Every finding on record at Hallmark HC of Carlinville

Based on interview, observation, and record review, the facility failed to maintain an effective pest control program. This has the potential to affect all 38 residents living in the facility. Findings include: 1. On 4/7/25 at 11:45 AM, the medication room was observed; mouse droppings were found around the baseboards. 2. On 4/7/25 at 11:50 AM, the laundry room was observed; mouse droppings were found around the baseboards in the dirty room. 3. R2's Face Sheet, print date of 4/7/25, documents R2 was admitted on [DATE] and has a diagnosis of Diabetes. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact. On 4/7/25 at 8:46 AM, R2 stated, I did see mice last week. They caught two in the room and 1 in the bathroom. On 4/7/25 at 8:50 AM, under R2's window, mouse droppings are observed. 4. R3's Face sheet, print date of 4/7/25, documents R3 was admitted on [DATE] and has diagnoses of a History of Heart Attack and Dependence on Renal Dialysis. R3's General Note, dated 4/2/2025, documents, Resident arrived by hospital transport in w/c (wheelchair) accompanied by wife and daughter, pleasant. Alert and oriented. On 4/7/25 at 8:35 AM, R3 stated, I saw 2 (mice) on the floor and one jumped up and ran across my chest while I was sleeping. I did let someone know. I don't remember their name. They put a mouse trap in here. On 4/7/25 at 8:38 AM, R3's room was observed; mouse droppings were in the closest and in the bathroom. 5. R4's Face Sheet, print date of 4/7/25, documents R4 was admitted on [DATE] and has a diagnosis of Bipolar Disorder. R4's MDS, dated [DATE], documents R4 is cognitively intact. On 4/7/25 at 8:50 AM, mouse droppings were observed in R4's closet. R4's room and bathroom had no mouse traps in it. On 4/7/25 at 9:05 AM, R4 stated, I did have mice in the room, but they came in and put traps down. 6. R5's Face Sheet, print date of 4/7/25, documents R5 was admitted on [DATE], and has a diagnosis of Dementia. R5's MDS, dated [DATE], documents R5 is severely cognitively impaired. On 4/7/25 at 8:59 AM, R5 stated she does see mice on the floor of her room. On 4/7/25 at 9:00 AM, R5's closet has mouse droppings in it. In the closet, there is a laundry basket with 3 items of clothing. The clothing has mouse droppings on them. On 4/7/25 at 8:20 AM, V1, Administrator, stated, Today is my first day. I am unsure about a mouse problem. The Maintenance Director recently quit. On 4/7/25 at 8:53 AM, V3, Housekeeping stated,About a week ago, I saw a mouse in the laundry room. We put glue traps out. On 4/7/25 at 8:56 AM, V4, Housekeeping, stated, I have noticed mice. We keep putting traps down. On 4/7/25, V6, Certified Nurse Aide, stated, Mice have been around or a couple of months. We were putting out traps and we caught quite a few, but then we stopped catching them, so we switched to glue traps. On 4/7/25 at 9:22 AM, V9, Exterminator, stated he visits the facility 2 times a month. One visit is for the outside and the other is for the inside. When I do the inside, I do the kitchen, common areas, and the offices. I don't go into residents' rooms because usually they are asleep. I was aware of a mouse problem and I put out 4 new bait boxes outside and looked for holes to seal up. I do not remember if the facility let me know they had an active problem or not. I will walk around with (V1) today when I come. At 1:04 PM, V9 stated he is adding 5 more bait boxes to the outside, and will come back next week to check on the progress and effectiveness of the new bait boxes. The policy Pest Control, dated 7/1/24, documents, It is the policy of this faciilty to maintain an effective pest ontrol program so that it remains free of pests and rodents. The Long Term Care Facility Application for Medicare and Medicaid, dated 4/7/25, documents the facility has 38 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to provide pain medication for 1 of 1 resident (R34) reviewed for pain in the sample of 43. This failure resulted in R34 not having Morphine available for 9 hours, which resulting in undue pain. Findings include: R34's Face Sheet, print date of 2/25/25, documents R34 was admitted in 10/3/23 and has diagnoses of Hyperkalemia and Dementia. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 2 hours as needed for restlessness and agitation. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliter) Give 0.25 milliliter by mouth every 2 hours as needed for pain and shortness of breath. R34's Hospice Notes, dated 2/24/2025 11:30 PM, documents, Resident cont (continued) with hospice care. Respirations labored with gurgling noted. Breath sounds wet, not moving secretions out. Skin cool & clammy to the touch. Afebrile. Occasional moan noted. SPO2 (oxygen saturation) 94% 4L (liters) O2 (oxygen) via mask. Residents eyes open & resting in bed with HOB (head of bed) elevated. PRN (as needed) morphine et (and) ativan not yet delivered from pharm (pharmacy). Unable to pull from backup. Hospice notified. NOR (new order received) to start Hyoscyamine (used for secretions) 0.125 SL (sublingual) q (every) 4 hrs (hours) PRN et 650 mg (milligram) acetaminophen rectal suppositories q 4 PRN. Hospice to f/u (follow up) on Rx (prescription) that was sent last week to (pharmacy) to get delivered asap (as soon as possible). On 2/25/25 at 9:11 AM, V10, Licensed Practical Nurse, stated, (R34's) Morphine and Ativan are not in from pharmacy yet. They got a prescription sent into the local pharmacy that just opened up. (Pharmacy) is our regular pharmacy but they haven't delivered it yet. I checked on (R34) earlier; I think he is comfortable. He does have the Tylenol and Hyoscyamine if he needs it. R34's Medication Administration Record (MAR) documents R34 received Morphine on 2/25/25 at 9:35 AM for pain of a 4 on a 0 - 10 scale. On 2/25/25 at 12:14 PM, V10, stated, The facility was able to get the morphine and ativan. I gave it to him about 20 minutes after I talked to you this morning. He is more comfortable now. On 2/25/25 at 2:49 PM, V1, Administrator, stated, We sent the order to pharmacy. They have cut off times. At night when we didn't have it, the nurse tried to get into (facility medication dispensing machine) to get the medication and she was unable to. (V2) even came up and she was not able to get into it either. There was a problem with the (medication dispensing machine) which is fixed now. We called again this morning and the pharmacy was able to get it to us. We did end up getting the medication from our pharmacy and not the local one, because our pharmacy was on the way before the in-town pharmacy opened. On 2/25/25 at 2:52 PM, V2, stated she did come up the night before and try to get the Morphine and Ativan out of the (medication dispensing machine), but she was unable to. (Pharmacy) Illinois Pharmacy Information, undated, documents, for new orders on Monday - Friday the cutoff Time is 11:00 AM and 11:00 PM. Medication Ordering Reminders. If a medication is needed before the next delivery will arrive, call the pharmacy to request a STAT delivery.

Based on interview, observation, and record review, the facility failed to provide pain relief for 1 of 1 resident (R34) reviewed for pain in the sample of 43. This failure resulted in R34 not having R34's pain controlled. Findings include: R34's Face Sheet, print date of 2/25/25, documents R34 was admitted in 10/3/23 and has diagnoses of Hyperkalemia and Dementia. R34's Physician Order, dated 2/24/2025 at1:15 PM, documents, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 2 hours as needed for restlessness and agitation. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliter) Give 0.25 milliliter by mouth every 2 hours as needed for pain and shortness of breath. R34's Hospice Notes, dated 2/24/2025 11:30 PM, documents, Resident cont (continued) with hospice care. Respirations labored with gurgling noted. Breath sounds wet, not moving secretions out. Skin cool & clammy to the touch. Afebrile. Occasional moan noted. SPO2 (oxygen saturation) 94% 4L (liters) O2 (oxygen) via mask. Residents eyes open & resting in bed with HOB (head of bed) elevated. PRN (as needed) morphine et (and) ativan not yet delivered from pharm (pharmacy). Unable to pull from backup. Hospice notified. NOR (new order received) to start Hyoscyamine (used for secretions) 0.125 SL (sublingual) q (every) 4 hrs (hours) PRN et 650 mg (milligram) acetaminophen rectal suppositories q 4 PRN. Hospice to f/u (follow up) on Rx (prescription) that was sent last week to pharmscripts to get delivered asap (as soon as possible). R34's MAR documents R34 received Tylenol on 2/24/25 at 11:20 PM for pain of a 4 on a 0 - 10 scale. No other doses of Tylenol given. On 2/25/5 at 9:08 AM, R34 is lying in bed, eyes closed and open mouth breathing. R34 has a nonrebreather oxygen mask on. R34 is twitching his left arm and hand. R34 has twitching of his bilateral feet. On 2/25/25 at 9:11 AM, V10, Licensed Practical Nurse, stated, (R34's) Morphine and Ativan are not in from pharmacy yet. They got a prescription sent into the local pharmacy that just opened up. (Pharmacy) is our regular pharmacy but they haven't delivered it yet. I checked on (R34) earlier I think he is comfortable. He does have the Tylenol and Hyoscyamine if he needs it. R34's MAR documents R34 received Morphine on 2/25/25 at 9:35 AM for pain of a 4 on a 0 - 10 scale. On 2/25/25 at 12:12 PM, R34 is lying in his bed, eyes closed, and open mouth breathing. R34 has a nonrebreather oxygen mask on. R34 is lying still, no twitching observed. On 2/25/25 at 12:14 PM, V10, stated, The facility was able to get the morphine and ativan. I gave it to him about 20 minutes after I talked to you this morning. He is more comfortable now. On 2/25/25 at 2:49 PM, V1, Administrator, stated, We sent the order to pharmacy. They have cut off times. At night when we didn't have it, the nurse tried to get into (facility medication dispensing machine) to get the medication, and she was unable to. (V2) even came up and she was not able to get into it either. There was a problem with the (medication dispensing machine) which is fixed now. We called again this morning and the pharmacy was able to get it to us. We did end up getting the medication from our pharmacy and not the local one because our pharmacy was on the way before the in town pharmacy opened. On 2/25/25 at 2:52 PM, V2, stated she did come up the night before and try to get the Morphine and Ativan out of the (medication dispensing machine), but she was unable to. The policy Management of Pain, dated 5/16/22, documents, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity.

Based on interview, observation, and record review, the facility to dispose of expired stock medications used by all residents. This failure has the potential to affect all 37 residents in the facility. The Findings Include: On [DATE] at 8:40 AM, the Unit Med Cart was reviewed with V4, Registered Nurse (RN), with the following medications expired: Fiber Laxative 625 MG (milligram) caplets that expired on ,d+[DATE]. A resident (R28) had a bottle of Atropine 1% ophthalmic solution that expired on ,d+[DATE]. On [DATE] at 8:45 AM, the Main Floor Med Cart was reviewed with the following medications expired: Mucus Relief 400 MG expired on ,d+[DATE], Acidophilus 200 million cells/dose expired on ,d+[DATE], Vitamin C 500 MG expired on ,d+[DATE], and Cetirizine 10 MG that expired on ,d+[DATE]. On [DATE] at 8:55 AM, the Medication Room reviewed with the following expirations: Mucus Relief 400 MG bottles with 300 caplets - three bottles total, and all had expired on ,d+[DATE]. Benadryl 12.5 MG 8 OZ (ounce) bottle expired on ,d+[DATE]. Tylenol Suppositories 650 MG expired on ,d+[DATE]. Influenza Vaccines, ,d+[DATE] formula, with 39 syringes expired on [DATE], 10 syringes that expired on [DATE], and Influenza Quadrivalent vaccination with 18 syringes that expired on [DATE]. On [DATE] at 9:15 AM, V4, stated, We had a clinic come in and provide all vaccinations to the residents and they brought their own vaccinations, so the facility did not use ours, that is why they are all expired. All the medications that were expired in the med cart, and the influenza vaccines, were stock meds and can be and are used by all residents when needed. On [DATE] at 8:20 AM, when asked who is responsible for checking expirations on medications, V10, Licensed Practical Nurse (LPN), stated I don't know, (V2, Director of Nursing) who is responsible for checking expirations on medications? On [DATE] at 8:22 AM, V2, Director of Nursing (DON), stated, Everyone is responsible for checking the expirations on medications. They really should be checking them when they have the bottle out to give that medication. The Facility's Medication Storage policy, dated [DATE], documents, The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date. The Resident Census and Conditions of Residents, CMS 671, dated [DATE], documents the facility has 37 residents living in the facility.

Based on interview, observation, and record review, the facility failed to store food at the needed temperature and discard expired food to prevent food borne illness. This failure has the potential to affect all 37 residents living in the facility. Findings include: On [DATE] at 8:21 AM, the stand up freeze had a temperature of 33 degrees. This freezer contained: large bag of carrots, bag of mix vegetables, and a bag of mixed onions and peppers that were thawed and mushy, a box of popsicles that were liquid, 16 precooked chicken patties that were thawed, 21 magic cup ice cream that were liquid, a large box of sausage patties that were completely thawed, a large box of hamburger patties that were partially thawed, 3 loaves of garlic bread that were thawed, and a box of multiple bags of whip cream that is liquid. The stand up refrigerator had a precooked ham that was dated ,d+[DATE], a carton of ready care thickened water dated ,d+[DATE], a carton of prune juice dated ,d+[DATE], and a carton of orange juice dated ,d+[DATE]. On [DATE] at 8:25 AM, V15, Cook, stated the freezer stopped freezing at the beginning of the week and they were told they could keep using it as long as it stayed at 32 degrees or lower. Most of our frozen food is across town at our sister facility. We just bring over what we need for a few days. On [DATE] at 8:30 AM, V16, Dietary Aide, stated the beverage cartons are dated when they are opened. On [DATE] at 10:02 AM, V17, Dietary Manager, stated, The freezer has been out since Friday. We moved most of our product to (sister facility). Friday I brought over just enough food for the weekend. I have thrown all the food out now. Leftovers are only good for 4 days. I don't believe the ham was from ,d+[DATE]; I think it was dated wrong. The date on the beverage cartons is when it came in not when it was opened. On [DATE] at 3:00 PM, V1, Administrator, stated, We went a bought a new freezer. The policy All time/ Temperature control for Safety ((TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code, dated [DATE], documents, Freezer temperatures will be maintained at a temperature of 0 F (Fahrenheit). This policy fails to address how long left overs and open cartons of beverages are to be kept. The Resident Census and Conditions of Residents, CMS 671, dated [DATE], documents the facility has 37 residents living in the facility.

Based on interview and record review, the facility failed to provide residents with a written explanation as to why they are being transferred to the hospital for 3 of 3 residents (R28, R29, R34) reviewed for hospitalization in the sample of 43. Findings include: 1. R28's Face Sheet, print date of 2/25/25, documents that R28 was admitted on [DATE] and has a diagnosis of Dementia. R28's Progress Note, dated 2/22/25, documents, Resident has been transported to (local hospital) d/t (due to) fall per orders from On-call DR. R28's Notice of Transfer of Discharge, dated 2/22/25, fails to document the reason R28 was sent out to the hospital. 2. R29's Face Sheet, print date of 2/24/25, documents R29 was admitted on [DATE] and has diagnoses of Severe Protein - Calorie malnutrition, Type 2 Diabetes Mellitus, and Dementia. R29's General Note, dated 2/22/2025 01:30, documents, Resident has been transported to ER (Emergency Room) d/t (a fall and c/o (complaint of) hip and lower back pain. R29's Notice of Transfer or Discharge fails to document the reason R29 was sent to the hospital. 3. R34's Face Sheet, print date of 2/25/25, documents R34 was admitted on [DATE] and has a diagnosis of Alzheimer's. R34's Change of Condition / Transfer, dated 2/17/2025 10:49, documents, (R34) was transferred on a gurney via ambulance to acute care hospital Sent To: OTHER ACUTE CARE HOSPITAL Date: 02/17/2025 10:55 Sent From: (facility) Unit: Station B Reason(s) for Transfer: Other -- Critical Potassium level 6.8. R34's Notice of Transfer or Discharge, dated 2/27/25, fails to document the reason for transfer. On 2/24/25 at 10:41 AM, V10, Licensed Practical Nurse, stated when she sends someone to the hospital, she does not give them a written notice as to why they are going to the hospital. On 2/24/25 at 10:45 AM, V2, Director of Nurses, stated she did not believe the residents are given anything in writing as to why they are going to the hospital. The policy Bed Hold Notification, undated, fails to address the need to provide a written explanation as to why a resident is being sent to the hospital to the resident.

Based on interview, observation, and record review, the facility failed to provide the prescribed pressure ulcer treatment for 1 of 2 residents (R29) reviewed for pressure ulcers in the sample of 43. Findings include: R29's Face Sheet, print date of 2/24/25, documents R29 was admitted on [DATE] and has diagnoses of Severe Protein - Calorie malnutrition, Type 2 Diabetes Mellitus, and Dementia. R29's Minimum Data Set, dated dated [DATE], documents R29 is severely cognitively impaired and has 1 Stage 3 pressure ulcer. R29's Treatment Administration Record, start date of 1/11/25 with a discontinue date of 2/25/25, documents, Silver sulfadiazine External Cream 1 % (Silver Sulfadiazine) Apply to Sacrum topically every night shift for wound care Cleanse area with WC (wound cleanser), pat dry, apply SSD (Silver Sulfadiazine), Hydrogel, collagen, calcium alginate, cover with ABD (abdominal pad) pad, secure with retention tape daily and PRN (as needed). This treatment was signed off on night shift on 2/23/25. R29's Treatment Administration Record, start date of 1/31/25, documents, Sacrum: cleanse with wound cleanser, apply calcium alginate, collagen particles, SSD (Silver Sulfadiazine) and iodoform packing strip and apply ABD daily and PRN until healed. This treatment was signed off on night shift on 2/23/25. The Wound Assessment Report, dated 2/20/25, documents R29 has a Sacrum Pressure Ulcer Stage 3 measuring 2.0 cm x 0.70 cm x 0.50 cm undermining from 9 o'clock to 3' o'clock 2 cm. On 2/24/25 at 2:16 PM, V2, Director of Nurses, removed the sacrum dressing dated 2/24/25. The dressing had brown yellowish drainage. There was no iodoform packing strip in the tunneling of the wound. V2 cleansed the pressure ulcer with wound cleanser, measured the pressure ulcer at 3 centimeters (cm) x 0.7 cm. V2 did not measure the depth. The pressure ulcer tunnels up toward 12 o'clock. On 2/24/25 at 3:10 PM, V2 stated there was no iodoform packing strip in the pressure ulcer tunnel. V2 acknowledged the two conflicting wound orders in place for R29. On 2/25/25 at 3:01 PM, V21, Wound Nurse Practitioner, stated, They should have been following the orders the way they were written. It is hard to say if it caused him harm because he has so many other contributing factors. The policy Pressure ulcer Prevention, Identification, & Treatment, dated 10/16/23, documents, It is the responsibility of the charge Nurse / designee to care for pressure areas, and provide treatments as ordered.

Based on observation, record review, and interview, the facility failed to clean soiled surfaces for 2 of 8 residents (R21,R31) reviewed for infection control in the sample of 43. Findings include: 1. On 2/23/2025 at 10:53AM during incontinent care, V5, Certified Nursing Assistant (CNA), and V9, CNA, transferred R21 from wheelchair to bed. R21 had dark blue sweat pants on that had visible wet area on seat of pants. R21was incontinent of a large amount of loose watery stool. After incontinent care provided to R21, V5 and V9 did not sanitize R21's wheelchair. On 2/25/2025 at 2:48PM V13, CNA, stated if during incontinent care a resident is soiled through clothing onto chair, the chair should be cleansed. 33112 2. On 2/23/25 at 12:48 PM, V5 and V19, CNA, transferred R31 from the bed to the wheelchair. The wheelchair seat had a soiled napkin and a large spot of dried food in the seat. Neither CNA cleaned off the seat before sitting R31 down. On 2/25/25 at 2:50 PM, V1, Administrator, stated, The wheelchair should have been cleaned before they (R31) down. I will look for a policy. R31's Face Sheet, print date of 2/25/25, documents R31 was admitted on [DATE] with a diagnosis of Dementia. As of 2/26/2025 at 10:38 AM, no policy has been provided.

Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in all resident bedrooms. This has the potential to affect all 37 residents living in the facility. Findings include: The facility has a total of 25 resident rooms. Each of these two-bed resident rooms have less than 80 square feet of floor space for each resident. The residents residing in these rooms are R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, 34, R35, R37, R38, and R40. Two rooms, rooms [ROOM NUMBERS], are currently being used as a dining room on the Dementia Unit. On 2/23/25 at 10:30 AM, all resident rooms measured, were less than 80 square foot per resident. On 2/23/25 at 11:00 AM, V1, Administrator, stated, All of our rooms are less than 80 square foot per resident. We have a room waiver for this. On 2/23/25 at 11:05 AM, V6, Maintenance Director, stated, I don't have a list of the rooms with their sizes, I just know they are all less than 80 square foot per resident. The facility's Resident Census and Conditions of Residents, CMS 671, dated 2/23/25, documents there are 37 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to identify, monitor, and treat a wound for 1 of 4 (R9) residents, reviewed for repositioning, in a sample of 45. This failure resulted in R9 obtaining a wound to her coccyx, buttocks, and causing R9 to experience pain. Findings include: R9's Admission Profile, print date of 1/22/4, documented R9 was admitted on [DATE], with diagnosis of Unspecified Fracture of Third Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Displaced Fracture of greater Trochanter of Left Femur, subsequent encounter for closed fracture with routine healing, Chronic Obstructive Pulmonary Disease. R9's Care Plan, dated 1/9/24, documented, (R9) has the potential for impaired skin integrity related to incontinence, limited mobility. It continues Pressure redistribution mattress to bed. Provide diet as ordered. Labs as ordered. Evaluate Skin at least Weekly. Medications as ordered. R9's Minimum Data Set, dated dated [DATE], documented R9 is severely cognitively impaired, frequently incontinent of bowel and bladder, and requires moderate assist of staff to reposition in bed and no skin impairment. On 1/16/2024 from 9:50 AM to 12:50 PM, with 15-to-30-minute intervals, R9 was lying in the bed on her back. On 1/16/2024 at 9:40 AM, V17, Certified Nurse's Assistant (CNA), stated R9 has not been doing well. V17 also stated R9 has been weak and was not feeding herself. On 1/16/2024 at 9:50 AM, R9 stated she has a sore on her bottom, and it hurts. On 1/17/2024 at 9:10 AM, R9 was lying in bed on her back, with a partially eaten tray on bedside table, out of R9's reach. On 1/17/2024 at 9:12 AM, R9 had facial grimacing, and stated her bottom hurts. R9 attempted to shift weight, unsuccessfully. R9 stated she was not able to turn herself. R9 stated, I can't get off my butt. It hurts really bad. On 1/17/2024 at 9:17 AM, V17, CNA, informed R9 after she finishes with her food, she would reposition her. On 1/17/2024 at 9:21 AM, V17, CNA, and V18, CNA, performed incontinent care. R13 was incontinent of urine and bowel. V18 cleansed R9's peri area. V17 and V18 then turned R9 onto her left side exposing R9's bottom. R9's buttock was fire engine red, with deep linear indentations. A pressure ulcer measuring approximately 0.5cmx1cm x0.2cm (centimeters) was observed to the coccyx area. On 1/17/2024 at 9:21 AM, V17, CNA, stated the pressure ulcer was not there yesterday. V17 stated R9's buttocks have been red, but not open. On 1/18/2024 at approximately 10:00 AM, R9 was lying on her left side with buttocks exposed. R9's sacrum, coccyx, and buttocks, were red in color, and no treatment in place to the pressure ulcer. On 1/18/2024 at approximately 2:15 PM, R9 stated she was still having pain to her buttocks. R9 stated she could not give a number on a scale, but that it hurt a lot. On 1/18/2024 at 3:00 PM, when asked what they were doing about R9's pressure ulcer, V1, Administrator, and V3, Regional Clinical Nurse, both stated they were not aware of R9 having a wound. On 1/22/24 at 1:02 PM, V13, Licensed Practical Nurse/LPN, stated she was not notified of R9 having the open area until Friday. V13 stated the process when finding a new wound is that the aide will notify the nurse immediately. V13 stated she would then assess the resident. V13 stated she would notify the doctor and hospice nurse. V13 stated R9 now has a treatment to her area, and that it's changed every 72 hours. On 1/23/2024 at 1:05 PM V23, Nurse Practitioner, stated she was made aware of R9 having an open wound on Friday. V23 stated she saw the area on Friday and today. V23 stated she believes the area was due to R9 overall decline related to bronchitis. V23 stated she believes the area was caused by moisture, related to R9 being incontinent of both bowel and bladder, which is a change for R9. V23 stated she would expect to be notified of the wound when first identified. V23 stated the treatment would start then. V23 stated R9 knows when she is in pain and can verbalize it. V23 stated not treating the wound would contribute to R9's pain. The Skin Protocol policy provided by the facility, not titled nor dated, documented, PURPOSE: To provide guidance to facility staff on the proactive approach to maintaining resident's skin integrity and the prevention/treatment of pressure ulcers. It also documents Preventative Measures: 1.Turning, positioning and pressure redistribution (off-loading) will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. 3. Minimizing exposure to moisture.

Based on interview, observation, and record review, the facility failed to employ a Registered Nurse (RN) in the role of full time Director of Nursing (DON), and to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 43 residents residing in the facility. Finding includes: There was no consecutive 8-hour RN coverage in 24 hours for the entire Month of October 2023, 11/1, 11/2, 11/4 to 11/30, the entire month of December 2023 and 1/1/2024 to 1/15/2024. On 01/16/24 at 1:38 PM, V9, Certified Nursing Assistant (CNA), stated \V1, Administrator, is also the DON (Director of Nursing). On 1/16/2024 at 11:40 AM, V10, CNA, stated V1 is also the facility DON. On 1/16/2024 at 1:40 PM, V1, Administrator, stated they do not have RN coverage. V1 stated they are actively recruiting for RNs. V1 stated V3, Regional Nurse, comes to the building once or twice a week. On 1/16/2024 at 12:20 PM, V3, Regional Nurse, stated they are actively recruiting for the Director of Nursing position. V3 stated they did have a DON for a short time and she was not willing to perform the required duties of that facility and quit. On 1/16/2023 at 3:06 PM, V3, Regional Nurse, stated the facility does not have a staffing policy. V3 stated she follows the staffing guidelines. The facility's Resident Census and Conditions of Residents, CMS 672, dated 1/17/24, documents there are 43 residents residing in the facility.

Based on interview and record review, the Facility failed to ensure the minimum required staff were present at the Monthly Quality Assurance Meetings. The failure has the potential to affect all 43 residents residing in the Facility. Findings include: On 1/16/2024 at 12:20 PM, V3, Regional Nurse, stated they are actively recruiting for the Director of Nursing position. V3 stated they did have a DON for a short time, and she was not willing to perform the required duties of the facility and quit. On 1/22/2024 at 8:14 AM, V1, Administrator, stated the Quality Assurance team meets monthly and should include every department head. V1 added, When I get a DON (Director of Nursing), she'll be there. The Facility's Quality Management Program Meeting Verification Forms, dated 10/18/2023, 11/15/2023, and 12/20/2023, were reviewed, and did not include a signature/title for the DON position. The Resident Census and Conditions of Residents, CMS 671, dated 1/16/24, documents the facility has 43 residents living in the facility.

Based on observation, interview, and record review, the facility failed to properly store medication, and label tuberculin and insulin vials. This has the potential to affect all 43 residents living in the facility. Findings include: On 01/16/2024 at 10:07 AM, the facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 1- 5 ml open and partially used multi dose vial of Apisol. No open date on the box or the vial. The Apisol package insert, dated 3/2016, documents Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 1/16/2024 at 10:15 AM, the medication cart was inspected. The cart contained the following: 2. R2's open and partially used multi dose vial of Lantus. No open date. 3. R1's open and partially used multi dose vial of Lantus. No open date. On 1/2/2024 at 9:55 AM, V7, Licensed Practical Nurse (LPN), stated, The Apisol medication is a stock medication and used for all residents in the facility. Unless they have an allergy, all residents get an Apisol shot at least yearly. This would be the medication that would be used. V7 verified the multi dose vial was open and in use. V7 stated she had not used the insulin pen, as it is scheduled for evenings. V7 stated the pen, once put in use, should have the resident name on it and the open date. V7 stated the multi dose vial and the insulin pen have different expiration days once open. V7 stated the expiration date decreases. V7 stated the open date lets them know when that date is. V7 stated the Apisol and Lantus vials expire in thirty days after opening. On 1/17/2024 at 2:06 PM, V13, LPN, stated when opening the multi dose TB (tuberculin) and insulin vials, the open date is put on the box and the vial. V13 stated she is not sure of the exact date for the TB, but knows it is shorter than the manufacture. V13 stated the insulin vials are only good for 30 days. V13 stated the open date is placed to let them know when the medication has to used by. The facility's Storage of Medication, dated 1/1/21, documents the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The facility's Medication Administration Policy/Procedure Insulin Administration via vial Procedure, dated 9/27/22, documents General Guidelines Characteristics and Types of insulin 4. Check the expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date on the vial (follow manufacturer recommendations for expiration after opening.) The facility's Resident Census and Conditions of Residents, CMS 672, dated 1/17/24, documents there are 43 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to provide privacy and dignity for 4 of 9 (R4, R18, R31, R33) residents, reviewed for resident rights, in a sample of 45. Findings include: 1. R31's face sheet, dated 1/18/24, documented R31 was admitted to the facility on [DATE], with diagnosis of dementia, type 2 diabetes, dysphagia, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side, aphasia, osteoarthritis, hypertension, atherosclerosis, peripheral vascular disease, cardiomyopathy, and atherosclerosis. R31's Minimum Data Set (MDS), dated [DATE], documented R31 is severely cognitively impaired. R31's Care Plan, dated 3/21/23, documented R31 requires extensive assistance with Activities of Daily Living (ADLS) and requires one-person physical assistance with eating. On 1/16/24 at 12:15 PM, R31's lunch was served to her in the dementia unit. At 12:57 PM, R31 had not taken any bites of her lunch, and V9, Certified Nurse Assistant (CNA), fed R31 a few bites of food, while V9 was standing beside R31. The dementia unit did not have any additional chairs for the facility staff to sit in when assisting residents with eating. 2. R33's face sheet, dated 1/18/24, documented \R33 was admitted to the facility on [DATE], with diagnosis of dementia, Alzheimer's disease, atherosclerosis, congestive heart failure, chronic kidney disease, and osteoarthritis. R33's MDS, dated [DATE], documented R33 is severely cognitively impaired. R33's care plan, dated 11/26/22, documented R33 requires extensive assist with all ADLS and requires one-person physical assistance with eating. On 1/16/24 at 12:46 PM, R33 was sitting in his wheelchair in the dementia unit dining room. R33 was not feeding himself. V9, CNA, verbally cued R33 to eat. R33 did not respond to the verbal cues. V9 then fed R33 some of his lunch. V9 was standing while feeding R33. The dementia unit dining room did not have any additional chairs for the facility staff to sit in when assisting residents with eating. On 1/22/24 at 8:30 AM, V1, Administrator, stated she would expect the CNA's to be sitting while feeding residents. The facility policy for feeding the dependent resident, dated 9/15/19, documents 4. When feeding in dining room: A. Identify resident. B. Ensure that proper diet is being served. Check tray card to content of plate. C. Ensure proper consistency. D. Position resident for comfort. E. Protect clothing with clothing protector. F. If the resident cannot see the tray, tell him/her the position of each item on the tray. G. Cut or divide food into small portions and give resident a small amount at a time. Do not force the resident to eat. H. Do not discuss unpleasant subjects while the resident is eating. I. Never make the resident feel that the meal must be hurried, but that the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident when possible. 38759 3. On 1/17/24 at 3:37PM, R4 was transferred from her wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides (CNA's) using a full mechanical lift, removed R4's soiled pants, and bowel movement soiled incontient brief. R4's was placed at the window side, with window blinds open, and multiple plants in the windowsill, and a divided curtain from R4's roommate was not closed to provide privacy. On 1/18/24, V4 CNA/Business office Manager, stated she would expect privacy be provided to any resident during care services. 40701 4. R18's, Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact. On 1/16/2024 at 10:25 AM, V12, CNA, was repositioning R18 to her left side. R18's bare buttocks were exposed towards the door of R18's room, facing the hallway. At this time, another unknown staff member knocked on R18's door and opened it, requesting the mechanical lift. At this time,V11, CNA stated R18 should have a curtain to provide privacy, and she would let maintenance know. On 1/17/2024 at 9:30 AM, R18 still did not have a privacy curtain. On 1/17/2024 at 11:53 AM, R18 stated, I would like a curtain. It does bother me. That is my only complaint about my care, especially since there is a man across the hall. On 1/17/2024 at 2:14 PM, V7, Licensed Practical Nurse (LPN), stated her and V11, CNA, discussed R18's need for a privacy curtain and added, especially since there are men across the hall. V7 continued to state, If we open the door and she is on her side, she is exposed. We try to cover her but if the person outside the door doesn't know . On 1/18/2024 at 1:32 PM, V1, Administrator, stated R18 should have a curtain for privacy. The Facility's Dignity Policy, dated 9/15/2019, documents, All residents will be treated with dignity and respect. Federal and State laws guarantee certain basic rights to all residents of this facility. It continues to document residents have the right to privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to maintain the building in good repair for 11 of 13 (R2, R6, R10, R14, R19, R19, R26, R29, R31, R33, R36, and R37) of 13 residents, reviewed for a homelike environment, in a sample of 46 reviewed for a homelike environment. Findings include: On 1/16/24 at 10:00 AM, during the facility tour of the dementia unit, the following maintenance concerns were observed: 1. R19 and R31's had multiple missing floor tiles in room. 2. R14 and R29's room had multiple missing floor tiles, the closet door was off the track, and the peach-colored painted walls were covered with white dry wall patches throughout the entire room. 3. R2 and R26's room hadroom had multiple missing floor tiles, the wall paint was chipped in multiple areas throughout the room, and the closet doors were off the track. 4. R37's room was missing the closet doors. 5. R33 and R36's room had multiple areas of wall damage with torn and missing wallpaper, the trim on the middle of the wall was missing revealing damaged drywall, the bathroom door and door jamb had multiple areas with rust coming through the white paint; the bathroom had missing floor tiles, the base of the bathroom vanity cabinet was rusty and coming apart, the closet doors were off the track and the track was damaged and the bedside table was stained and chipped. 6. R6 and R10's room had base board off the wall, there was broken sheet rock at the base of the wall, multiple damaged and missing floor tiles, the closet door was missing on one side of the closet and the bathroom door jamb and bathroom door had multiple areas of rust coming through the paint. On 1/16/24 at 11:55 AM, V9, Certified Nurse Assistant (CNA), stated the facility has an app (application) they are supposed to use to notify the maintenance department of repairs needed, but no one ever uses the app. V9 continued to state she just lets the new maintenance man know if something needs fixed. On 1/18/24 at 9:40 AM, V19, Maintenance Director, stated the staff tell him or leave him a note if something needs fixed. V19 continued to state he does not having any ongoing maintenance plans for the dementia unit, other than he might remodel the shower. The Maintenance Guarding Angel Rounds documents, dated 12/1/23 through 1/22/24, did not document any of the needed repairs on the dementia unit. The facility's General Maintenance and Monitoring Policy, undated, documented, The purpose of the policy is to provide guidelines on maintenance rounds for facility upkeep to maintain a safe and hazard free environment. The guidelines are to: 1. The Maintenance Director is responsible for upkeep and repair of facility equipment. 2. Staff are to notify Maintenance verbally or using a work order maintenance request concerning any equipment, furniture, general maintenance concerns. Maintenance needs to follow up with the repairs based on the priority in a timely manner. 3. The Maintenance Director will complete daily environmental rounds of the facility to observe any needed repairs. 4. The Administrator and the Maintenance Director will complete monthly rounds to further observe for any environmental or equipment issues. 5. Department Heads will also be responsible for monitoring and reporting any concerns related to the equipment and environment at the daily morning meeting. 6. The Administrator will monitor that repairs are completed in a timely manner.

Based on observation, interview, and record review, the facility failed to wear appropriate personal protective equipment (PPE) as identified in Infection Control procedures, and failed to cleanse hands after removing gloves following resident incontinence care, to prevent/control spread of infection for 4 of 5 residents (R4, R9. R18 and R33) reviewed for Infection Control in a sample of 45. Findings include: 1. R4's, Physician Orders, dated 1/17/2024, documented R4 receives iron supplement tablet, 325 milligrams (mg) every morning and evening for Anemia. R4's Care Plan, last revision date of 11/23/22, documented R4 requires extensive care assistance due to a medical diagnosis of dementia, impaired mobility, weakness; behavioral disturbance of screams and yelling; also, documented R4 receives only one assistance from staff with transfers, which was last reviewed/revised on date of 2/16/2017. R4's Impaired skin integrity Focus area was last reviewed/revised on 11/23/22, for interventions to monitor R4's incontinence. On 1/17/24 at 3:37PM, R4 was transferred from her position in a wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides (CNA's), using a full mechanical lift. R4's was laid flat on her back in bed and R4's left pant leg was up, leaving R4's left lower ankle exposed, and revealing dark black dried streaks. V14 and V15 washed their hands, and placed on clean gloves. V14 was on R4's on left side of bed and V15 on R4's right side of bed. They removed R4's pants and soiled incontinent brief. R4 was heavily soiled with black, thick bowel movement from her front perineum area, inner lateral thighs, and streaks of black stool were down her inner left thigh to her ankle, and in between her toes. V14 and V15 positioned R4 to her left side, as V14 cleansed R4's perianal area. During R4's cleansing, V14 had stool on her gloves, folded the wet wash cloth, and continued to clean R4's buttock. V14 changed her soiled gloves, put on clean gloves, and placed R4 on her back to clean R4's front side. At this time, V14 and V15 stated they needed more wash cloths to clean R4. V15 changed her gloves, washed her hands, and left the room to get more clean wash cloths, and V15 re-entered the room. During this time, V14 and V15 discussed who was now dirty and who was clean to complete R4's incontinent bowel care. V14 then cleansed R4's front perineum area. R4 was heavily soiled with bowel movement from her perineum. V14 continued to use a clean wash cloth, folded cloth, and continued to cleanse R4's inner labia folds were not cleansed, only partially. R4 was then positioned to her right side, and V15 stated to V14, Am I clean or dirty now? V15 then cleaned R4's left side of perianal area and placed on a clean incontinent brief. R4 again rolled over to her left side, V14 and V15 fastened the incontinent brief. V14 then wiped the black dried stool from R4's inner left leg and between toes. On 1/17/24 at 4:05PM, both V14 and V15 stated they knew they did not do R4's incontinent care correctly. They both stated they came on thier shift at 2:00PM, and were immediately involved caring for another resident that was heavily incontinent of bowel movement, and they are the only two CNA's to attend to these resident on this hall on the evening shift. The facility's' policy and procedure, entitled, Hand Washing, dated, 9/4/2020, documented, this facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with contaminate substance, and continues to document the following: when hands are visibley dirty or soiled with body fluids, after removing gloves, hand hygiene is always the final step after removing and disposing of personal protective equipment. 42108 2. R9's Admission Profile, print date of 1/22/4, documents R9 was admitted on [DATE], with diagnoses of Unspecified Fracture of Third Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Displaced Fracture of greater Trochanter of Left Femur, subsequent encounter for closed fracture with routine healing, and Chronic Obstructive Pulmonary Disease. On 1/17/2024 at 9:21 AM, V17, CNA, and V18, CNA, provided incontinent care to R9. R9 was incontinent of urine and feces. V17 and V18 washed their hands and applied gloves. V17 then cleansed urine and feces from R9's peri area. V17 and V18 rolled R9 onto her right side exposing R9's bottom. V17 then cleansed urine and feces from R9's bottom. V17 then, using the same urine and feces soiled gloves, placed R9's clean undergarment beneath R9 and manipulated R9's clothing and gloves, with the same urine and feces soiled gloves. 49494 3. R14's face sheet, dated 1/18/24, documented R14 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, osteoporosis, major depressive disorder, and macular degeneration. R14's MDS (Minimum Data Set), dated 1/9/24, documented R14 is severely cognitively impaired. On 1/16/24 at 9:10 AM, V9, CNA, entered R14's room and assisted R14 to the restroom. V9 donned gloves, without the benefit of hand hygiene, and then assisted R14 onto the toilet. V9 removed R14's clothing and disposable brief. V9 changed gloves, without the benefit of hand hygiene, and assisted V9 with perineal hygiene. V9 then placed a new disposable brief on R14 and dressed R14. V9 removed the gloves and donned new gloves, no hand hygiene performed. V9 then assisted R14 into bed. V9 removed the gloves and did not perform hand hygiene before leaving the room or after leaving R14's room. V9 then returned to the dementia unit dining room and assisted other residents. 4. R33's face sheet, dated 1/18/24, documented R33 was admitted to the facility on [DATE], with diagnoses of dementia, Alzheimer's disease, atherosclerosis, congestive heart failure, chronic kidney disease, and osteoarthritis. R33's MDS, dated [DATE], documented R33 is severely cognitively impaired. R33's care plan, dated 11/26/22, documented R33 requires extensive assist with all ADLS (activities of daily living). On 1/16/24 at 9:40 AM, V9, CNA, and V10, CNA, entered R33's room with a mechanical lift. V9 and V10 donned gloves without the benefit of hand hygiene. V9 and V10 transferred R33 onto the bed with the mechanical lift. V9 and V10 repositioned R33 and checked R33's disposable brief for incontinence. R33 was not incontinent at this time. V9 and V10 removed their gloves and left R33's room. V9 and V10 did not perform hand hygiene. On 1/22/24 at 8:31 AM, V1, Administrator. stated she would expect the CNA's to be completing hand hygiene before and after resident care, and before and after changing gloves. 40701 5. R18's Care Plan, dated 7/26/2024, documented R18 has an actual pressure ulcer to her sacrum, right and left buttocks, and requires assistance with turning and repositioning. R18's Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact and has 3 stage four pressure ulcers. R18's, Culture Report of sacrum, right and left buttock, dated 10/29/2023, documented R18 has Methicillin-resistant Staphylococcus aureus (MRSA). R18's, Progress Notes, dated 1/15/2024, documented R18 remains on isolation precautions for MRSA of the wounds to buttocks and sacrum. On 1/16/2024 at 10:30 AM, there was a Contact Precautions sign outside R18's room. At this time, V12, Certified Nursing Assistant (CNA) was observed assisting R18 with repositioning in bed. R18's bed linens were visibly soiled with a moderate amount of serosanguinous (clear/yellow) drainage. R18 had 3 open areas of skin on her backside. V12 did not have a Personal Protective Equipment (PPE) gown on. On 1/17/2024 at 2:14 PM, V7, Licensed Practical Nurse (LPN), stated R18 was on isolation for an infection of her wounds. V7 continued to state staff should be wearing a gown while providing direct care to R18. On 1/18/2024 at 1:31 PM, V1, Administrator, stated R18 is on contact precautions for MRSA of her wounds and she would expect staff to wear a gown and gloves while providing direct care, such as turning and repositioning, especially when there is drainage present. The Facility's Transmission Based Precautions Policy, dated 3/22/2023, documents, Purpose: To provide staff guidelines for transmission-based precautions to protect resident and themselves while providing cares. Policy: Transmission based precautions are initiated when a resident develops signs and symptoms of a transmission able infection, arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Responsibility: It is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. It further documents when a resident is on contact precautions, Staff are to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on observation, interview, and record review, the facility failed to provide complete incontinent care for 2 of 4 residents (R4, R13) reviewed for incontinent care, in a sample of 45. Findings include: 1. R4's, Care Plan, dated 11/23/22, documented, (R4) requires extensive care assistance, due to a medical diagnosis of dementia, impaired mobility, weakness with incontinence of bowel and bladder. R4's, Physician Orders, dated 1/17/2024, documented R4 receives iron supplement tablet, 325 milligrams (mg) every morning and evening for Anemia. On 1/17/24 at 3:37 PM, R4 was transferred from her position in a wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides, (CNA's), using a full mechanical lift. After laid flat on her back in bed and left pant leg up, R4's left lower ankle was exposed, revealing dark black dried streaks. V14 and V15 washed their hands, and placed on clean gloves. V14 was on R4's on left side of bed, and V15 on R4's right side of bed. They removed R4's pants and soiled incontinent brief. R4 was heavily soiled with black, thick bowel from her front perineum area, inner lateral thighs, and streaks of black stool down her inner left thigh to her ankle and in between her toes. V14 and V15 positioned R4 to her left side, as V14 cleansed R4's perianal area. During R4's cleansing, V14 had stool on her gloves; V14 folded the wet wash cloth and continued to clean R4's buttock. Then V14 changed her soiled gloves, placed on clean gloves, and placed R4 on her back to clean R4's front side. At this time, V14 and V15 stated they needed more wash cloths to clean R4. V15 changed her gloves, washed her hands, and left the room to get more clean wash cloths, and V15 re-entered the room. During this time, V14 and V15 discussed who is now dirty and who was clean to complete R4's incontinent bowel care. V14 then cleansed R4's front perineum area. R4 was heavily soiled with bowel movement from her perineum. V14 continued to use a wash cloth, folded cloth, and continued to cleanse; R4's inner labia folds were not cleansed, only partial. R4 was then positioned to her right side. V14 and V15 then placed a clean incontinent brief to R4. On 1/17/24 at 4:05PM, V14,CNA, and V15, CNA, both stated, they knew they did not do R4's incontinent care correctly. They both stated they came on their shift at 2:00PM, and they were immediately involved caring for another resident that was heavily incontinent of bowel, and they were only two CNA's to attend to these resident on this hall on the evening shift. 42108 2. R13's MDS, dated [DATE], documented her cognition was severely impaired and that she was frequently incontinent of urine and feces. R13's Care Plan, dated 11/21/22, documented, One person physical assist required. On 1/17/2024 at 9:21 AM, V17, Certified Nurses Assistant (CNA), and V18, CNA, performed incontinent care. R13 was incontinent of urine. V17 and V18 assisted R13 into the bed using a standing mechanical lift. Using a wet washcloth and spray soap, V18 cleansed R13's peri area. V17 and V18 then assisted R13 onto her right side. V18, using a wet wash cloth, cleansed R13's entire left buttock and partial right buttock V18 then placed an incontinent brief partially behind R13 and assisted R13 onto her back. V17 and V18 then turned R13 onto her left side and pulled the incontinent brief completely behind R13. V17 and V18 then turned R13 onto her back and fastened the brief. V17 and V18 did not cleanse R13's entire right buttock. The facility' policy and procedure, entitled, Incontinence Care, dated, 9/15/19, documented, provide proper incontinence are in order to clean skin clean, dry. wash all soiled skin areas and dry very well, especially between skin folds.

Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in multiple resident bedrooms. This has the potential to affect all 43 residents living in the facility. Findings include: The facility has a total of 25 resident rooms. Each of these two-bed resident rooms have less than 80 square feet of floor space for each resident, according to the facility document, Resident Room Square Footage, dated 2/21/20. Two rooms, rooms [ROOM NUMBERS], are currently being used as a dining room. On 1/16/24 at 10:30 AM, 1 of these two-bed resident's rooms, measures 72 square feet. The resident residing in this room is R24. On 1/16/24 at 10:30 AM, 2 of these two-bedroom resident's rooms, measure 77 square feet per resident's bed. The residents residing in these rooms are R19, R23, R31 and R32. On 1/16/24 at 10:30 AM, 6 of these two-bed resident's rooms, room [ROOM NUMBER], 5, 7, 21, 22, and 23 measure 78 square feet per resident's bed. The residents residing in these rooms are R5, R11, R17, R18, R25, R26, R28, R37, R32, and R38. On 1/16/24 at 10:30 AM, 14 of these two-bed resident's rooms, measure 79 square feet per resident's bed. The residents residing in these rooms are R1, R2, R3, R4, R6, R7, R8, R9, R10, R12, R13, R14, R15, R16, R21, R22, R23, R27, R29, R30, R32, R33, R34, R35, R36, R141, R142, and R143. On 1/18/24 at 9:45 AM, V1, Administrator, stated there have been no changes to the room sizes, and all the rooms have been covered by a room waiver the facility requested the previous year. The facility's Resident Census and Conditions of Residents, CMS 672, dated 1/17/24, documents there are 43 residents residing in the facility.

Based on interview and record review, the facility failed to have a Registered Nurse working 8 hours a day, 7 days a week. This failure has the potential to affect all residents in the facility. Findings include: On 2/21/2023 at 10:36 AM, V1, Administrator, stated (V2) Director of Nursing (DON) is the only Registered Nurse (RN) on the schedule. V2 works 8-10 hours a day Monday through Friday. They do not have RNs 8 hours a day that work Saturdays or Sundays. They are actively looking for a weekend RN, but they haven't had any luck. On 2/22/2023 at 2:25 PM, V2, DON, stated she works Monday through Friday, from 8:00 AM to 6:00 PM; she doesn't work Saturday or Sunday. The facility's daily staffing sheets from 2/7/2023 through 2/24/2022 document no RN worked on the weekends. On 2/24/2023 at 12:38 PM, V1 stated the facility doesn't have a policy for an RN 8 hours a day 7 days a week; they follow state guidelines on RN staffing.

Based on observation, interview, and record review, the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen to prevent contamination of the ice. This has the potential to affect all 41 residents living in this facility. Findings include: On 2/22/23 at 8:00 AM, the drain hose from the ice machine was down inside the drain hole in the kitchen floor, along with the hose coming off the furnace. There was no air gap between the drain hole and the drain hose from the ice machine. On 2/22/23 at 10:45 AM, V3, Dietary Manager, stated the ice machine in the kitchen is the only ice machine in the facility, and is used for all the residents in the facility. On 2/22/23 at 10:48 AM, V6, Maintenance Supervisor, stated he is not really sure how much of an air gap there is supposed to be between the drain and the drainage hose from the ice machine, but he thinks it's about 3 or 4 inches. V6 stated he doesn't know how long the drainage hose has been down inside the drain, but they just replaced the ice machine a couple of months ago, so they may have set it up that way at the time they put it in. V6 stated he did not have a specific routine for checking proper placement of the drainage hose coming from the ice machine to make sure there is an air gap. V6 stated the facility does not have a policy regarding what the air gap for the ice machine drain hose should be. Section 890.1040 of the 77 Illinois Administrative Code 890 Air Gaps documents: The air gap between an indirect waste and the drainage system shall be at least two (2) times the diameter of the fixture drain or drainage pipe served, but shall never be less than (1) one inch. The facility's Resident Census and Conditions of Residents form 672, dated 2/21/23, documents there are 41 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to obtain and administer prescribed pain medications as ordered for 1 of 5 residents (R2) reviewed for pain management in the sample of 5. This failure resulted in R2, a newly admitted resident with post-surgical repair of a fractured leg with an Open Reduction Internal Fixation (ORIF) device, not receiving her pain medication, being in excruciating pain for over 48 hours to the point of attempting to go back to the hospital for pain control. Findings include: R2's Discharge Orders from the hospital, dated 3/26/22, documents medications to take after discharge, including [MEDICATION(S)]-Acetaminophen 5-325 mg every six hours for pain. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan, dated 3/26/22, documents (R2) Self-care deficit: Needs assistance with Activities of Daily Living (ADL). Interventions: Non-Weight bearing to Right Lower Extremity (RLE), Ambulation restrictions/precautions, Pressure redistribution device. It continues (R2) Short term stay in facility for rehabilitation. It continues (R2) is at risk for falls and injuries related to medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note, dated 3/26/22 at 4:51 PM, documents, Writer (V1, Administrator) spoke with (V8, R2's daughter) regarding concerns for her mother's (R2) medications. She advised her mother called her regarding her medications. I advised (V8) that since her mom just arrived at the facility, all medications would be sent to the facility by the pharmacy and that we could give her mother what we have in stock until her medications arrive. She voiced understanding. R2's Progress Note, dated 3/27/22 at 4:07 PM, documents, Staff nurse from the (local hospital) called to notify this RN (V3) that the Physician that released the resident states he cannot write a script for [MEDICATION(S)] and [MEDICATION(S)] for (R2) as (R2) has left their facility. This RN contacted (another local hospital) again to request the on-call MD (Medical Doctor) to write the script for (R2). Again, Awaiting call back. R2's Progress Note, dated 3/27/22 at 7:12 PM, documents, Received call from the on-call MD, who stated that he would not provide scripts for controlled substances since (R2) has not been seen by a MD yet and that (the discharging hospital) will need to provide scripts. R2's Progress Note, dated 3/27/22 at 7:34 PM, documents, Call placed to (discharging hospital) and spoke with charge nurse, who stated the resident's scripts were sent to (local pharmacy) in (another city) because that is the pharmacy the resident listed and that they are unable to send scripts to us. Writer (V10, Licensed Practical Nurse, LPN) made resident and daughter aware. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note, dated 3/28/22 at 00:01 AM, documents, External fixation with five pins in place to right ankle. Currently awaiting scripts for controlled substances. (R2) upset with transition to facility. R2's Progress Note, dated 3/28/22 at 8:05 AM, documents, Writer (V1) went to (local pharmacy) in (another city) to pick up scripts that (local hospital) advised were sent there for (R2). (Local Pharmacy) advised writer that they do not have scripts from (local hospital) for (R2). R2's Progress Note, dated 3/28/22 at 10:28 AM, documents, (R2's) pain level a 10, (R2) states she wants to go back to the hospital in order to get pain under control. (R2) came into facility via ambulance from (local hospital) without orders for pain medication. Unable to get pain medication over the weekend due to resident not being in system for on-call MD. Ambulance called, they would not take resident for pain only to hospital, (V5, Physician's Assistant, PA) to order pain prescription. Resident stated understanding. R2's Progress Note, dated 3/28/22 at 1:05 PM, documents (R2's) order for [MEDICATION(S)] received and given. On 3/29/22 at 2:40 PM, R2 was sitting in R2's wheelchair with R2's right leg elevated. R2 has an ORIF (Open Reduction Internal Fixation) device attached to R2's right leg with a clean, dry dressing attached. R2 was on Oxygen at two liters per nasal cannula continuously. R2 had an abdominal peg tube that was capped off and not being used at that time. R2 was grimacing in pain, and described R2's pain level to be at a seven (on a scale of 1-10). On 3/29/22 at 2:50 PM, R2 stated, I was admitted to the facility on Saturday (3/26/22) from (a local hospital) where I was a patient for forty five days. I don't even know what exactly happened. I somehow broke my right leg and the next thing I knew, I woke up in the intensive care unit. I was told I have super brittle bones and they had to take some bone from my upper leg to fix my lower leg. I was discharged from the hospital on Saturday and got here around 3:00 PM, they had most of my medications available except for the pain pills. The hospital wouldn't send them because they were narcotics. The facility tried to call their Physician and he did not answer or call back. The hospital said they called the prescription in to my pharmacy in (another city) and someone from this facility went there to get it, but the pharmacy did not receive the prescription. I am thinking the hospital sent the prescription to the wrong pharmacy. I went from 12:30 PM Saturday (3/26/22) until my first dose around 12:00 PM yesterday (3/28/22) without any pain medications. The pain was excruciating and I asked for them to send me to the ER (emergency room ) so I can get some pain medicine. They finally got a hold of our Medical Director's Physician Assistant (PA) who wrote the prescription for [MEDICATION(S)], and then he came and visited me yesterday. On 3/30/22 at 8:10 AM, R2 stated, They are keeping up with my pain medications. As soon as I can have some, they bring them to me. I am still hurting at maybe a six (on a scale of 1-10) today, but it feels like a different pain this morning. On 3/30/22 at 11:50 AM, V5, PA, stated, The facility's staff called me on Sunday (3/27/22) around 9:00 PM to explain the situation about (R2). I believe they went down the Physician call list and even called the hospital where she was discharged from to get some help. (R2) wasn't part of our patient list so she wasn't in our system. She was assigned to (V6, Medical Director) because she was at that facility, but he nor I actually saw her before. The hospital should have sent a prescription with the resident, even if it was for a couple days to hold her over. If she was in our system, I would have come right in and taken care of things. I had to get her face sheet and information and enter her into the computer system in order to write her the prescription. I did come in and actually assess her after I sent the prescription. Unfortunately, this happens too often when a patient leaves the hospital and something should be done to avoid this again. On 3/30/22 at 8:25 AM, V3, Registered Nurse (RN), stated, I was here when (R2) was admitted on Saturday. The hospital did not send her (R2) prescriptions for her pain medication because it was a narcotic. I asked them to please send with her so we can give her the medications and they did not do it. I called the hospital back and talked to the physician there and he would not write the prescription because she was out of their care now. I tried to call our on-call physician (V6, Medical Director) three times and did not get a hold of him. I called the (local hospital) who always has a physician covering him when he is off and that physician would not write the prescription either because he did not see her. (R2) did get all of her other medications but not the pain medication. This happens frequently when we get someone discharged from hospital on the weekends. The Director of Nursing (DON) did come in and try to work things out, but I don't think she was able to do anything either. On 3/31/22 at 9:40 AM, V9, Certified Nursing Assistant (CNA), stated, I came in on Sunday morning (3/27/22) and she (R2) was already here. I remember she kept putting her call light on asking if her pain medications ever came in. I could tell she was in pain because she was making faces and grimacing. She looked like she was in pain. On 3/30/22 at 1:15 PM, V6, Facility's Medical Director, stated I just saw (R2) and I increased the frequency of her pain medicine to try and get her pain controlled a little better. My PA (V5) talked to me about this situation and the hospital should have at least given a prescription for maybe seventy two hours worth to get her through the weekend. The Hospitalist or the discharge planners need to address problems like this. It shouldn't happen at all. I have never seen (R2) before and if she is not in our computer system, it is a big hassle to get prescriptions written. I was not on call the evening that she was admitted here. (V7, Medical Doctor) was on call. I did not receive any phone calls on my cell phone from this facility, especially not three of them. If I would have even gotten one call, I always respond back, even if I'm not on call. I would have at least called them and helped to take care of this situation. I will make sure they are calling the correct number. On 3/31/22 at 9:20 AM, V1, Administrator, stated, We have a hospital liaison that works for us. That person usually makes sure all of the resident's discharge orders and prescriptions are ready and the prescriptions are sent to our pharmacy. If it is a controlled substance, we have to have a hard copy of that prescription come with the resident. That hard script will be faxed directly to our pharmacy and they will fill it and send us the medication. As for (R2), there were no hard scripts sent for her [MEDICATION(S)] so the pharmacy would not fill it. We even called 911 to send her (R2) to the hospital to get pain medications. They showed up here with three Emergency Medical Technicians (EMT) and then refused to take her to the hospital. On 3/31/22 at 9:25 AM, V1, Administrator, stated, Yes, the staff should have gone ahead and called our Medical Director, even though he wasn't on call, once the on-call physician refused to write the script. I just don't think they were thinking that way. They just figured since he was not on call, they couldn't call him. On 3/31/22 at 2:15 PM, V2, Director of Nursing (DON), stated, I really didn't do much for this situation. I came in on Sunday morning because I thought we were going to get the prescription and it takes two nurses to get a controlled medicine out of the cubex machine. When I found out the doctor wasn't going to write a script, I left. I think the staff did all that they could do, but we couldn't get someone to write a script. Yes, the staff probably should have called our Medical Director to help us out, but they were told if he is not on call to use the physician on call. I'm new here and didn't realize the policy stated that verbal orders are permitted for Schedule II Controlled Medications. I think we all have some learning to do. The facility's Admission Criteria policy, dated 3/2019, documents 1. The objectives of our admission criteria policy are to: It continues, c) address concerns of residents and families during the admission process; and, e) assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. It further documents, 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: It continues, b) Medication orders, and c) Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. The facility's Pharmacy Policy Controlled Substance Prescriptions, dated 9/2018, documents A chart order is not equivalent to a prescription for controlled medications. Therefore, the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery of the medication. The written prescription may be faxed to the pharmacy for long-term facility residents. Verbal orders for controlled medications are permitted for Schedule II substances only in emergency situations. The facility's Pharmacy Policy Receiving Controlled Substances, dated 9/2018, documents Controlled substances prescribed for a specific resident are delivered to the facility on ly if a valid prescription has been received by the pharmacy prior to dispensing. The facility's Pharmacy Policy Emergency Pharmacy Service and Emergency Kits, dated 9/2018, documents Emergency pharmacy service is available twenty four hours a day. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in portable, sealed containers in compliance with applicable state regulations. It continues 2. The facility should ensure there is a Physician on call twenty four hours a day/seven days a week. 3. The pharmacy is called if an emergency arises requiring immediate pharmacist consultation concerning appropriateness of therapy, drug information, etc. 4. The pharmacy supplies emergency or STAT medications according to the pharmacy provider agreement. It continues 6. The emergency supply along with a list of supply contents and expirations dates are maintained in the medication room, or in accordance with facility policy and state regulations. The facility's Pharmacy Emergency Supply Kit labeled as Cubex Contents, undated, documents there are several pain medications available at the facility in their locked medication dispenser including [MEDICATION(S)]-Apap 5-325 mg tabs, [MEDICATION(S)]-Apap 7.5-325 mg tabs, and [MEDICATION(S)] 10-325 mg tabs.

Based on interview and record review, the facility failed to follow standard of care practice for transfers for 1 of 3 residents (R2) reviewed for transfers in the sample of 3. This failure resulted in R2 receiving fractures to the 2nd and 3rd toes on the right foot during transfer into the shower. Findings include: R2's Clinical Record, dated 1/3/18, documents in part: R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and requires 2+ person physical assist for transfers, total dependence. R2's nurse's notes, dated 4/22/18 at 8:37 PM, document: Right foot - toes are red, swollen, and sore to touch, still able to move foot and toes, fax sent to V11, Medical Doctor. R2's Physician order [REDACTED]. R2's POS, dated 5/16/18, documents orders from V10, Orthopedic Doctor: Wear Bledsoe boot with ambulation for right second and third Proximal Phalanx fractures. R2's POS, dated 1/3/18, documents in part, Skin Inspection/Nursing Weekly Assessment on Wednesday night shift. R2's Non-Pressure Skin Condition Report started on 5/16/18 for R2's toes. Skin Inspection was not started on 4/22/18 when redness swelling and pain was first observed. The facility Incident Tracking System, Monthly Incident Summary Log Report, dated (MONTH) (YEAR), documents on 5/16/18, R2 had an X-Ray done on her right foot at her routine doctor appointment which documented fractured 2nd and 3rd toes on her right foot. The facility Incident Investigation/Administrative Summary, dated 5/16/18, documents in part: Type of Incident: Fractures. Brief description of the Incident/event: Resident returned from MD office, c/o (complaint of) toes right foot, x-ray done. Summary of Investigative findings: Resident returned from doctor visit, stated x-ray of right foot had been done. Staff assessed foot. Resident had admitted to the facility initially due to right femur fracture. Resident required a mechanical lift for transfers. Resident stated she had bumped her toes once in shower room when being assisted into shower stall a while back in shower chair. Staff had stated they had turned the shower chair side ways to assist in getting chair up into stall safely. (V5, Certified Nurse Aide) CNA stated that she heard a slight scrape of what sounded like residents toe nail on the wall. (R2) stated to (V5) do you know you hit my toenail on the wall. (V5) told (R2) she was sorry, (V5) then assessed (R2's) toes and did not see any redness, bruising or sore areas, (V5) stated (R2) did not complain of any discomfort at that time. (V5) stated she had turned the shower chair sideways to make it easier to get the chair into the stall. Upon assessing the shower stall and wall, no rough or protruding areas were assessed. The flooring at stall had small squares of tile and CNA stated it was harder to get chair over edges and up into shower stall unless turned sideways. V10's Physician report, dated 5/16/18, documents in part: Imaging Note, 3 views of the right foot obtained in clinic today demonstrates nondisplaced fractures at the base of the second and third proximal phalanx. No other fractures or dislocations seen. Assessment: 1. S/P (status [REDACTED]. 2. status [REDACTED]. Right knee painful hardware. 4. Nondisplaced proximal phalanx fractures, right 2nd and 3rd. Discussion/Summary, Plan: She can begin weight bearing as tolerated in a short Bledsoe boot to allow for the toe fractures to heal. She should begin PT for the right knee and ankle for range of motion and gait training. Follow up in 1 month for repeat assessment of the femur and toes. On 8/6/18 at 2:03 PM, R2 stated, (V5) was upset because I had a doctor's appointment that morning and she had to give me a shower; it was probably about 6 or 6:30 AM, I can't remember the exact date. She was rushing around and banged my foot up against the wall in the shower room. I told her, 'I think you broke my toes.' She said, 'I didn't hurt you; I just brushed your toenail up against the wall.' I told her I wanted someone else to give me a shower, she told me, 'there is no one else.' (V6 Licensed Practical Nurse, LPN) was the only nurse that looked at my foot and said it was red and swollen and she was going to call (V11). At my next appointment with (V10), I told him a CNA banged my foot into the shower wall. I told him to take an x-ray of my foot, he did and it showed the broken toes. On 8/8/18 at 1:00 PM, V2, Director of Nurses (DON), stated, The first time I heard of this incident was after (R2's) Doctors appointment on 5/16/18, I was not aware of it before that. When asked if she would expect the CNA to inform her or a nurse about the incident, V2 stated, Yes, but (V5, CNA) assessed it herself and didn't see any problems with her toes. On 8/8/18 at 3:28 PM, V5 stated, I put her on the shower chair and turned the chair sideways. While I was pulling her up into the shower, I scraped her toenails on the wall. I did not report it to the nurse because I looked at it and didn't see anything wrong with her toes. I should have reported it, but I didn't. I don't remember when this was; it's been awhile go. (V13, CNA) was helping me, but she doesn't work here anymore. On 8/9/18 at 11:00 AM, V14 (V10's nurse) stated, This office keeps Encounter sheets. They are a heads up on what is going on with our patients and it is documented that (R2) stated a CNA at the Nursing Home that she lives in ran her foot into a wall and she states her 2nd and 3rd toes were painful. On 8/13/18 AM at 2:50 PM, V10 stated, I cannot comment on the toe fractures that happened at the Nursing Home. The facility Policy for Incident Management, revised (MONTH) (YEAR), documents in part, Basic Responsibility: Facility Administrator and Director of Nursing. Policy: It is policy that all incidents or accidents involving residents, visitors, volunteers, etc. will be properly documented, investigated, and reported so as to meet all company, regulatory, and insurance carrier requirements, as well as reduce legal risk to the facility. Purpose: To promptly acknowledge and manage facility incidents and accidents to ensure the medical needs of affected individuals are identified and addressed; to analyze contributing factors and environmental conditions that may be modified in order to provide a safe environment and reduce incidence of reoccurrence, to provide a process for tracking and trending incident data for improved quality of care and facility safety, as well as reduce legal risk to the facility. Definitions: Incident is defined as any event in which an injury was sustained by a resident, visitor or volunteer or any happening that is not consistent with the routine operation of the facility or care of a resident which has caused or may have the potential for causing injury. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Procedures: *Any employee who witnessed an accident or incident involving a resident, visitor, or volunteer, etc., regardless of how minor the occurrence may be, must report such occurrence to his/her supervisor as soon as practically possible. *The Nurse Supervisor and/or Charge Nurse is to immediately examine individuals involved in accidents or incidents to determine the presence and extent of any physical injuries or trauma; render medical assistance or basic first aid and it necessary, transfer individuals with urgent medical needs to the emergency room or medical treatment center. *All incidents will be reviewed and investigated to identify any underlying risk factors, precipitating events, contributory conditions, or environmental issues that may need to be addressed in order to reduce recurrence and contribute to a safer environment. The facility Policy for Skin Integrity, dated (MONTH) (YEAR), documents in part, Basic responsibility: Licensed Nurses. Procedure: 14. Weekly head to toe assessment will be completed of all residents by a Licensed Nurse.

Based on interview and record review the facility failed to provide supervision to prevent falls for 2 of 3 residents (R1 and R2) of 3 reviewed for falls in the sample of 6. This failure resulted in R1 falling and receiving multiple facial fractures and a subdural hemorrhage. R2 fell and received a laceration requiring 7 sutures to close the wound. Findings include: 1. R1's MDS dated [DATE] documented that R1 required extensive assistance and two plus physical assistance for bed mobility, transfers, and toileting. R1's Fall Risk assessment dated [DATE] documented a score of 55, with a score of 45 or higher indicating a high risk for falls. R1's Fall Risk assessment dated [DATE] and 12/07/17 documented a score of 55. R1's Fall Risk assessment dated [DATE] documented a score of 75. R1's Care Plan dated 4/8/15 documented R1 was at high risk for falls related to paralysis to left side. R1's Care Plan documented R1 had history of falls The facility's Fall Report of Incident dated 2/17/17 documented that R1 fell out of R1's wheelchair and received a skin tear to right hand, Left side of face bruising and hematoma to left face and eye. The Facility Fall Report of Incident dated 2/28/28 at 17:26 PM documented R1 fell out of wheelchair during transport. The report documented R1 received laceration and bruising. The facility Verification of Incident Investigation/Administrative Summary, dated 2/28/18, documented that R1 was being transferred from bed to wheelchair by a CNA. The Summary documented that R1 was assisting with the transfer by placing R1's feet on the floor. The summary documented once R1 was positioned in the wheelchair the CNA reached down beside the bed to get the wheelchair pedals and R1 was noted to fall to the floor. The summary documented under investigative finding that R1 was alert with confusion and has decreased safety awareness due to a [DIAGNOSES REDACTED]. It also documented R1 required 2 staff physical assistance with mechanical lift transfer as Needed (PRN). R1's Cat Scan of Head done at the hospital on [DATE] documented under impression: 1. Scattered acute subarachnoid hemorrhage, most pronounced in the frontal regions, slightly increased since prior exam one day earlier. 2. New small acute intraventricular hemorrhage. 3. There may be a small acute subdural hematoma along the right tentorial leaflet. 4. Redemonstration of acute left orbital/maxillofacial fractures. On 3/12/18 at 1:02 PM, V2, Director of Nurse's, when asked by surveyor if MDS documented 2 plus physical assistance for transfers, would that be the staff expectation to transfer R1. V2 responded yes. The Facility's Fall Management Procedure dated (MONTH) 2014 documents in part the facility will evaluate risk factors and provide interventions to minimize risk, injury and occurrences. The facility will initiate a fall prevention are plan when appropriate with strategies to minimize risk and potential for injuries. Review, revise and evaluate care plan effectiveness at minimizing falls and injuries. 2. R2's physician's orders [REDACTED]. R2's Care Plan dated 2/16/18 documented R2 had a self care deficit as evidenced by: Needs extensive assistance with Activities of Daily Living (ADL) related to recent stroke and weakness. R2's Care Plan lists intervention: two person physical assistance required for toileting. R2's Care Plan documented R2 was at risk for fall and injuries related to poor cognition, recent stroke and weakness. Interventions listed were to assess R2's toileting needs, encourage use of call light and low bed. R2's admission Fall Risk assessment dated [DATE] documented a score of 60, with a score of 45 or higher indicating a high risk for falls. R2's Minimum Data Set ((MDS) dated [DATE] documented R2 required extensive assistance and two plus physical assistance for transfers and toileting. R2's MDS documented that R2 had functional limitation in range of motion on one side of both the upper and lower extremity. R2's Progress Notes Late Entry for 3/2/18 10:20 A.M., documented resident fall reported. Resident in stable condition. POA (Power of Attorney) aware. POA arrived at 11:15 A.M. requesting resident be sent to emergency room (ER). Transport arranged. Resident sent to ER at 12:01 PM. R2's Verification of Incident Investigation/Administrative Summary, signed and dated by V2, Director of Nurse's (DON) on 3/2/18, documented Resident lost balance while sitting on toilet and fell on to floor. The Summary documented Res (Resident) was escorted back from therapy stating she needed to go to the toilet. Res was assisted per 2 staff assist and gait belt onto toilet in shower room. Res stated to CNA (Certified Nurse's Aide) that she need to have a bowel movement but couldn't get it to 'come out.' CNA stepped to door that was feet from toilet where resident was sitting. CNA stated she opened the bathroom door just a fraction to maintain privacy to tell nurse resident had request a laxative. In turning around, res was noted to have lost balance and fell on to bathroom floor. The Summary documented she sustained a laceration to her left forehead. On 3/8/18 at 10:00 AM, V5, emergency room Physician stated R2 was brought to the emergency room with a [MEDICAL CONDITION]. V5 stated she closed the wound with 7 sutures. V5 stated that R2 stated she had been left in the toilet. V5 Physician stated that R2 recently had a stroke and has Left side [MEDICAL CONDITION] and should never be left alone on the toilet. V5 stated this fall and injury could have been prevented had staff not left R2 alone in the bathroom. On 3/8/18 at 10:55 AM, V4, Licensed Practical Nurse (LPN) stated that R2 required assistance with bed mobility, transfers and toileting. When asked by surveyor if R2 could be left alone on toilet safely, V4 stated I wouldn't.

Based on record review and interview the facility failed to timely assess, monitor, identify risk factors and treat to prevent potential dehydration for 1 of 4 residents (R5) reviewed for hydration in the sample of 9. This resulted in R5 being sent to the hospital with a [DIAGNOSES REDACTED]. Findings include: R5's Physician order [REDACTED]. R5's Nurse's Note, dated 10/11/18 at 8:30 AM documented R5 left the dining room due to complaints of not feeling well. The Nurse's Note documented R5 had one bout of diarrhea with emesis noted. The Nurse's Note documented R5's vital signs as : Blood Pressure,100/52; Pulse,56; Respirations,16 and Temperature 97.2 degrees Fahrenheit. The Nurse's Note documented at 9:30 AM, E7 Licensed Practical Nurse (LPN) notified Z2, Physician Assistant (PA) on call for R5's Doctor, of R5's complaints and made him aware R5 received the flu shot on 10/10/14. Nurses notes documented Z2 advised E7 to monitor R5 at this time. R5's Fluid Intake record for 10/11/14 documented R5 had no fluids for breakfast, 480 cubic centimeters (cc) fluids for lunch and no fluids for dinner. There was no other documentation in R5's Medical Record recording R5 had consumed any other fluids that day. On 10/12/14, R5's fluid intake record documented R5 had 120 cc fluid for breakfast and 120 cc fluid intake for lunch. The was no other documentation in R5's Medical Record recording R5 had consumed any other fluids this day. R5's Nurse's Notes, dated 10/12/14 at 5:15 PM, documented Z1, Power of Attorney (POA) wants R5 to go to local hospital related to lethargic and cold symptoms. Nurse's notes on 10/12/14 at 5:20 PM, documented R5 went with family to hospital in family's car. The local emergency room lab reports dated 10/12/2014 documented R5's urinalysis results as: color dark yellow, clarity cloudy, leuk (leukocytes) 3+,[MEDICATION NAME] positive, protein 3+, [MEDICATION NAME] trace, blood trace, bacteria 4+. Complete Blood Count documented White Blood Cells 19.3,Hemoglobin 8.7, Hematocrit 31.0. Complete Metabolic Panel documented a Blood Urea Nitrogen (BUN) 67, Creatinine 4.0, Potassium 6.0. The Emergency Departments Physician Impression documented Acute [MEDICAL CONDITION], Hypovolemic Shock, [MEDICAL CONDITION], Urosepsis and Septic shock. Hypovolemic Shock is defined as " a medical or surgical condition in which rapid fluids loss results in multiple organ failure due to inadequate circulating volume and subsequent inadequate perfusion.( emedicine.medscape.com, Copyright 1994-2014 by Web MD LLC)". R5's Nurse's Notes on 10/12/14 at 9:05 PM, documented, the local Emergency Department sent R5 to another Hospital for [MEDICAL CONDITION], Septic Shock and Hypovolemia. On 10/16/14 at 2:00 PM, E5 Certified Nurse Assistant (CNA) who was assigned to care for R5 on 10/11/14 and 10/12/14 on the 6-2 shift, was interviewed regarding how many times did R5 have an emesis on E5's shift. E5 said, "On Saturday, I would say she vomited three times and had diarrhea four times. E5 said R5's diarrhea was very watery." E5 said on Sunday R5 had vomited two times and had diarrhea three times. On 10/16/14 at 2:10 PM, E6 CNA, who was assigned to care for R5 on the 2-10 PM shift, was interviewed regarding how many times R5 had emesis and diarrhea on E6's shift. E6 said R5 had no vomiting and one bout of diarrhea on 10/11/14. On 10/12/14, E6 said R5 complained of nausea a couple of times before she went to the hospital. E6 said on Saturday R5 was very alert and talking but on Sunday she just wanted to sleep. E6 said R5's Husband had been visiting on Sunday and told E6 he was going home to call the boys because he said R5 was not doing well and he had told E6 that R5 had been talking out of her head. On 10/15/14 at 2:30 PM, E4 LPN, was interviewed and asked if he was the nurse caring for R5 on 10/11/14 and 10/12/14, E4 said yes. E4 was asked to describe R5's symptoms. E4 said R5 had "cold symptoms, when asked to describe the cold symptoms E4 said, generalized weakness, emesis and diarrhea." E4 said, R5 "received the flu shot on Friday (10/10/14) and thought R5's symptoms were related to that." E4 was asked if R5's intake and output was being monitored and E4 said "No, but I am sure she had at least a liter of fluids in on Saturday." E4 was asked if he had notified Z2 on 10/11/14 or 10/12/14 that R5's symptoms were ongoing, E4 said "No". E4 was asked if he had notified Z2 that R5's family said R5 was not doing well and took her to the local Emergency Department in their own vehicle. E4 said "No, I did not let the PA know." On 10/16/14 at 3:00 PM, E11, Regional Clinical Director, said "I would expect staff to measure both intake and output for residents who develop symptoms of emesis and diarrhea." On 10/16/14 at 4:00 PM, Z2 was asked if he had been notified except on Saturday (10/11/14) at 9:30 AM, by staff that R5's condition had not improved or that R5's family had taken her to the local emergency roiagnom on Sunday (10/12/14). Z2 said "No, the only phone call he received about R5 was on Saturday morning." The facilities Policy on Intake and Output documented under Basic Responsibility: Nursing Staff. Under Policy:" It is the policy of this facility to monitor intake and output and accurately document when it is determined that monitoring is necessary to evaluate hydration status, compliance with fluid restrictions, or to assist in the assessing and managing fluid needs."