1's MDS section G dated 6/10/2022 documents R1 requires extensive 2 person assist for bed mobility and transfers. Review of R1's nursing note by V3 (LPN) dated 7/30/22 documents the following: Writer informed by assigned CNA that resident was observed on the floor. Per assigned CNA, she was getting resident dressed for breakfast. Placed the bed in lowest position and went to get help form another CNA. Per assigned CNA, left the room for approximately 5 min. Resident put back into bed. Resident complained of pain to left lower extremity. Noted with decreased range of motion on said site. No discolorations, abrasions noted at time of assessment. Administered as needed Tylenol. Supervisor called to assess resident. Power of Attorney and Medical Doctor notified. Per Medical doctor sent resident to the hospital for evaluation. Review of nursing note by V10 on 7/30/2022 documents: called hospital for the status of the resident, admitted with left [CONDITION(S)]. Review of R1's Fall Care Plan documents resident with history of fall on 9/4/20, 6/6/21, 12/9/21, 7/29/22 and 7/30/22. Review of R1 post fall follow up dated 12/17/21 documents the following: Staff educated about proper and safe way of transferring resident with emphasized on how to transfer residents who require two-person. Staff verbalized understanding on education. Review of R1's Morse fall scales dated 6/8/2022, 7/29/2022, and 7/30/2022 document R1 is a high risk for falls as noted by fall risk scores of above 45. The facility's Fall Prevention Program Policy dated 2/4/2022 documents the following: The facility is committed to reducing the number of falls, and to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all residents from falling is not possible, it is the facility's policy to identify those residents at high risk by assessing, planning a preventive strategy, and maintaining as safe an environment as possible.

Based on interview and record review, the facility failed to supervise a resident (R5) with high fall risk, dementia, Alzheimer's disease, and poor safety awareness of 3 residents reviewed for falls. This failure resulted in R5 having an unwitnessed fall resulting in a fractured wrist and jaw. Findings include: On 5-26-22 at 11:31 AM, V1 (DON) said R5 is alert and oriented x 0. She might be able to make her simple needs known. She is primarily Greek speaking. R5 has Alzheimer's and dementia. She has poor safety awareness. R5 is a high fall risk. R5 had an unwitnessed fall. R5 was up walking by herself. R5 needs handheld assistance with walking. R5 walked by herself and fell . On 5-24-22 at 1:17 PM, V7 (CNA) said R5 has Dementia, confusion, unable to make her needs known. R5 had a steady decline and is unsteady with ambulation. R5 is a high fall risk due unsteady and very poor safety awareness. Facility provided low bed, floor pads, non-skid socks, call light in reach, and toileting before and after meals. speaking only Greek. R5 needs constant monitoring for safety. R5 is impulsive and will get up by herself. V7 was not working the day of the fall however, V7 would always check on R5 every 30 minutes. On 5-24-22 at 1:29 PM, V8 (LPN) said R5 is alert oriented x 1-2, speaks Greek only, and responds to Greek speaking staff only. R5 has dementia, very poor safety awareness, history of falls, high fall risk and has an unsteady gait. R5 has verbal aggression which can turn to physical aggression. R5 requires frequent monitoring. On 5-26-22 at 10:12 AM, V15 (Restorative Nurse) said R5 is alert, oriented x 1, follows simple and commands. R5 makes her simple needs known and primarily speaks Greek. R5 has dementia, Alzheimer's Disease with impaired cognition, poor safety awareness, agitation, and verbal and physical aggression. R5 can be impulsive and try to get up without assistance. R5 is a high fall risk with poor safety awareness, impulsivity, and aggressive behaviors. R5 had an unwitnessed fall on 4-22-22. R5 got up by herself and fell . R5 requires frequent monitoring. During this interview V15 said R5 was agitated and restless. V15 said R5 was up walking. V15 said she walked with R5 and left R5 to call the nurse for assistance and R5 fell . R5 was being monitored by V15 but V15 left R5 to find another staff for assistance. Fall Prevention Policy revision date 2-4-22 documents it is a facility policy to identify those residents at high risk by assessing, planning a preventative strategy, and maintaining a safe environment as possible. MDS (Assessment Reference Date: 4-28-22) documents R5 is never understood. BIMS- response locked. Transfers (self): Extensive Assist, Transfers (support): 2-person physical assist. Moving from seated to standing position: not steady, only able to stabilize with staff assistance. Walk in Corridor: (support) 1 person assist. Diagnoses (not limited to:) Alzheimer's, Non-Alzheimer's Dementia, Anxiety, Depression, Initial State Reportable dated 4-22-22 documents R5 had an unwitnessed fall at 11:04 AM. R5 was observed to have a 2 CM laceration on her chin with bleeding gums and nose. R5 was confirmed admitted at local hospital with diagnosis of left mandibular ramus fracture with sutures on chin. Final State Reportable dated 4-29-22 documents Conclusion: R5 was admitted to hospital with fractured wrist and fractured mandible. R5 was walking the halls, lost her balance, and fell to the floor. Hospital Record dated 4-22-22 documents Clinical History: [AGE] year-old female brought in by EMS status post unwitnessed fall at the nursing facility. Per EMS nursing states that R5 was walking in the hallway when she fell forward and hit her head. Pt has a chin laceration, right upper lip laceration, and has some cuts in her mouth. Impression: bilateral maxillary fractures, with blood in the maxillary antra. Impression: nondisplaced fracture of the base of the 5th metacarpal. ADL Care Plan documents Intervention: R5 able to ambulate without assistive device, needs handheld assist x1 staff for walking safety (initiated on 2-1-22). R5 requires extensive assist x 1-2 staff for ADLs at this time (initiated on 4-14-22).

Based on record review and interview the facility failed to have two staff members perform a safe transfer for one of three residents (R1) reviewed for fall in a sample of eight. This resulted in R1 sustaining a laceration requiring sutures. Findings include: Incident report dated 11/21/15 6:55AM indicated during transfer from bed to wheelchair , R1 had a witnessed fall and sustained a cut on her mid forehead area . R1 was sent to the hospital where she was treated ( required stitches) and then sent back to the facility. R1's Minimum (MDS) data set [DATE] indicated R1 required a two person physical assist for transfer assistance. R1's care plan dated 11/17/15 stated R1 has a Self Care Deficit due to generalized weakness due to multiple medical issues , resident is non ambulatory and requires 2 person assist with transfers at this time. R1 on 12/7/15 2:15PM stated the staff person tried to get me up two times. She pulled my bed around. When we tried to get in my wheelchair I fell . They had to take me to the hospital. They just took the stitches out. E3 (certified nurse aide/ CNA) signed statement dated 11/21/15 indicated the following event: E3 was getting R1 up from the side of bed . R1 was sitting on the side of bed. While E3 was standing R1 up , the catheter was in E3's way. E3 got caught in the catheter. E3 stumbled . R1 got hit on the forehead. E3 did not know where R1 hit her forehead but stated possibly on the floor. E3 ( Certified Nurses Aid ) 12/8/15 9:48 per phone interview stated around 7 AM 11/21/15 R1 was dressed. I put the Foley catheter in the protective bag. I put the protective bag on the floor on the right side of R1. I put the wheelchair next to the bed. I sat R1 up in the bed and put the gait belt around R1. The wheelchair was locked and next to the bed. I tried to put R1 in the chair and I got caught in the tubing. I couldn't turn completely to put R1 in the chair. We both fell to the floor together. R1 was bleeding. I tried to stop the bleeding. I called the nurse. I don't know where she hit her head. R1 is a two person physical assist for transfer. I looked outside the room for help and there was no one. The other workers were giving showers. That was my mistake. I could have asked the nurses but I didn't. It was my mistake. Hospital emergency department record dated 11/21/15 states R1 had a 4 centimeter laceration to her forehead. R1 required 9 sutures. No other injury was diagnosed . R1 was treated and sent back to the facility.

Based on interview and record review, the facility failed to perform a resident transfer according to the care plan for 1 of 3 residents (R2) reviewed for falls/fractures in the sample of 3. As a result of this failure, R2 sustained injuries that required transfer to the local hospital emergency room (ER) for treatment of [REDACTED]. Findings include: The Minimum Data Set (MDS), dated [DATE] and August 8, 2012 notes that R2 is to be transferred by a mechanical lift with two staff person minimum. The care plan for R2 dated May 1, 2012, states that R2 requires a mechanical lift and two staff minimum for transfer. Nursing notes dated June 6, 2012 at 6:50 p.m. stated that E7, Nurse, found resident in bed with multiple injuries. Resident was noted with a deep cut on right foot approximately 2.5 inches between big toe and 2nd toe, left lower extremity had swelling and a bruise. E7 asked R2 if she knew how this incident happened; E7 documented that R2 was confused and did not know how the injuries occurred. Doctor was paged and ordered R2 to be sent out to hospital (ER) for evaluation. Facility Unusual Occurrence Report dated June 6, 2012 noted R2 in bed lying down with an injury on the right (R) foot; bleeding between big toe and second toe; left (L) lower leg swelling and painful to touch. R2 was transferred to the local ER for possible suturing and evaluation. Nursing notes dated June 7, 2012 at 5:30 a.m., stated that R2's brother called the facility and advised E7 that R2 received 9 sutures to the right (R) foot between the great toe and the second toe and that R2 had her left leg broken in two places. Nursing notes for R2 dated June 7, 2012 at 7:00 a.m. indicated ER (emergency room ) nurse contacted facility and "confirmed" left leg fracture of the tibia and fibula and nine stitches to right foot between great toe and 2nd toe. physician's orders [REDACTED]. Record titled "After Visit Summary" from local Orthopedic specialist indicated that R2 had an office visit on July 23, 2012 at 3:30 p.m. for [DIAGNOSES REDACTED]. July 26, 2012 at 2:30 p.m. E2, Director of Nursing (DON - Director of Nursing), stated that during her investigation it was determined that R2 sustained multiple injuries as a result of improper transfer by a Certified Nursing Assistant (CNA). E5, CNA admitted to E2 that she knew that R2 was a mechanical lift for transfer, but attempted to transfer R2 by herself without a mechanical lift device. E2 stated that E5 told her R2 hit her feet against the bed rail. E2, DON stated that E5 has been an employee of the facility for several years and was aware of R2's condition related to transfer. July 27, 2012 at 11:00 a.m. E2, DON was asked if E5, CNA was available for interview, E2 stated that E5 was no longer employed with them. E2 stated she had to terminate E5 as a result of the incident on June 6, 2012 involving R2.