Every finding on record at Haven of Champaign

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment by failing to address ongoing water intrusion and deterioration of building materials throughout the facility. This failure has the potential to affect all 57 residents residing in the facility. Findings include: On 7/22/2026 at 8:46 AM, observations were conducted with V3 (Maintenance Director). These observations identified evidence of water intrusion and structural deterioration in multiple areas of the facility. Water damage was observed on the walls around the air conditioning units in R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13's rooms. Water damage to the tile was observed in the south shower room. Black fuzzy growth was observed on the wall behind the bed in R6's room. The wall was shared with the south shower room, where additional black fuzzy growth was observed around the bottom tile in the shower area. The drywall and door frame surrounding the south shower room entrance were crumbling and unstable. The north shower room had a strong musty odor. In addition, the lower portion of the wall behind the left double hallway door outside R6's room was soft and deteriorated when touched.During the observation on 7/22/2026 at 8:46 AM, V3 confirmed the water damage in R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and R13's rooms. As well as the damaged tile and black fuzzy growth in the south shower room, and around the wall air-conditioning units in the dining room. V3 stated repairs had previously been completed to the wall in R6's room; however, the black fuzzy growth returned. V3 stated environmental testing had not been performed to determine the nature or source of the black fuzzy growth. V3 confirmed the musty odor in the north shower room. V3 stated emails were sent to the corporate office on April 3, 2026, and April 6, 2026, regarding the identified concerns and V3 was informed that capital budget approval was required before the necessary repairs could be completed.On 7/22/2026 at 11:34 AM, V10 (Housekeeping Supervisor) stated there was mold in R6's room caused by a leak originating from the south shower room.On 7/23/2026 at 9:00 AM, V3 stated the leak in the south shower room had not been repaired since it was first identified in April 2026. V3 stated corporate personnel had assessed the issue; however, no corrective action had been taken to repair the leak or eliminate the ongoing water intrusion. Facility Room Roster dated 6/9/2026 documents 57 residents in house.The Housekeeping Services Policy, undated, documents the facility is to ensure facility equipment, furnishings and resident rooms are maintained in a sanitary manner to provide a comfortable environment and to prevent the development and transmission of infection.

Based on interview and record review the facility failed to complete neurological assessments post head injury per facility policy for one resident (R1) reviewed for accident/incident on the sample list of 12 residents.Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively impaired.On 4/29/26 at 8:50 AM, V15 Certified Nursing Assistant (CNA) stated V15 had R1standing in the shower, holding onto the rail while putting a depend on R1 after showering. V15 CNA stated R1 started to slip but V15 caught R1 under R1's arms to keep R1 from falling. V15 CNA stated V15 helped R1 back in the shower chair at that time. V15 CNA stated R1 was confused and doesn't enjoy showers, so V15 was trying to hurry. V15 CNA stated V15 didn't notice any injury until V15 had R1 back in R1's room and was combing R1's hair, noticing a small amount of blood. V15 CNA then went to get the nurse. V15 CNA stated V15 did not see R1 hit R1's head.On 4/29/26 at 2:05 PM, followed V18 CNA to the shower room. V18 stated V18 helped V15 CNA get R1 into the shower chair from the wheelchair then V18 left. V18 CNA stated V18 told V15 CNA that V18 would be back in 15 minutes. V18 CNA stated V18 returned to help V15 get R1 back in the wheelchair from the shower chair. V18 stated that V15 told V18 they slipped a bit but V15 caught R1. V18 stated V15 didn't say anything about R1 hitting R1's head. V18 CNA stated that when they got R1 back to R1's room, they noticed a small amount of dried blood on R1's head when brushing R1's hair and that's when they notified the nurse. V18 stated the only thing V15 could think of was that R1 hit R1's head on the wheelchair or handlebar but nobody knows.On 4/29/26 at 2:30 PM, V12 Licensed Practical Nurse (LPN) stated V12 saw R1 when R1 was already back in R1's room. There was only a small amount of blood observed. V12 immediately sent R1 to the hospital.On 4/29/26 at 2:50 PM, V2 Assistant Director of Nursing (ADON) stated neurological checks were not done due to R1 going to the hospital. V2 stated they should have been done with R1 returning to facility that same day.Nursing assessment dated [DATE] documents Certified Nursing Assistant (CNA) reported to the nurse R1 hit the back of R1's head, got a cut on R1's left back side of R1's head during a shower, and the cut was 4cm (centimeters) long.Hospital summary dated 2/26/26 documents R1 had two staples placed for a laceration to R1's head.Facility Investigation Report dated 2/27/26 documents R1 had behaviors during the shower, bumping R1's head on the shower room wall, resulting in R1 receiving two sutures.The Neurological Assessment Policy dated August 2008 documents to generate neurological assessments for head injuries to be performed for a seventy two hour period unless otherwise ordered by the attending physician as follows every fifteen minutes for four hours, every hour for four hours, every two hours for four hours, every two hours for eight hours and every four hours until the seventy two hour period is complete.

Based on interview and record review the facility failed to record and maintain documentation for food temperatures taken prior to meal service and temperatures of refrigerator and freezers used to store facility food. This failure has the potential to affect all 50 residents residing in the facility. Findings Include: The Service of Food policy, last revised in June 2023, documents foods will be held between 135- and 140-degrees Fahrenheit or higher for service. Food temperatures should be taken on the food service line by the culinary team prior to serving each meal and recorded in a temperature logbook. On 2/22/26 at 1:15 PM V8 [NAME] confirmed he did not document food service line temperatures on the log sheets for that day's noon meal. V8 also confirmed there were other meals on the log with no temperatures documented. The Weekly Food Temperature Sheet dated February 2026 was missing documentation for meal temperatures for nine meals total from 2/1/26 through 2/22/26. The Record of Refrigeration Temperatures log dated February 2026 was missing refrigerator and freezer temperatures for three days (2/19, 2/20, 2/21) and only ever recorded temperatures once per day. The Food Storage policy, last revised in June 2023, documents the facility will monitor refrigerator and freezer temperatures twice daily and they will be recorded on temperature monitor log sheets. On 2/23/26 at 2:50 PM V7 Dietary Manager stated staff should be monitoring refrigerator and freezer temperatures twice daily and recording them on the temperature monitor log sheets. V7 also confirmed staff should be taking temperatures on the food service line prior to serving each meal and recording them on the log sheet. The Long-Term Care Facility Application for Medicare and Medicaid dated 2/22/26 documents a facility census of 50 residents.

Based on observation, interview, and record review the facility failed to provide food to six residents (R31, R20, R19, R7, R28, R10) that was attractive palatable, and in a form, they could easily consume of 37 residents reviewed for dining in a sample of 37 residents.Findings include: The facility's Service of Food policy, revised June 2023, states: PolicyIt is the policy of Extended Care LLC to distribute and serve food in a safe, accurate, timely, and acceptable manner. PurposeThe purpose of this policy is to create an exceptional culinary experience for residents that reflects the philosophy and vision of the organization and is delivered in the most efficient and safe manner. Process Hot foods will be held at 135–140 degrees F or higher, and cold foods will be held at 40 degrees F or below for service. Properly cooked roasts may be held at 130 degrees F or above. Maintain cold food at 41 degrees F or below. Frozen food must remain frozen. Food temperatures will be taken on the line by culinary team members prior to serving each meal and recorded in a temperature logbook. Temperatures will be taken using a sanitized food probe. Hot and cold production orders will be provided daily to prep and line culinarians, communicating the type and modification of foods in the amounts specified. Appropriate hot and cold foods will be prepared fresh in the main kitchen as required and transported to the satellite kitchen. Hot foods will leave the kitchen above 140 degrees F and cold foods below 41 degrees F. Culinary staff will be responsible for delivering food carts to the appropriate areas. Residents will be served meals by a Culinary Host in the main dining room. All meals will be served in a timely manner. Dietary aides are responsible for clearing and cleaning tables in the dining room. 1.R31's Minimum Data Set (MDS) dated [DATE] documents R31 is cognitively intact. On 2/22/26 at 12:15 p.m., R31 was observed sitting at the lunch table with her lunch in front of her. The meal included a slice of roast pork, mashed potatoes, Brussels sprouts, a cookie, and beverages. When asked how lunch was, R31 stated, The pork is really tough. R31 attempted to cut the pork with a butter knife but was unable to. The pork appeared dry. The Brussels sprouts appeared pale and mushy. 2. R20's MDS dated [DATE] documents R20 is mildly cognitively impaired. On 2/26/25 at 12:20 p.m., R20 was seated in the common area with his lunch in front of him. R20 was served roast pork, mashed potatoes, Brussels sprouts, a cookie, and beverages. When asked how lunch was, R20 stated, I don't have teeth and I can't eat the meat. It's tough. R20 pointed to pieces of meat he had attempted to chew but had to spit out because they were tough. The pork appeared dry. The Brussels sprouts appeared pale and mushy. On 2/22/26 at 12:30 p.m., the surveyor requested to sample the pork roast and Brussels sprouts. Even with gravy, the meat was very difficult to cut and chew and was dry. The Brussels sprouts were mushy and watery and had very little taste. 3. On 2/22/26 at 12:45 p.m., the surveyor took the remainder of the pork roast to V6, Regional Nurse, and demonstrated how difficult it was to cut and chew. V6 verified the pork was tough and the Brussels sprouts were mushy and pale. On 2/24/26 at 9:43 a.m., V11, Registered Nurse (RN), stated R7 and R19 have voiced concerns to her regarding cold and undesirable food on several occasions. On 2/24/26 at 10:27 a.m., R19 stated she is often served cold food, with breakfast being the worst. R19 stated the steamed vegetables the facility serves are mushy and unappealing. R19 stated the food is often bland and the meat is frequently difficult to chew. 4. On 2/24/26 at 1:18 p.m., R19 was observed sitting in her room in a wheelchair with a plate of uneaten food on a bedside table. The plate contained a large portion of meat, Brussels sprouts, and mashed potatoes that appeared extremely dry. R19 stated the meat was pork and was extremely tough to cut or chew. R19 attempted to demonstrate cutting the meat with her fork but was unable to do so. R19 stated the mashed potatoes were very dry and moved them around the plate, causing them to crumble into a clumpy consistency with a powdery texture. R19 stated the Brussels sprouts were very mushy and unappealing to eat. R19 demonstrated by smashing one on the plate and stated, See how much water comes out of these? On 2/24/26 at 10:58 a.m., R7 stated she received a piece of pork loin a few days earlier at lunchtime that was cold and too tough to chew. R7 stated breakfast meals she receives at the facility are cold more often than not. R7 stated she feels the food quality at the facility is unacceptable. R19's care plan documents an admission date of 1/9/26 with diagnoses including Anxiety Disorder, Essential Hypertension, and Nondisplaced Fracture of the Seventh Cervical Vertebra. R19's undated care plan documents the resident is to receive a no-added-salt, regular-texture, thin-liquid diet. R19's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R19 is cognitively intact. R7's care plan documents an admission date of 1/15/26 with diagnoses including Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus with Hyperglycemia, personal history of urinary infections, and hypertension. R7's diet order documents R7 is to receive a no-added-salt/low-concentrated-sweets diet with regular texture and consistency. R7's Minimum Data Set Section C dated 1/26/26 documents a Brief Interview for Mental Status score of 13, indicating R7 is cognitively intact. 5. On 2/22/26 at 12:37 p.m., R28 was observed in the dining room consuming only 75% of her pork roast during lunch. R28 stated the meat was too tough. R28's MDS dated [DATE] documents R28 is alert and oriented. 6. On 2/22/26 at 12:37 p.m., R10 was observed in the dining room eating lunch. R10's meal included pork roast, a dinner roll, mashed potatoes with gravy, Brussels sprouts, a cookie, and two glasses of beverages. R10 stated she liked the mashed potatoes and Brussels sprouts but that the meat was tough. R10's MDS dated [DATE] documents R10 is alert and oriented.

Based on observation, interview, and record review the facility failed to follow physician's orders for oxygen for three residents (R22, R33, R55) of three residents reviewed for oxygen in a sample list of 37.Findings Include: 1. R55's Physician's Order Sheet (POS) includes an order dated 12/8/25 for oxygen at two liters per minute as needed. R55's progress notes document that R55 received oxygen on 12/8/26 at three liters per minute from 1:38 PM until 11:39 PM. There is no physician's order authorizing oxygen at three liters per minute for R55. On 2/24/26 at 1:13 PM, V2, Director of Nursing, verified that R55's oxygen was increased to three liters per minute without a physician's order. V2 stated, The nurse increased the oxygen flow rate when R55's oxygen saturation went lower and he became short of breath. My expectation would be that the nurse should call the doctor to obtain an order as soon as possible after increasing the oxygen flow rate. 2. On 2/22/2026 at 9:24 AM, R33 was sitting in his wheelchair in the dining room. R33 had a portable oxygen tank on the back of his chair. The tank was observed to be empty, as evidenced by the needle on the pressure gauge being in the red zone, indicating no oxygen. R33's Face Sheet, printed 2/24/26, documents diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, and Chronic Respiratory Failure with Hypoxia. R33's physician's order dated 5/13/25 documents, Oxygen at 2 liters per minute via nasal cannula every shift. R33's care plan dated 3/11/2024 documents, The resident has shortness of breath (SOB) related to COPD. He uses oxygen at 2 liters via nasal cannula continuously. On 2/24/2026 at 8:19 AM, V12, Licensed Practical Nurse (LPN), stated that the red zone on the pressure gauge of an oxygen tank means it is empty. V12 stated staff check residents' oxygen tanks when getting them up for the day. V12 further stated that Certified Nursing Assistants (CNAs) notify the nurse if the oxygen tank is empty and needs replacement, and that nurses also check residents' oxygen tanks when they are in common areas. On 2/24/2026 at 1:15 PM, V2, Director of Nursing (DON), stated she expects nurses to monitor residents who require oxygen and replace portable oxygen tanks before they become empty. 3. On 2/22/26 at 8:40 a.m., R22 was observed lying flat on her back in bed with the head of the bed only slightly elevated. R22 did not complain of difficulty breathing; however, her respirations appeared slightly labored when she spoke. R22 had a nasal cannula in place with oxygen flowing at 6 liters from an oxygen concentrator, and the humidification water canister attached to the concentrator was empty. On 2/23/26 at 10:35 a.m., R22 was observed lying flat on her back in bed. The shower aide stated she had just completed giving R22 a bed bath and was repositioning her before leaving the room. R22's bed remained flat. R22's nasal cannula was in place, and oxygen was running at 5.5 liters. On 2/23/26 at 11:12 a.m., R22 was again observed lying flat on her back with the bed flat. The oxygen concentrator was running at 5.5 liters via nasal cannula. On 2/24/26 at 8:30 a.m., R22 was observed sleeping in her bed with the head of the bed slightly elevated to approximately 20 degrees. Oxygen was running at 4.5 liters. R22 appeared to be breathing heavily while sleeping. R22's Minimum Data Set (MDS) dated [DATE] documents respiratory diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Failure with Hypoxia, and Chronic Pulmonary Embolism. Section J of this MDS indicates that R22 experiences shortness of breath with exertion, when sitting at rest, and when lying flat. R22's Care Plan dated 8/14/2025 documents that the resident has COPD and emphysema and uses oxygen continuously at 2 liters. The care plan includes an intervention to keep the head of R22's bed elevated to help alleviate COPD symptoms and to position the resident in Fowler's position to facilitate breathing. Another listed intervention is to monitor R22 for difficulty breathing during exertion. R22's Care Plan dated 2/20/2026 documents that the resident has a terminal diagnosis of Heart Failure with Preserved Ejection Fraction, with the stated goal of care being to keep R22 comfortable. R22's electronic medical record (EMR) documents that a modification to the MDS is currently in progress due to a significant change in R22's condition. R22's EMR documents a physician's order dated 8/8/2024 for oxygen at 2 liters per minute via nasal cannula. R22's Treatment Administration Record (TAR) for February 2026 documents staff signatures indicating administration of oxygen at 2 liters per minute via nasal cannula; the order is dated 5/14/2026. R22's EMR documents an oxygen saturation of 85% on 2/23/2026 at 10:58 a.m. On 2/23/26 at 2:22 p.m., V4, Licensed Practical Nurse (LPN), and the writer observed R22 in her bed. At that time, V4 checked R22's oxygen concentrator settings and stated, Oh yes, R22 is often left at 6 liters because of shortness of breath. R22 is hospice, so it's okay to turn it up. Sometimes the facility staff turns it up and sometimes hospice does. V4 further stated that at lunchtime that day, V5, Certified Nursing Assistant (CNA), notified her that R22 was screaming, I need air, I can't breathe, help me. V4 stated she offered to send R22 to the hospital, but R22 declined and subsequently settled down. On 2/23/26 at 2:26 p.m., V5, CNA, stated that while staff were passing meal trays, R22 began screaming, I need air and help me. V5 stated he notified V4, LPN, who then assessed the resident. V5 confirmed that the nasal cannula was in R22's nostrils and that the oxygen concentrator was running, stating that the water was bubbling. On 2/24/2026 at 1:29 p.m., V2, Director of Nursing (DON), stated that R22 often yells at staff to increase her oxygen flow because she feels she cannot breathe and that R22 has experienced a recent decline in condition. V2 stated she plans to educate nursing staff regarding adjusting oxygen settings without obtaining a physician's order. Policy Review The facility's Oxygen Administration policy dated March 2004 documents that the purpose of the procedure is to provide guidelines for safe oxygen administration. The policy states that, in preparation for this procedure, staff should: Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs. Assemble equipment and supplies as needed. The policy further states that the following equipment and supplies are necessary: Portable oxygen cylinder (secured to stand) Nasal cannula or mask as ordered Humidifier bottle No Smoking/Oxygen in Use signs Regulator Personal protective equipment (e.g., gowns, gloves, mask, as needed) The policy also states that before administering oxygen, and while a resident is receiving oxygen therapy, staff should assess for: Signs or symptoms of cyanosis (bluish tone to skin or mucous membranes) Signs or symptoms of hypoxia (rapid breathing, rapid pulse, restlessness, confusion) Signs or symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, slow or shallow respirations) Vital signs Lung sounds Arterial blood gases and oxygen saturation, if applicable Other laboratory results (hemoglobin, hematocrit, complete blood count), if applicable

Based on observation, interview, and record review the facility failed to treat residents with dignity and respect, and provide care for each resident in a way that promotes their quality of life. This failure affected three of three residents (R3, R12, R18) reviewed for dignified care on the sample list of 37.Findings Include: The Facility's Resident Rights for People in Long-Term Care Facilities policy dated November 2018 documents the facility must treat each resident with dignity and respect and must care for each resident in a manner that promotes their quality of life. 1. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires staff assistance for showering, transfers, hygiene and toileting. On 2/22/26 at 9:33 AM R3 stated she does not like how the staff always rush through things when providing her care. R3 stated she feels like staff view her as a task and not a human. The staff don't seem caring and do not provide thorough care. R3 stated staff often rush through her showers and she doesn't feel clean and doesn't get dried off completely before they are trying to put on her clothes. R3 stated staff often will provide incontinence care and assist her when she is wet but often do not change her bedding when it is soiled and instead just throw another sheet on top of the dirty one. R3 stated she believes she should feel comfortable and well cared for and she does not. On 2/22/26 at 9:35 AM R3's bed was covered with multiple blankets. One blanket appeared soiled and had another blanket folded and laid on top of it. On 2/23/25 at 11:00 AM R3's bed had the same blankets on it from the day before but had an added folded up sheet in the middle of her bed that was visibly soiled. 2. R12's Minimum Data Set, dated [DATE] documents R12 is cognitively intact and requires staff assistance for showering, transfers, hygiene and toileting. On 2/22/26 at 9:33 AM R12 stated staff are always rushed. They seem disinterested and most of them don't seem to really care. Many staff make it seem as though you are bothering them. 3. R18's Minimum Data Set, dated [DATE] documents R18 is cognitively intact and requires staff supervision for showering, transfers, hygiene and toileting. On 2/22/26 at 10:35 AM R18 stated staff all appear rushed or have bad attitudes. Staff make it seem like they never have time to care for residents. R18 stated he can do a lot for himself, but his roommate (R5) needs a lot of help. Staff often tell R5 they will be back to help him and don't return for over an hour. R18 stated the housekeeping staff quickly clean around everything and never move anything or take the time to thoroughly clean the floors, around the edges, or underneath things. R18 stated he would like the staff to appear like they are here to care for people not just cash a paycheck. 2/23/26 at 2:40 PM V2 Director of Nurses confirmed staff should be moving at the resident's pace and not make them feel rushed. Staff should create a caring environment where residents feel well cared for and comfortable. Staff should be completing things thoroughly and with the residents' needs and feelings in mind.

Based on observation, interview, and record review, the facility failed to provide necessary feeding assistance for a resident who was observed eating with his hands. This failure affected one (R4) of three residents reviewed for nutrition from a total sample of 37 residents.Findings include:On 02/22/2026 at 8:28 a.m., R4 was observed lying in bed with the head of the bed elevated, eating breakfast using his fingers, and no eating utensils were present on the tray. R4's meal consisted of scrambled eggs, a pancake with syrup, sausage, and cream of wheat, with cranberry juice and water provided. R4 was unable to answer questions and responded only with yes/no answers.On 02/24/2026 at 8:15 a.m., V19 (R4's family member) stated that R4 wants to be independent and that his stroke affected his right side, making it more difficult for him to use utensils with his left hand. V19 stated he does not know how R4 would feel knowing he was having to use his hands to eat. V19 further stated that he does not feel the facility has done much to help R4 maintain the abilities he had regained while receiving therapy at the hospital following his stroke. V19 recalled an occasion during a visit when R4 was served spaghetti and was eating it with his hands. V19 stated that R4 remains in bed most of the time, and although he had hoped to eventually take R4 home to live with him, he no longer feels this is possible because R4 has lost significant functional ability and now requires around-the-clock care. V19 stated he believes R4 would benefit from therapy but was told at admission that the facility did not currently provide therapy services.R4's Electronic Medical Record (EMR) documents that R4 was admitted to the facility on [DATE].R4's Minimum Data Set (MDS) dated [DATE] documents that R4 has the following health conditions: aphasia, hemiplegia or hemiparesis (right side), and dysphagia.R4's MDS dated [DATE] documents that R4 requires partial to moderate staff assistance with eating, defined as the helper performing less than half of the effort. This level of assistance is described as the helper lifting, holding, or supporting the resident's trunk or limbs while providing less than half of the total effort required.R4's MDS dated [DATE] documents that R4 has severe cognitive impairment.R4's Care Plan dated 3/7/2024 documents that R4 is dependent on staff to complete activities of daily living tasks and requires one-person assistance.On 02/24/2026 at 9:00 a.m., V14, Licensed Practical Nurse (LPN) and MDS Coordinator, stated she is responsible for the facility's restorative program, which she took over in December. She reported that she is new to the role and still learning the processes. V14 stated that V18, Restorative CNA, is the program aide who works directly with residents and would have more information regarding interventions in place for R4. V14 stated she was aware that R4 uses his hands to eat finger foods and was unsure whether any therapy assessments had been completed to determine if R4 would benefit from modified utensils or plates.On 02/24/2026 at 10:52 a.m., V18, Restorative CNA, stated she is familiar with R4 and reported that he is impaired on his right side and requires supervision for eating. V18 stated that the CNAs are primarily performing restorative tasks with R4. V18 was unable to provide documentation showing that R4 was participating in the Restorative Program as outlined in his Care Plan.On 02/24/2026 at 1:29 p.m., V2, Director of Nursing (DON), stated that R4 is a hand eater and is provided finger foods. V2 stated she does not believe R4 has participated in any type of Occupational Therapy and that she is only aware of Restorative Therapy provided by the facility.The policy documents that guidelines for this policy are in accordance with the comprehensive assessment. Together with respect for individual resident needs and choices, the facility provides care and services for a variety of activities, including eating meals and snacks.This policy documents that the professional team, in collaboration with the resident and/or resident representative:Will recognize and evaluate an inability to perform ADLs or risk for decline in any ability to perform ADLs.Will develop and implement interventions in accordance with the resident's evaluated needs, goals for care, and preferences and will address the identified limitation in the ability to perform ADLs.Will monitor and evaluate the resident's response to care plan interventions and treatments.Will revise the approaches to care as appropriate.

Based on observation, interview, and record review the facility failed to implement interventions to maintain expanded barrier precautions (EBP) for one resident (R25) who has open wounds of five residents reviewed for EBP in a sample list of 37.Findings include:R25's Care Plan initiated 2/22/26 includes the following diagnoses: presence of left artificial hip joint, presence of cardiac pacemaker, malignant neoplasm of abdomen, cataract, atrial fibrillation and flutter, hypertension, chronic obstructive pulmonary disease, congestive heart failure, wound of left great toe, peripheral vascular disease, and chronic kidney disease stage III.R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact.R25's wound assessment dated [DATE] documents R25 has an unstageable pressure ulcer on his left heel.On 2/22/26 at 9:00 a.m., R25's door was open to the hall. There was no sign on the door or anywhere else visible to indicate R25 was on Enhanced Barrier Precautions (EBP). There was no dirty linen or red trash container in or near R25's room. R25 was seated on the edge of his bed. R25 denied that staff who enter his room wear gowns or gloves when they are performing his daily wound care. R25 had a gauze wrap on his left foot and ankle and was wearing a heel protector. There was no personal protective equipment (PPE) in or near R25's room.On 2/23/26 at 10:00 a.m., there was no sign on the door or anywhere else visible to indicate R25 was on EBP. There was no dirty linen or red trash container in or near R25's room. There was no personal protective equipment (PPE) in or near R25's room.On 2/23/26 at 11:00 a.m., V2, Director of Nursing, and V3, Assistant Director of Nursing (ADON) and Infection Preventionist, were asked if R25 should be on EBP. Both stated that R25 is on EBP. After checking R25's room, V2 and V3 verified R25 did not have precautions in place.The facility's policy, Enhanced Barrier Precautions, revised 3/21/24, states, It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy further states, Clear signage will be posted on the door or wall outside of the resident's room indicating the type of precautions, required PPE, and high-contact care activities that require the use of gown and gloves.

Based on interview and record review the facility failed to complete infection surveillance documentation and ensure one resident (R25) met the criteria for initiation of an antibiotic of four residents reviewed for antibiotic stewardship in a sample of 37 residents. Findings Include:R25's Care Plan initiated 2/22/26 includes the following diagnoses: Presence of Left Artificial Hip Joint, Presence of Cardiac Pacemaker, Malignant Neoplasm of Abdomen, Cataract, Atrial Fibrillation and Flutter, Hypertension, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Wound of Left Great Toe, Peripheral Vascular Disease, and Chronic Kidney Disease Stage III. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25's Wound assessment dated [DATE] documents R25 has an unstageable pressure ulcer in his left heel and left great toe. R25's Medication Administration Record (MAR) for February documents a physician's order dated 2/5/26 for Bactrim Oral Tablet 400-80 MG(Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for Wound Infection w/ cellulitis for 14 Days. This medication is documented as not given past 2/11/26 as R25 was hospitalized at that time. R25's hospital record dated 2/11/26 documents the reason for hospitalization was a ruptured abscess of the scrotum. R25's Medication Administration Record (MAR) for February also documents a physician's order dated 2/18/26 (upon return from the hospital) for Sulfamethoxazole-Trimethoprim Oral Tablet 400-80 MG (Sulfamethoxazole-Trimethoprim) Give 2 tablet by mouth two times a day for abscess for 2 Administrations. This was documented as given.The facility's infection tracking and trending for February does not include data for R25. There is no documentation to ensure R25 met the criteria for initiation of an antibiotic or the antibiotic chosen was the correct antibiotic. No cultures are documented in R25's medical record.On 2/23/26 at 2:10PM V3 Assistant Director of Nursing and Infection Preventionist stated, I guess I just missed (R25) on the tracking and verified she could not locate a McGreer Criteria or other Antibiotic Stewardship Assessment. On 2/24/26 V2, Director of Nursing verified that R25's infection should have been included in the tracking and an assessment for the appropriate use of the antibiotic should have been completed but was not. The facility's policy Antibiotic Stewardship guidelines reviewed 4/29/25 states Purpose: The purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance.The purpose of the antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use.Responsible Party: Infection Control/ QAPI Committee__________________________________________________________________________________ObjectiveThe Antimicrobial Stewardship Program will be to improve patient outcomes through optimization of antimicrobial therapy by selection of appropriate antibiotic dose, route, and duration of treatment.Potential benefits include the following: Improve patient safety by decreasing side effects and toxicity. Support the education of all healthcare providers, patients and families about antimicrobial stewardship practices including antimicrobial resistance and appropriate antimicrobial use. Minimize the development of antimicrobial resistance by appropriately selecting antibiotics. Reduce the rates of facility-acquired infections. Reduce risk of Clostridium difficile infections, disruption of normal flora and the emergence of multidrug-resistant organismsGuidelineThe facility will incorporate all seven core elements outlined by the CDC. Leadership Commitment: The facility leadership is committed to provide the necessary resources Accountability: The physician, nursing, and pharmacy are the leads responsible for promoting and overseeing antibiotic stewardship activities. Drug Expertise: The facility maintains a consultant pharmacist/other individual with antibiotic stewardship-specific drug expertise Action: The facility will implement policies and procedures to improve antibiotic use Tracking: The facility will monitor antibiotic use and outcomes from antibiotic use. Reporting: The facility will provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff Education: The facility will provide resources to clinicians, nursing staff, residents, and families about resistance and appropriate antibiotic use. The facility will utilize McGeer's criteria when considering initiation of antibiotics. The facility will work with the hospital and the attending physician for new residents that are admitted to the facility with a physician's order for a course of antibiotics to validate criteria used for initiation of antibiotics, including culture and hospital criteria used.

Based on observation, interview, and record review the facility failed to assess residents using antipsychotics, failed to identify and track resident specific targeted behaviors, and failed to follow physician's order for gradual dose reduction for three residents (R43, R13, R2) of five residents reviewed for psychotropics in a sample list of 37 residents.Findings Include: 1. R43's Medication Administration Record (MAR) for February 2026 includes a current order initiated 1/29/26 for Seroquel Oral Tablet 25 mg (Quetiapine Fumarate): give 1 tablet by mouth two times a day for Major Depressive Disorder and Anxiety. On 2/22/26 at 9:15 a.m., R43 was seated in a wheelchair in her room. R43 reached down with her right hand several times as though she was picking something up from the floor. There was nothing visible that she was reaching for. On 2/24/26 at 2:00 p.m., V2, Director of Nursing, verified no baseline assessment was performed when R43 was ordered Seroquel in January. V2 provided a generic list of behaviors and interventions to support that the facility is tracking behaviors; however, when asked if R43 regularly picks up invisible objects from the floor, V2 stated, All the time. We are afraid she will fall, so we monitor her. V2 verified the facility is not tracking that behavior and has not identified an effective intervention related to it. 2. R13's Medical Diagnoses List dated February 2026 documents R13 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety, and Depression. R13's Physician Order Sheet documents R13 was started on Lurasidone (antipsychotic) 40 milligrams per day on 5/8/25 for bipolar disorder. This medication had a dosage increase on 2/5/26 to 60 milligrams per day. R13's Behavior and Psychotropic Medication Reviews from 10/1/25 and 12/1/25 did not include Lurasidone. On 2/23/26 at 2:45 p.m., V6, Regional Clinical Nurse, confirmed the facility did not complete quarterly psychotropic medication assessments for R13's antipsychotic medication, Lurasidone. V6 confirmed the facility should be monitoring this medication closely and that the quarterly assessments should include all psychotropic medications. 3. R2's Minimum Data Set (MDS) dated [DATE] documents that R2 has active psychiatric diagnoses that include Anxiety, Depression, Psychotic Disorder, and Schizophrenia. Section E of the same MDS indicates that R2 did not exhibit any behavioral symptoms during the assessment period, including no documented physical, verbal, or other behavioral expressions. R2's Progress Notes dated 2/12/2026 document that a Medication Regimen Review (MRR) was completed by the pharmacist, who then provided a monthly report to the Director of Nursing (DON) for necessary follow-up actions. A Monthly Pharmacist Report to the Attending Physician/Prescriber dated 2/12/2026 documents that R2's condition is stable. The pharmacist recommended attempting a Gradual Dose Reduction (GDR) of Mirtazapine from 7.5 milligrams (mg), taken by mouth at bedtime, to 3.75 mg, taken by mouth at bedtime. R2's Physician's Order Sheet documents an active order for Mirtazapine Oral Tablet 7.5 mg, to be administered as one tablet by mouth at bedtime for mood and behavioral symptoms. R2's February 2026 Medication Administration Record (MAR) documents that R2 continues to receive Mirtazapine 7.5 mg by mouth at bedtime for mood and behavior. On 2/24/26 at 1:58 p.m., V15, Licensed Practical Nurse (LPN)/MDS Coordinator, stated she has not communicated the pharmacist's recommendation for GDR of Mirtazapine dated 2/12/2026 for R2 to the psychiatrist or attending physician. V15 stated she typically waits until the psychiatrist visits residents on Thursdays and added that the psychiatrist probably won't agree anyway, stating that in the past he documented that a dose reduction was contraindicated. On 2/24/2026 at 1:29 p.m., V2, Director of Nursing (DON), stated she had not contacted the psychiatrist or attending physician about the pharmacist's recommended Mirtazapine dose reduction for R2, saying that this is V15's responsibility and that she does not have the psychiatrist's contact information. The facility's Psychotropic Medication Policy (not dated) states, This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising residents' health and safety, ability to function appropriately, or the safety of others. The policy further states, Licensed nurses, in conjunction with the pharmacist and physician, shall be responsible for monitoring and assessing the resident's responses to antipsychotic drug therapy by reviewing behavior tracking tools, nursing progress notes, physician orders, and observation of resident behaviors. Licensed nurses shall document in the record and care plan the specific behavioral symptom(s) for which the drug was ordered. This behavior identification step is critical for proper monitoring and should be a specific behavior (e.g., biting, scratching, kicking, hitting, etc.).

Based on observation, interview, and record review the facility failed to develop a care plan to address a resident's hearing loss and implement interventions to maintain or improve his communication for one of 16 (R20) residents reviewed for care plans in the sample of 37.Findings include: R20's Minimum Data Set (MDS) dated [DATE] documents R20 is alert and oriented and has moderate hearing loss.R20's care plan, reviewed on 1/27/2026, does not include a care plan addressing R20's moderate hearing loss or interventions to assist R20 with communicating his needs effectively.On 2/22/2026 at 9:34 a.m., R20 was sitting at bedside eating breakfast but did not respond when this surveyor spoke with him. The surveyor attempted several times, speaking in a loud tone of voice, to communicate with R20 and asked if he was alright. R20 gestured toward his ear and stated, I cannot hear. R20 stated he does not have a hearing aid. R20 reported he told the facility he wanted a hearing aid and that the facility was supposed to schedule an appointment, but he did not know what happened with it. R20 stated he cannot hear anything out of his left ear and only a little out of his right ear. At that time, there were no alternative communication devices available in the room. This surveyor used paper and pen to communicate with R20, and he was able to answer questions appropriately.On 2/23/2026 at 8:31 a.m., R20 was lying in bed and was able to understand what the surveyor was saying as long as he could read her lips.On 2/23/2026 at 9:47 a.m., V4, Licensed Practical Nurse (LPN), confirmed R20 is hard of hearing. V4 stated R20 does not have a hearing aid and that no other communication devices are used, other than speaking louder and repeating themselves when communicating with R20.On 2/23/2026 at 12:01 p.m., V2, Director of Nursing (DON), stated R20 is hard of hearing and does not have a hearing aid because he keeps losing them. V2 confirmed there are no alternative communication devices used, and staff just have to speak louder for R20 to hear them.On 2/24/2026 at 9:07 a.m., V13, Social Services Director (SSD), stated, R20 is hard of hearing, but a lot of it is selective hearing. Yes, he is hard of hearing. He does not have a hearing aid. He was seen by audiology on 1/27/26. I think they were trying to get him one, but I don't think he will wear them. He never had one that I know of. He is the one that wants to be left alone. We just communicate like normal; he will usually ask what you said, and we just repeat it.On 2/24/2026 at 1:15 p.m., V2 stated she expects the V15 MDS Coordinator to include a care plan and interventions for residents who have sensory impairments.On 2/24/2026 at 1:26 p.m., V15 stated she was never asked to create a care plan for residents with sensory impairments such as impaired hearing. V15 stated she does not complete this assessment and that it is usually the Social Services Director who performs it.The facility's policy, Care Plan (Comprehensive), updated October 2022, documents, An individualized comprehensive care plan that includes measurable objectives and a timetable to meet the resident's medical, nursing, mental, and/or psychological needs is developed for each resident.

Based on observation, interview, and record review the facility failed to ensure staff provided appropriate intervention to assist a resident with moderate hearing loss to communicate his needs effectively for one of one resident (R20) reviewed for hearing loss in the sample of 37. Findings include:R20's Minimum Data Set (MDS) dated [DATE] documents R20 is alert and oriented and has moderate hearing loss.R20's care plan, reviewed on 1/27/2026, does not include a care plan addressing R20's moderate hearing loss or interventions to assist R20 with communicating his needs effectively.On 2/22/2026 at 9:34 a.m., R20 was sitting at bedside eating breakfast but did not respond when this surveyor spoke with him. The surveyor attempted several times, speaking in a loud tone of voice, to communicate with R20 and asked if he was alright. R20 gestured toward his ear and stated, I cannot hear. R20 stated he does not have a hearing aid. R20 reported he told the facility he wanted a hearing aid and that the facility was supposed to schedule an appointment, but he did not know what happened with it. R20 stated he cannot hear anything out of his left ear and only a little out of his right ear. At that time, there were no alternative communication devices available in the room. This surveyor used paper and pen to communicate with R20, and he was able to answer questions appropriately.On 2/23/2026 at 8:31 a.m., R20 was lying in bed and was able to understand what the surveyor was saying as long as he could read her lips.On 2/23/2026 at 9:47 a.m., V4, Licensed Practical Nurse (LPN), confirmed R20 is hard of hearing. V4 stated R20 does not have a hearing aid and that no other communication devices are used other than speaking louder and repeating themselves when communicating with R20.On 2/23/2026 at 12:01 p.m., V2, Director of Nursing (DON), stated R20 is hard of hearing and does not have a hearing aid because he keeps losing them. V2 confirmed there are no alternative communication devices used and that staff just have to speak louder for R20 to hear them.On 2/24/2026 at 9:07 a.m., V13, Social Services Director (SSD), stated, R20 is hard of hearing, but a lot of it is selective hearing. Yes, he is hard of hearing. He does not have a hearing aid. He was seen by audiology on 1/27/26. I think they were trying to get him one, but I don't think that he will wear them. He never had one that I know of. He is the one who wants to be left alone. We just communicate like normal; he will usually ask what you said, and we just repeat it.The facility's policy dated 04/2007, Sensory Impairments - Clinical Protocol, documents, As part of the initial assessment, the staff and physician will help identify individuals with sensory impairments, including hearing, taste, vision, smell, and touch. For a resident with impaired hearing, the staff will check for cerumen and may (as indicated) help the individual obtain a hearing evaluation, hearing aid, or employ written or other means to communicate with the individual.

Based on interview and record review, the facility failed to ensure Registered Nurse coverage for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 50 residents residing in the facility.Findings include:The Facility assessment dated [DATE] with a review date of 10/9/2025 documents the following: Staffing: The facility will be staffed according to resident needs and required staffing guidelines and considerations of continuity of care.The facility's Daily Assignment Sheets dated December 16, 2025 through December 31, 2025 documents no Registered Nurse coverage on 12/25/25.On 12/31/25 at 10:24am, V2 (Director of Nursing) confirmed the facility did not have Registered Nurse coverage for 8 consecutive hours on 12/25/25. V2 stated the registered nurse who was scheduled had called off and V2 did not come in that day to cover the shift.The facility Room Roster dated 12/30/25 documents 50 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to effectively manage resident's pain according to physician orders, the resident care plan, and the resident's preference. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. This failure resulted in a decline in R1's ability to participate in routine activities of daily living. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 8:40 AM, R1 was lying in bed in her own room. R1 could not make a complete fist with her left hand which was visibly swollen with taught skin. R1 had a compression wrap on her visibly swollen left knee. On 4/24/25 at 11:50 AM, R1 could not touch the thumb of her left hand to any of the fingers of her left hand. R1 stated she is left handed which makes everything inconvenient. R1 stated, and demonstrated, she could not grasp the television remote control with her left hand. R1 stated she can not get out of bed when she wants to anymore because of pain in her left knee, and can not propel her own wheelchair due to her left hand being painful and swollen. R1 stated she did not get out of bed every day prior to the incident which caused her injuries, but did get out of bed when she wanted to go socialize and engage in Bible study, but now she can not get out of bed when she wants to because the staff can no longer use the sit-to-stand lift with her but have to use the full body lift because her knees are too painful to bear weight and she can not grip the grab bars on the sit-to-stand lift with her hand being so painful. R1 stated when being lifted with the full body lift, the carrying cradle lets her legs hang over the edge which causes her knees to bend which is very painful. R1 stated that prior to the incident, when she was up in her wheelchair, she could propel her own wheelchair, but now some staff member has to propel her wheelchair because her left hand is too painful to grip and push on the wheels. R1's Nurses Notes do not document the fall incident which resulted in R1's pain and swelling of her hand and knee, but do document on 3/16/25 that R1 began to complain of excessive pain since falling out of the sit-to-stand on 3/9/25. This same note documents R1 was sent to the emergency room for an evaluation. This same note documents R1 had been refusing to get out of bed due to the excessive pain since the fall incident. R1's Nurses Notes dated 3/20/25 document further complaints of pain, numbness and tingling of R1's left hand, left knee pain and swelling, and right wrist pain. This note documents R1's physician (V10) examined R1 and sent her to the emergency room for further evaluation. R1's Hospital Discharge Note dated 3/28/25 documents R1 was admitted to the hospital 3/20/25 through 3/28/25 for complaints of left wrist and hand pain, bilateral knee pain, and right wrist pain. These notes document R1 had received morphine for pain management at the hospital, and document a physician ordered increase in R1's prescription of Hydrocodone 5 milligrams with Acetaminophen 325 milligrams (Norco) from every 6 hours as needed to every 4 hours as needed. R1's Physician Order Sheet dated for April 2025 document R1's order for Hydrocodone was increased to every 4 hours as needed on 4/8/25. R1's current Care Plan (void of dates) provided by V11, Minimum Data Set Coordinator, documents R1 likes to attend group activities. This Care Plan documents R1 experiences pain and has medication ordered which should be administered as ordered by the physician, and to assess if the pain intensity is acceptable to the resident.

Based on observation, interview and record review, the facility failed to conduct a procedure with a mechanical lifting device in a safe manner to prevent a resident fall. This failure affects one resident (R1) out of five reviewed for falls and mechanical lift use on the sample list of five. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 8:40 AM, R1 was lying in bed in her own room. R1 could not make a complete fist with her left hand which was visibly swollen with taught skin. R1 had a compression wrap on her left knee. R1 stated a CNA (Certified Nursing Assistant, V6) had transferred her using a sit-to-stand mechanical lift, R1 tried to inform the CNA that she could not hold on to the grab bar on the mechanical lift, but the CNA did not pay any attention to her and she fell to the floor. R1 stated the CNA did not use the safety belt with the mechanical lift. R1 stated her physician (V10) had spoken with her since the incident to let her know that the fracture V10 thought she had from x-rays was not a fracture but was later determined by computed tomography scans to be a Gout flare up and a new onset of Rheumatoid Arthritis. R1 stated V10 told her some of the swelling and pain of her left hand was related to the fall from the mechanical lift, but the Gout and Arthritis also makes swelling and pain. On 4/24/25 at 9:28 AM, V5, Lead Certified Nursing Assistant, stated that all of the facility CNAs receive training in the proper use of the mechanical lifts and must pass a competency evaluation in order to be allowed to operate the lifts. V5 further stated the safety belt must always be used with the lifts and there must be two staff members present whenever a mechanical lift is being used to lift a resident. On 4/24/25 at 9:30 AM, V3, Assistant Director of Nursing, stated all of the CNAs must pass a competency evaluation before being able to use the mechanical lifts. V3 stated as far as she knows, all of the staff use the safety belt when using the lifts. V3 stated the CNA (V6) was using the mechanical lift by herself and was subsequently terminated. On 4/24/25 at 9:50 AM, V1, Administrator, stated V6 was terminated for operating the mechanical lift to lift a resident by herself and an unsafe transfer. On 4/24/25 at 9:57 AM, V3 stated she had interviewed V6 after the incident when R1 fell from the mechanical lift to ask V6 who was the second staff member with her when the incident happened. V3 stated that V6 claimed she didn't know she was supposed to have a second person with her. V3 stated that V6 had received the training and competency evaluation to operate the mechanical lifts, but the previous Director of Nursing no longer works at the facility and no one could locate the documents for the trainings or competency evaluations. On 4/24/25 at 11:50 AM, R1 clarified that prior to the incident of falling from the sit-to-stand lift, she had experienced a bowel incontinent episode and requested V6 transfer her back to the bed to get cleaned up. R1 further stated V6 raised her up with the sit-to-stand lift and began cleaning her incontinence. R1 again stated V6 did not use the safety belt and she was being lifted up on the lift with only her own arm strength. R1 stated she informed V6 she could not hold on to the grab bar on the mechanical lift for the length of time it took to get her cleaned but V6 did not listen to her. R1 stated she did not have any problem holding on to the grab bar on the mechanical lift for the time it took to go from her wheelchair to the bed, which was why she had asked V6 to transfer her to the bed to get cleaned. R1 stated that her hands lost grip of the grab bar and she grabbed hold to the center bar of the lift and again told V6 she could not hold on, but V6 did not listen and that is when she fell to the floor. R1 stated that V6 had been alone when the incident happened and did not have a second staff member present to assist in using the sit-to-stand lift. R1's Nurses Notes do not document the fall incident, but do document on 3/16/25 that R1 began to complain of excessive pain since falling out of the sit-to-stand on 3/9/25. This same note documents R1 was sent to the emergency room for an evaluation. The facility's Initial (3/16/25), Final (3/21/25), and Addendum (3/24/25) Reports to Illinois Department of Public Health document R1 experienced a fall incident on 3/9/25, began to complain of pain on 3/16/25, was sent to the emergency room and determined by x-ray to have a fracture of the left radius, later determined by computed tomography scans to rule out a fracture and diagnosed with Gout and new onset of Rheumatoid Arthritis. The facility policy Safe Lifting and Movement of Residents dated August 2008 documents the facility uses mechanical lifting devices to promote resident safety and quality of care. This policy documents mechanical lifting devices will be used for any resident who requires a two person assist, staff will be trained on the use of the mechanical lifts, staff competency in the use of the lifts will be conducted annually, and there will be sufficient staff present on every shift who have been trained in the use of the lifts.

Based on observation, interview, and record review, the facility failed to acquire, dispense, and administer a resident's pain medication as ordered by the physician. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 11:50 AM, R1 stated she had been experiencing increased pain in her left hand and knees ever since she fell off of the sit-to-stand mechanical lift on 3/9/25. R1 stated her doctor (V10) had prescribed Norco (Hydrocodone 5 milligrams with Acetaminophen 325 milligrams) that she is supposed to be able to have every 4 hours if she needs it. R1 further stated the facility had not had any supply of her pain medication for about a week. R1 stated she receives Tylenol (Acetaminophen) three times per day but it doesn't help anything. R1 concluded by stating that whoever is responsible for ordering the medication refills needs to order it in enough time ahead so it doesn't run out. R1's Physician Order Sheet dated April 2025 documents a physician order for R1 to be able to receive Norco 1 tablet every four hours as needed for pain. On 4/24/25 at 12:20 PM, V9, Licensed Practical Nurse, stated she was the nurse on duty for the hall R1 resides on. V9 stated she became aware this morning when she came on duty that R1 did not have any Norco present in the medication cart when the night shift nurse gave her report. V9 confirmed it had been 3 days since R1's Norco had run out of supply. On 4/24/25 at 12:20 PM, the medication cart for the hall R1 resides on did not have any of the Norco medication for R1. On 4/24/25 at 12:25 PM, R1's Medication Administration Record documents R1 had not received any Norco since 4/21/25 at 4:30 PM. On 4/24/25 at 12:25 PM, R1's Controlled Drug Receipt/ Record/ Disposition Form dated 4/9/25 documents R1 had received a refill of Norco which was sent from the pharmacy in an amount of 12 tablets. This form documents R1 had requested and received three or four tablets per day since the date of receipt until 4/21/25 at 4:30 PM when the tablet count reached zero.

Based on observation, interview, and record review the facility failed to respect residents' right to be treated with dignity and respect for seven (R10, R31, R19, R29, R37, R45, R57) of seven residents reviewed for resident rights in the sample list of 39. This failure resulted in psychosocial harm of R10 and R57 causing R10 and R57 to be visibly upset and tearful. Findings include: The undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 1.) The facility's Resident Council Minutes dated 9/19/24 document call lights need answered timely and Certified Nursing Assistants (CNA) say not my resident when asked to provide care or answer call lights for unassigned residents. The facility's Resident Council Minutes dated 10/17/24 document concerns with CNAs and Nurses needing attitude adjustments and using phrases not my job, not my resident. The facility's Resident Council Minutes dated 11/21/24 document concerns that kitchen staff refuse things when asked. The facility's Resident Council Minutes dated 12/20/24 document the CNAs need attitude adjustments and concerns with CNAs being on their cellular phones and not answering call lights timely. The Resident Council Minutes dated 2/20/25 document concerns with CNA, nurses and dietary staff needing attitude adjustments, and residents have to call the nurse's station due to call lights not being answered. On 3/09/25 at 2:07 PM a resident council meeting was conducted. R29, R57, R37, R19 and R45 all confirmed call light wait times have been an ongoing problem with call lights being on for 45 minutes to an hour. R29 stated R29's main concern is that CNAs say I'll be right back or I'm not your CNA. R57 stated the CNA attitudes are atrocious and all residents agreed staff attitudes have been an ongoing problem. R29 and R57 stated when the residents complain about staff, the staff then intentionally don't answer their call lights, but were unable to identify which staff. R37 stated about a month ago R37 fell on the floor in his bathroom and waited for an hour and half with the call light on. R37 stated no staff came to answer R37's call light so R37 had to self transfer off of the floor and R37 reported this to unidentified staff. R29 stated V9 [NAME] had R57 in tears yesterday because R57 asked what the alternative was for dinner. R57 stated V9 said it's soup and sandwich and then V9 turned to an unidentified coworker and said V9 was tired of this and V9 was ready to clock out and go home. R57 stated staff, including V16 CNA, witnessed this incident. R57 stated R57 didn't feel V9's actions were considered abuse but more of a dignity and respect issue. R57 stated R57 felt scolded like a child. R29, R57, R37, R19 and R45 all stated V9 has a terrible attitude and tells the residents take it or leave it when it comes to the food. These residents also stated V13 CNA is always on V13's phone, V13 is rude, V13 has an attitude and tells residents that V13 will be right back but then doesn't return to answer the call light. On 3/10/25 at 2:28 PM V16 CNA stated V16 witnessed the incident between R57 and V9 that occurred in the evening of 3/8/25. V16 stated R57 wanted to know what food was being served and V9 fired off at (R57) and was rude to R57. V16 stated V9 said R57 was getting on V9's nerves and V9 was ready to clock out and go home. V16 stated at that time R57 was upset/tearful and R57 didn't want anything to eat. V16 stated V16 reported this immediately to V1 Administrator. On 3/10/25 at 10:41 AM V12 CNA stated V9 is short with the residents, V9's tone is loud, and V9 does not always get the residents the foods that they request from the kitchen. On 3/10/25 at 2:09 PM V1 Administrator stated V1 had not been made aware of any concerns with V9's and V13's attitudes or dignity/respect. V1 stated V1 will need to follow up and do customer service education. On 3/11/25 at 10:37 AM V1 stated the dignity is part of the Resident Rights packet, which is what the facility uses as a policy. 2.) On 3/09/25 at 9:51 AM R31 stated CNAs (later identified as V16 and V15) got mad at R31's room mate, R10, causing R10 to cry. R31 stated R31 reported this to V8 Social Service Director who said V8 would follow up with V1 Administrator. R10 stated sometime last week the CNA (V16) came in to assist R10, this CNA was upset because night shift had not changed R10 or applied R10's lymphedema compression machine to R10's legs. R10 stated the CNA said night shift should have already applied R10's compression machine and changed R10. R10 told V16 that R10 was disgusted and V16 told R10 well it's my job. R10 stated the CNA caused R10 to cry, like I'm (R10) going to now. R10 was visibly upset and tearful. R10 stated R10 didn't feel abused by V16, but that it was more of a dignity/respect issue. R10 stated it was V16's tone of voice and R10 felt scolded by V16. R31's Grievance/Complaint Form dated 3/6/25 documents R31 reported the CNAs came in very early to wake up R10, the CNAs were loud and upsetting R10 while they assisted R10 out of bed. R31 had asked the CNAs why R10 had to get up so early and they replied that they had to, which caused R10 to be very upset. On 3/09/25 at 11:59 AM V8 stated on 3/6/25 R31 reported concerns that the CNAs had upset R10. The CNAs were complaining because R10 and R31 were complaining about getting up so early. V8 stated the CNAs told R31/R10 that was what they had to do. V8 stated this was reported to V1 on 3/7/25. On 3/10/25 at 10:41 AM V16 CNA recalled the incident with R10. V16 stated night shift had not completed their assigned tasks for R10 one day last week which caused more work for the dayshift. V16 stated V16 was frustrated and should not have vented to R10 because R10 took it personally. V16 stated R10 was upset/crying and V16 reassured R10 and apologized at that time. On 3/10/25 at 2:09 PM V1 stated V1 had not been made aware of any concerns with V15's and V16's attitudes or dignity/respect.

Based on observation, interview, and record review the facility failed to follow up on grievances and document actions taken for six (R19, R29, R36, R37, R45, R57) of six residents reviewed for grievances in the sample list of 39. This failure has the potential to affect all 51 residents in the facility. Findings include: The facility's undated Resident Council Policy documents the purpose of the council meeting is to protect and preserve resident rights and for residents to discuss grievances/problems and to participate in the resolution of these concerns. This policy documents suggestions and complaints will be presented in writing to the facility's Administrator, Social Services Director, and other facility staff to review and implement follow up actions. The Concern/Suggestion form will be used to document concerns and the Administrator will respond to all council recommendations and complaints in writing, and per the facility's grievance policy. The facility's Grievance policy dated November 2016 documents the facility will post information on how to file a grievance and the contact information for the grievance official. This policy documents grievances will be submitted in writing to the Administrator within five working days, the Administrator may delegate grievance investigations to relevant staff, and the Administrator will review the findings to determine corrective actions. This policy documents the resident or person who filed the grievance will be informed of the investigative findings and actions taken to correct the concern. The facility's Resident Council Minutes dated 9/19/24 document concerns with locating work order forms for repairs, wanting day and night snacks, repetitive meals, missing laundry items, overlapping times for medication passes, Certified Nursing Assistants (CNAs) not answering call lights timely, timely toileting/incontinence cares, trash cans not being emptied and liners not replaced. The Resident Council Minutes dated 10/17/24 document concerns with housekeeping not changing mop heads between rooms, missing laundry items, CNA and nurse attitudes, staff sleeping on the job, and prompt medication times. The Resident Council Minutes dated 11/21/24 document concerns with kitchen staff refusing to provide requested items, posting menus, laundry sent to the wrong closet, replacing trash can liners, and late medications. The Resident Council Minutes dated 12/20/24 document concerns with wanting larger portions for meals, meals being cold and not served on time, changing mop heads between rooms, laundry items need marked, replacing trash can liners, CNA attitudes, call lights, and staff sleeping on the job. The Resident Council Meeting dated 1/16/25 documents concerns with meals being late and cold, laundry being returned to the wrong closet, trash can liners not being replaced, and CNAs saying they will be back but not returning. The Resident Council Minutes dated 2/20/25 document concerns with dietary/CNA/nurse attitudes, food being cold, missing meals, larger portions of food, trash cans not being emptied, call lights, and medications being on time. The facility's Grievance Log ranging from 11/29/24-3/6/25 only documents grievances for resident council on 1/16/25 for laundry not being marked or returned, and on 2/20/25 for items not being returned timely or to the wrong closet. The Grievance/Complaint Report dated 1/16/25 documents concerns with housekeeping staff mopping restrooms and using the same mop head to mop the rest of the room. This form documents V1 Administrator spoke with the housekeeping supervisor, staff were re-educated on appropriate cleaning method, and this will be monitored by the housekeeping supervisor. The Grievance/Complaint Report dated 1/16/25 documents meals are served late and cold, V1 spoke with the kitchen staff about serving meals timely, and this will be monitored through ongoing observation and education. There are no other documented follow up actions for the concerns mentioned in the Resident Council Minutes. On 3/09/25 at 2:07 PM, during the resident council meeting, R29, R19, R37, R45, and R57 reported ongoing concerns with not being able to access their money on the weekends, call light wait times, medications being late, staff attitudes, replacement of trash can liners, evening snacks/coffee, V9 [NAME] attitude, V13 CNA attitude, and meals being served late/cold. R37 stated R37 has a pair of pants that have been missing for over two months, this was reported to V21 Housekeeping Supervisor and V21 searched and was unable to find R37's pants. R57 stated R57 has been missing a pillowcase from R57's bedding set for about a month, V21 was aware, but the pillowcase was never found. These residents were unsure who to report grievances/concerns to other than bringing it up during the council meetings and were unsure of what actions the facility was taking to follow up on their reported concerns. On 03/10/25 at 10:36 AM V33 Licensed Practical Nurse stated V33 is usually done with the morning medication pass by 10:00 AM. V33 stated the morning medications are scheduled to be given at 8:00 AM. At this time V33 was observed passing medications to R36. V33 confirmed V33's medications were R36's scheduled 8:00 AM medications. V33 stated R36 was the last resident for V33's morning medication pass. R36's March 2025 Medication Administration Record documents Amlodipine 10 milligrams (mg), Aspirin 81 mg, Multivitamin, Duloxetine 60 mg, Famotidine 20 mg, Ferosul 325 mg, Pregabalin 75 mg, Timolol 0.5% eye drops, Vitamin C 500 mg, Brimonidine 0.2% eye drops, Dorzolamide/Timolol eye drops, Sodium Bicarbonate 650 mg, Lisinopril 10 mg, and Torsemide 40 mg are scheduled to give at 8:00 AM. On 3/11/25 at 10:49 AM V7 Registered Nurse confirmed medications are suppose to be given within an hour window before/after the scheduled time. V7 stated once or twice a week there are times when V7 hasn't been able to give medications within that time frame. On 3/09/25 at 3:18 PM V18 Activity Director confirmed the repeated issues brought up in the resident council meetings. V18 stated V1 Administrator is notified of these concerns and V18 thought V1 documents the follow up actions. V18 reviews the concerns from the prior month at each meeting, but was unaware that V18 needed to have documentation on follow up actions taken for the concerns. On 3/10/25 at 9:43 AM V18 confirmed there were no documented follow up actions taken for the September 2024-February 2025 council meeting concerns, besides the 1/16/25 and 2/20/24 grievance forms. On 3/09/25 at 3:33 PM V8 Social Services Director stated she receives the final grievance forms for concerns brought up during the council meetings. V8 stated V8 conducted the January 2025 council meeting. On 3/11/25 at 9:50 AM V8 stated V8 was unable to locate documentation of any grievances for September 2024-November 2024 that were not listed on the provided grievance log. V8 stated V8 is the person that grievances, including missing items, should be reported to and is responsible for ensuring grievances are be followed up on. V8 reviewed council minute concerns from the January and February 2024 meetings and confirmed the only grievances documented were on 1/16/25 and 2/20/25 regarding housekeeping, meals being late, and missing items. V8 stated V8 may have to start reviewing the resident council meeting minutes after each meeting to ensure the concerns are being followed up on and documented as grievances. V8 stated V21 Housekeeping Supervisor has a list of missing laundry items and V8 should get that list to ensure follow up actions are taken and documented. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 3/9/25 documents the facility has a census of 51 residents.

Based on observation, interview and record review the facility failed to employ a Director of Nursing and failed to provide the services of a registered nurse for eight consecutive hours seven days a week. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 3/9/25, 3/10/25 and 3/11/25 there was not a full time Director of Nursing working in the facility. The resident roster dated 3/9/25 documents 51 residents reside at the facility. The facility's nursing working schedule from 2/24/25 to 3/10/25 documents the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 2/24/25, 2/27/25, 2/28/25, 3/1/25 and 3/2/25. On 3/10/25 at 9:00am V3 Assistant Director of Nursing stated the facility has not had a Director of Nursing (DON) since 1/31/25 when the pervious Director of Nursing took another job. V3 stated the facility does not always have Register Nurse coverage for eight consecutive hours seven days a week. V3 confirmed the documentation on the working schedule provided was an accurate record of RN coverage and that there has not been a full time Director of Nursing working in the facility since 2/1/25. On 3/11/25 at 10:00am V1 Administrator confirmed that the facility has not had a full time Director of Nursing working in the facility since 2/1/25, and that they don't always have a Registered Nurse working every day. The Facility's Assessment (no date) documents the Facility will Provide a full time Director of Nursing and proper nursing coverage.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 51 residents in the facility. Findings include: On [DATE] at 11:15AM and [DATE] 11:30am V3 Dietary Manager was actively supervising dietary operations in the facility kitchen. On [DATE] at 11:04am V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3's Food Safety/Dietary Manager Certificate expired over a year ago, and V3 is scheduled to take the test next month. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager or dietary manager. On [DATE] at 2:02pm V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required. The Facility Assessment (not dated) documents a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services is needed to provide competent support and care for the facility's resident population every day and during emergencies. The facility Long-Term Care Facility Application for Medicare and Medicaid ([DATE]) documents 51 residents reside in the facility.

Based on observation, interview and record review the facility failed to administer multiple doses of antibiotic and antianxiety medication as ordered by the physician for two of three residents (R6 and R4) reviewed for medication administration in a sample list of 11 residents. Failing to administer R6's antibiotic therapy resulted in R6's stage four Ischium pressure sore deteriorating. 1.) R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R6's Wound Evaluation and Management Summary (WEMS) dated 5/3/23 documents a physician order for Levofloxacin (Levaquin) 750 milligrams (mg) daily for fourteen days starting 5/3/23 and Clindamycin 300 mg three times per day for fourteen days starting 5/3/23 for a Right Upper Medial Ischium Stage 4 Pressure Ulcer infection. R6's Physician Order Sheet (POS) and Medication Administration Record (MAR) dated May 2023 does not document R6's physician orders for Levaquin or Clindamycin. R6's Medical Record documents a total of eight missed doses of Levaquin and 20 missed doses of Clindamycin. On 5/9/23 at 11:35 AM V21 Licensed Practical Nurse (LPN) provided wound care to R6's Pressure Ulcers. R6's Right Ischium Pressure Ulcer was open with approximately 50% covered with black soft tissue. R6's dressing was saturated with moderate amount of yellow and brown foul-smelling drainage. The peri-wound of this area was dark red and non-blanchable. R6's Left Buttock Stage 4 Pressure Ulcer had soft black center with yellow soft edges surrounded by open dark red tissue with moderate yellow and brown drainage. R6's Left Upper Lateral Calf Stage 3 Pressure Ulcer was dark brown and red soft tissue with copious amount of very foul, dark brown drainage. R6's prior dressing of Calcium Alginate and bordered foam was black, slimy and slid off of R6's leg as V21 LPN removed outer gauze wrap. R6's room had foul odor from infected wounds throughout dressing changes. On 5/9/23 at 2:30 PM R6's medication supply was observed and did not include Levaquin nor Clindamycin. On 5/9/23 at 2:35 PM the facility Emergency Kit (E-Kit) was observed to contain Levaquin and Clindamycin. On 5/9/23 at 12:00 PM V21 Licensed Practical Nurse (LPN) stated (R6's) wounds smelled horrible. I about had to leave the room. They have really gotten bad. I didn't know they were that bad. You can tell they are really infected. On 5/9/23 at 3:00 PM V25 Pharmacist stated the pharmacy has not received any physician orders for R6's Levaquin and Clindamycin antibiotics. On 5/10/23 at 10:00 AM V22 Wound Physician stated the facility caused harm to R6 by not providing antibiotic therapy due to R6's Right Ischium Pressure Ulcer had deteriorated. V22 stated No one knows what is going on here (facility) because no one wants to take responsibility for the care of the residents. Unfortunately it is the residents that suffer for the lack of care. 2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. R4's Physician Order Sheet (POS) dated May 1-31, 2023 documents a physician order of Xanax 1.0 milligram (MG) twice daily for Anxiety. R4's Medication Administration Record (MAR) dated May 1-31, 2023 documents R4's Xanax was not administered from 5/2/23-5/10/23 for a total of 14 missed doses. R4's Medical Record does not document notification to (V26) Physician from 5/2/23-5/10/23 for R4's missed doses of Xanax. On 5/6/23 at 9:20 AM the medication cart locked medication storage area did not have R4's Xanax nor Narcotic Administration count sheet to match. On 5/5/23 at 3:15 PM R4 stated with tears rolling down her cheeks Please help them (facility) get me my Xanax. I have terrible Anxiety. I just cry all the time if I don't have it. They (facility) were giving it to me and now they aren't. I really need it. On 5/6/23 at 9:30 AM V17 Licensed Practical Nurse (LPN) stated I don't have any Xanax for (R4). I don't know where it is but it is not in the cart. I will have to call pharmacy to find out what happened to it. (R4) has been asking me repeatedly for it. I know (R4's) anxiety is worse because she isn't getting it. On 5/9/23 at 3:00 PM V25 stated the pharmacy dispensed a 30 day supply of (R4's) Xanax on 3/31/23. We (pharmacy) can not provide (R4's) Xanax again without a current prescription. On 5/9/23 at 3:30 PM V1 Administrator stated We (facility) have been working today on getting (R4's) Xanax. (R4) has been very upset and crying more since she hasn't had it. We (facility) reached out to (V26) Physician today to ask for a renewed prescription. We (facility) haven't heard back yet. I don't know what took so long for us to attempt to contact (V26) Physician but (R4) should not have had any missed doses because of our (facility) error. The facility policy titled 'Medication Administration' revised 11/18/17 documents the facility is to document any medications not administered for any reason by circling initials and documenting on the back of the MAR the date, time, the medication and dosage, reason for omission and initials. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.

Based on observation, interview and record review the facility failed to transcribe and implement physician orders for pressure sore treatments and failed to update a pressure sore care plan for one of four residents (R6) reviewed for pressure sores in the sample list of 11 residents. These failures resulted in R6's pressure sores deteriorating. Findings include: R6's Medical Record documents medical diagnoses of Decubitus Ulcers, Multiple Sclerosis, Chronic Kidney Disease, Venous Insufficiency, Muscle Weakness, Obstructive Sleep Apnea and Needs Assistance with Personal Care. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 requires limited assistance of one person for bed mobility, extensive assistance of one person for dressing, toileting and personal hygiene and total dependence of two people for transfers. R6's Pressure Ulcer Risk assessment dated [DATE] documents R6 as high risk for pressure ulcers. R6's Care Plan did not include updated pressure ulcer interventions for R6's Pressure Ulcers. R6's Wound Evaluation and Management Summary (WEMS) dated 5/3/23 documents physician orders of Calcium Alginate covered with absorbent pad twice daily for R6's Right Upper Medial Ischium Stage 4 Pressure Ulcer, Left Buttock Stage 4 Pressure Ulcer, Right Upper Thigh Stage 3 Pressure Ulcer, Right Buttock Stage 3 Pressure Ulcer, and Calcium Alginate with absorbent pad twice weekly for R6's Right Calf Stage 3 Pressure Ulcer, Left Upper Calf Stage 3 Pressure Ulcer and Left Lower Calf Stage 3 Pressure Ulcer. R6's Physician Order Sheet (POS) dated May 1-31, 2023 does not document V22 Wound Physician ordered treatments for R6's Pressure Ulcers to Right Ischium, Left Buttock, Right Upper Thigh, Right Buttock, Right Calf, Left Upper Calf and Left Lower Calf. R6's Treatment Administration Record (TAR) dated May 1-31, 2023 does not document V22 Wound Physician ordered treatments for R6's Pressure Ulcers to Right Ischium, Left Buttock, Right Upper Thigh, Right Buttock, Right Calf, Left Upper Calf and Left Lower Calf. On 5/9/23 at 11:35 PM V21 Licensed Practical Nurse (LPN) provided wound care for R6's Pressure Ulcers. R6's Right Upper Medial Ischium Stage 4 Pressure Ulcer was open with approximately 50% covered with black soft tissue. R6's dressing was saturated with a moderate amount of yellow and brown foul-smelling drainage. The peri-wound area was dark red and non-blanchable. R6's Left Buttock Stage 4 Pressure Ulcer had soft black center with yellow soft edges surrounded by open dark red tissue with moderate yellow and brown drainage. R6's Left Upper Lateral Calf Stage 3 Pressure Ulcer was dark brown with red soft tissue with copious amount of very foul, dark brown drainage. R6's prior dressing of Calcium Alginate and bordered foam was black, slimy and slid off of R6's leg as V21 LPN removed the outer drainage soaked gauze wrap. R6's room had foul odor from infected wounds throughout dressing changes. R6's Sacrum had a softball sized, open, dark brown and red wound with moderate amount of brown and yellow drainage. This same wound was dressed with Calcium Alginate covered by silk tape that was adhered to R6's Sacrum, covered by an absorbent pad. R6's Coccyx had been packed with gauze. R6's coccyx was open with approximately an inch of depth revealing muscle tissue and a dime sized white firm area in the center. On 5/9/23 at 12:00 PM V21 Licensed Practical Nurse (LPN) stated (R6) has two new wounds on his Sacrum and Coccyx that are not documented in (V22's) Wound Physician notes from 5/3/23. Those wounds must be new. (R6's) wounds smelled horrible. I about had to leave the room. They have really gotten bad. I didn't know they were that bad. I checked the orders before changing the dressings but (R6's) wound orders were not on the POS or TAR so I just followed the orders on (V22's) Wound Physician progress notes. Those orders should be written on the POS and the TAR so the nurses know to change the dressings. It is no wonder they smelled so bad. On 5/9/23 at 2:00 PM V1 Administrator stated (R6's) physician orders from (V22) Wound Physician should have been transcribed to (R6's) POS and TAR. I am saddened to see that my staff has failed so terribly. (R6) deserves to have the best care possible and he did not receive that here (facility). It breaks my heart to know that (R6) now has more significant Pressure Ulcers beyond those that were already there. We (facility) did not do the treatments, we failed to transcribe the orders, didn't update the careplan and most of all we failed (R6). My facility has to do better than that or we (facility) will never survive. On 5/10/23 at 10:00 AM V22 Wound Physician stated This facility definitely caused harm to (R6) by not dressing all of his wounds as ordered. There is no continuity in staffing so the orders never get processed. There have been several Administrators here and a few Director of Nurses (DON). One time I am here (facility) and talk to one person about the wound program and the next time it is someone else. No one knows what is going on here (facility) because no one want to take responsibility for the care of the residents. I even asked the floor nurse one day if she wanted access to the online wound program physician notes so the orders could be printed off and she told me she 'didn't want to do all that'. It is that attitude that I see here (facility). (R6's) wounds could have been doing better but there is no continuity in care. V22 Wound Physician stated residents have voiced to V22 that V22 is the only person who changes the resident dressings. V22 stated (R6) has had pressure ulcers that have healed. (R6) definitely has the ability to heal. If the facility would start doing the treatments as ordered then maybe new wounds wouldn't keep showing up. The facility policy titled 'Conformance with Physician Orders' reviewed 9/27/17 documents the facility must maintain a complete and accurate listing of current orders on the resident's Physician Order Sheet (POS).

Based on observation, interview and record review the facility failed to transcribe and implement physician orders for wound treatments for one of four residents (R7) reviewed for wound care in a sample list of 11 residents. These failures resulted in R7's wounds deteriorating and R7 experiencing increased swelling and severe pain when staff failed to follow physician orders to wrap R7's legs/wounds. Findings include: R7's Medical Record documents medical diagnoses of Morbid Obesity, Diabetes Mellitus Type II, Chronic Kidney Disease, Macular Degeneration, Neuropathy, Lymphademic wounds of Right Lower Leg and Left Lower Leg. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 as requiring limited assistance of one person for bed mobility, transfers, and extensive assistance of one person for dressing, toileting and personal hygiene. R7's Care Plan documents an intervention dated 9/18/22 that instructs staff to treat Lymphademic wounds as ordered. R7's Wound Evaluation and Management Summary dated 5/3/23 documents R7's Lymphademic wound of Right Leg with partial thickness measuring 40 centimeters (cm) long by 16.5 cm wide by not measurable depth and Lymphademic wound of Left leg partial thickness measuring 40 cm long by 17 cm wide by not measurable depth. This same Summary documents physician orders to wrap both Right and Left leg Lymphademic wounds from ankles to knees with gauze wrap and elastic wrap twice per week for 30 days. R7's Weekly Wound Tracking Sheet dated 5/3/23 documents R7's Lymphadema wound on Right Leg measuring 40 cm long by 16.5 cm wide by non-measurable length with no drainage, no odor as new wound and Lymphadema wound on Left Leg measuring 40 cm long by 17 cm wide by not measurable with no drainage, no odor as new wound. R7's Physician Order Sheet (POS) dated May 1-31, 2023 does not document V22 Wound Physician orders to apply gauze wraps from ankles to knees and cover with elastic gauze wraps twice per week. R7's Treatment Administration Record (TAR) dated May 1-31, 2023 does not document V22 Wound Physician orders to apply gauze wraps from ankles to knees and cover with elastic gauze wraps twice per week. R7's Nurse Progress Notes do not document R7's Lymphadema wound dressings to Right and Left Lower Legs. These same progress notes do not document notification to Physician of treatments not being completed as ordered. On 5/6/23 at 1:00 PM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow drainage. R7's wound drainage was observed on R7's legs and on R7's bed sheets. On 5/7/23 at 9:30 AM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow/brown drainage. On 5/9/23 at 1:15 PM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow/brown drainage. R7's wound drainage was observed on R7's legs and on R7's bed sheets. On 5/6/23 at 1:05 PM R7 stated A week ago Friday (4/28/23) was the last day I was asked to get a shower. Someone cut off my dressings that day but then I didn't get my shower because I started not feeling well. No one has even offered to put them on since then (4/28/23) except (V22) Wound Physician. I know (V22) Wound Physician gave orders for them (staff) to wrap my legs because of my Lymphadema in both lower legs. My legs have been so swollen and painful since they (facility) are not doing their job. I ask the nurses to wrap them and they (staff) say they will but it never gets done. The pain isn't quite so bad when they are wrapped due to the compression. I just can't stand the pain. On 5/10/23 at 10:00 AM V22 Wound Physician stated This facility definitely caused harm to (R7) by not dressing her Lymphademic wounds as ordered. There is no continuity in staffing so the orders never get processed. There have been several Administrators here and a few Director of Nurses (DON). One time I am here (facility) and talk to one person about the wound program and the next time it is someone else. No one knows what is going on here (facility) because no one wants to take responsibility for the care of the residents. I even asked the floor nurse one day if she wanted access to the online wound program physician notes so the orders could be printed off and she told me she 'didn't want to do all that'. It is that attitude that I see here (facility). (R7's) wounds could have been doing better but there is no continuity in care. V22 Wound Physician stated R7 has voiced to V22 that V22 is the only person who changes the resident dressings. V22 stated (R7) has these wounds that come and go. When I was here on 5/3/23, I resolved (R7's) other wounds and found two more. Now this week those two have gotten worse. I have seen (R7) before without the dressings in place. If the facility would stay on top of the treatment orders and complete the dressings (R7's) Lymphademic wounds on her lower legs might heal up and stay healed. (R7) has a lot going against her but it certainly doesn't help when the facility isn't completing the treatments I order. The facility policy titled 'Conformance with Physician Orders' reviewed 9/27/17 documents the facility must maintain a complete and accurate listing of current orders on the resident's Physician Order Sheet (POS). The facility policy titled 'Dressing Change' reviewed 3/16/23 documents Licensed Personnel should document dressing changes in nurse progress notes.

Failures at this level required two different Deficient Practice Statements. A. Based on observation, interview, and record review the facility failed to investigate falls to identify root cause and develop/implement post fall interventions for two (R21, R26) of three residents reviewed for falls in the sample list of 39. This failure resulted in R21 falling and sustaining a forehead laceration that required sutures. B. Based on observation, interview and record review the facility failed to maintain a safe water temperature in resident's rooms for three residents (R102, R12, R101) and failed to secure an oxygen tank in a resident's room for one resident (R18). This failure affects four of seven residents reviewed for accidents in the sample list of 39. Findings include: a.)1.) On 04/23/23 at 8:26 AM R21 was asleep in bed. R21 had bruising to R21's right eye and R21's right forehead was covered with a gauze dressing. On 4/23/23 at 12:48 PM R21's right elbow was covered with a gauze dressing. R21 stated R21 had two recent falls. R21 stated R21 fell out of bed and hit R21's head while reaching for something on the floor. R21 was sent to the hospital following the fall. R21 fell a few days prior to the other fall while attempting to walk to the bathroom. R21 was unsure what steps the facility has taken to prevent falls. R21 stated R21 only uses R21's wheeled walker when ambulating outside of R21's room, and R21 did not have R21's wheeled walker when R21 fell . The facility's April 2023 Fall Analysis Log does not document that R21 fell on [DATE] and 4/21/23. R21's Minimum Data Set, dated dated dated [DATE] documents R21 has moderate cognitive impairment and requires limited assistance of one staff person for transfers, bed mobility, and toileting. R21's April 2023 Physician's Orders documents to administer Eliquis (anticoagulant) 5 milligrams by mouth twice daily. R21's Care Plan revised on 2/27/23 documents R21 has cognitive impairment and does not understand R21's mobility limits. Interventions include to observe and assess for use of mechanical devices and an interdisciplinary team review of assessments to determine safety interventions. This care plan does not identify R21 fell on [DATE] and 4/21/23 and does not document any post fall interventions after 2/27/23. R21's Nursing Note dated 4/19/23 at 1:00 AM documents the following: At 10:15 PM, R21 was found on the floor of R21's room. R21 reported that R21 was walking without R21's walker towards the bathroom, opened the bathroom door, and fell . R21 did not have any injuries. R21's 4/19/23 fall investigation is incomplete, and does not document the root cause or that post fall interventions were developed/implemented. R21's Nursing Notes document the following: On 4/21/23 at 9:00 PM documents R21 was found on the floor between the beds of R21's room. R21 was lying on R21's right side, head down, and partially on R21's abdomen. There was blood on the floor around R21. R21 had attempted to reach for an item on the floor, lost balance, and fell hitting R21's right elbow and right eyebrow causing laceration and hematoma (bruising/swelling.) R21 was transferred to the local hospital for treatment. R21 returned to the facility at 11:50 PM and the hospital closed R21's forehead laceration with glue. R21's 4/21/23 fall investigation documents the following: Prior fall interventions include use of call light to request assistance and R21's call light was within reach. R21's walker was not in use at the time of R21's fall. The root cause is identified as R21 reached for an item on the floor, and R21 occasionally does not recognize R21's limitations. The new post fall interventions documented include R21 was educated on safety and to use the call light to request assistance. R21's emergency room Note dated 4/21/23 documents fall, frontal head injury/laceration, contusion of right shoulder, and contusion with skin tear to right elbow as R21's reason for hospital visit. R21 was alert and oriented to person, place, time, and situation. R21 reported that R21 was sitting on the edge of R21's bed, reached for something on the floor, and fell forward striking R21's head. R21 had a 1-1.5 inch bleeding cut to the right upper eyebrow and two abrasions to the right elbow. The forehead laceration was closed with dissolving sutures. On 4/25/23 at 9:55 AM V2 Interim Director of Nursing stated R21 fell out of bed and hit R21's head on 4/21/23, and the fall was unwitnessed. R21's head laceration was glued/closed at the hospital. V2 stated fall investigations are reviewed in the interdisciplinary team meetings. Root cause and post fall interventions are documented in the fall investigation and on the care plan. At 11:20 PM V2 stated the root cause of R21's 4/21/23 fall was that R21 attempted to reach for R21's snacks. The intervention implemented was to keep R21's personal items within reach. V2 was not aware that R21 had a prior fall on 4/19/23. V2 confirmed R21's 4/19/23 fall investigation was incomplete and did not include an identified root cause or that post fall interventions were developed/implemented. On 4/25/23 at 12:18 PM V17 Nurse Practitioner stated the facility should evaluate falls and implement interventions to prevent additional falls. V17 stated it is hard to say if R21's 4/21/23 fall would have been prevented if post fall interventions were developed and implemented, since R21 is alert and oriented. V17 confirmed educational reminders for use of call light and wheeled walker would be appropriate fall interventions for R21. 41970 a.)2.) R26's Minimum Data Set (MDS) dated [DATE] documents R26 as cognitively intact. This same MDS documents R26 as requiring limited assistance of one person for bed mobility and transfers. This same MDS documents medical diagnoses of Cerebral Vascular Accident (CVA) Left side affected, Congested Heart Failure and Left side Hemiplegia. R26's Care Plan does not include updated fall interventions after R26's 4/21/23 fall. R26's Nurse Progress Notes does not document a fall in April. R26's last nurse progress note was dated 3/23/23. R26's medical record does not document R26's 4/21/23 fall nor fall investigation. R26's Fall Risk assessment dated [DATE] documents R26 as a high fall risk. Facility Fall Analysis Log dated January-April 2023 does not document any falls for R26. On 04/23/23 at 8:30 AM R26 stated I fell the other day. I was sitting up on the side of the bed. I tried to raise up a bit to reach my phone. The bed shifted over so when I sat back down, I fell on the floor. The staff came and lifted me back up to sitting on the side of the bed again. They (staff) told me the bed was not locked. I did not get hurt thank goodness but that could have been bad. I can't use my Left arm or Left leg that well so I could have been really hurt. On 04/24/23 at 12:18 PM V2 Interim Director of Nurses (DON) stated she is unaware of R26 falling in recent history. (R26) is alert and oriented. If (R26) said he fell , then he did. We (facility) were just not aware of it. No one reported it. All falls should be investigated. The resident care plan should be updated with each fall with the new interventions added. I will have to educate (V3) Care Plan Coordinator to include the dates on all new items added to the careplan. I know the careplans do not include dates with the fall interventions but we (facility) are working on that. On 04/24/23 at 12:24 PM V1 Administrator stated (R26) is alert and oriented. This fall on 4/21/23 was never reported to me, it was never investigated and not included on the fall tracking because we (facility) did not know about it. On 4/25/23 at 1:30 PM V1 Administrator stated I spoke with (R26) about his fall on 4/21/23. (R26) told me the staff put his cellular phone on the bedside table but it was on the far side away from him so he could not reach it. (R26) said he was trying to reach for his phone when the bed rolled because it was unlocked so he fell . If the staff would have put (R26's) belongings within his reach, he never would have fallen. Another part of that problem was that the staff never reported this fall to me or (V2) Interim DON. The facility was not able to follow up, investigate the fall or update the care plan. We (facility) have to do better. The facility policy titled 'Fall Prevention' revised 11/10/2018 documents conduct fall assessments on the day of admission, quarterly and with a change in condition. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. Immediately after any resident falls the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with the new intervention on the CNA assignment worksheet. Reports all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. 32853 b.)1.) R102's Care Plan with an admitted [DATE] documents R102 has a self care deficit and needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs (Activities of Daily Living). R102's Minimum Data Set (MDS) dated [DATE] documents R102 requires limited assistance with mobility. On 4/24/23 at 10:05 AM, R102 was in R102's room in a high back chair with R102's feet up in R102's wheelchair. On 4/25/23 at 8:35 AM, the hot water temperature in R102's sink in the bathroom read 133.8 degrees Fahrenheit. 2.) R12's MDS dated [DATE] documents R12 requires supervision for mobility and that R12 has disorganized thinking. On 4/25/23 at 8:30 AM, R12 was wheeling R12's self around R12's room and hallway in R12's wheelchair. The hot water temperature in R12's sink in the bathroom read 137.6 degrees Fahrenheit. On 4/25/23 at 10:33 AM the hot water temperature in R12's room was 136.7 degrees Fahrenheit. 3.) R101's Care Plan dated 4/5/23 documents R101 has a self care deficit and requires supervision and/or assist to complete ADLs. On 4/23/23 at 9:53 AM, R101 was in R101's room sitting on the side of the bed. On 4/2523 at 8:35 AM, R101's water temperature in the sink in R101's bathroom was 133.8 degrees Fahrenheit. On 4/25/23 at 11:48 AM, V15 Maintenance Supervisor and V16 Sister facility Maintenance Supervisor checked the water temperature in R12's bathroom sink and the temperature was 136.5 degrees Fahrenheit. V16 stated the water temperatures should be checked weekly. V15 stated that V15 has only been at the facility two weeks and yesterday (4/24/23) was the first time V15 had checked the water temperatures in the facility. V15 and V16 confirmed the water temperature was too high and could cause burns to the residents. V16 stated that some residents do not know to add cold water to the hot so they could get burnt. V16 stated the water temperature should be 110-112 degrees Fahrenheit. 4.) R18's Physician Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Obesity and Obstructive Sleep Apnea. This POS documents and admitted [DATE]. On 4/23/23 at 9:15 AM, there was an oxygen tank leaning up against a dresser in R18's room. The tank was not flat on the floor and the tank was not secured in any cart or other device. On 4/24/23 at 11:09 AM, R18 was not in R18's room but the oxygen tank was still leaning up against the dresser unsecured. On 4/26/23 at 12:33 PM, V2 Interim Director of Nursing confirmed the oxygen tank was leaning against the dresser and should not be. V2 stated that the oxygen tank should be secured in it's cart.

Based on observation, interview, and record review the facility failed to monitor and record urinary catheter output for three (R39, R5, R8) residents. The facility also failed to document catheter care, ensure proper positioning of a urinary drainage bag, and timely treat a urinary tract infection for three (R39, R8, R10) residents. This failure affects four (R5, R8, R10, R39) of five residents reviewed for urinary tract infections and catheters in the sample list of 39. This failure resulted in R5 being hospitalized and diagnosed with a catheter malfunction and urinary tract infection. Findings include: A.1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment and requires extensive assistance of one person for toileting. R5's Care Plan dated 1/3/23 documents R5 has altered bladder elimination, neurogenic bladder, and a urinary catheter. Interventions include assess and report symptoms of urinary tract infections (fever, pressure, odorous urine, dark urine, pain, confusion, and abdominal distension), keep tubing free of kinks, intake and output every shift, and monitor/record changes in urine including urinary output. R5's Nursing Notes document the following: On 1/16/23 at 6:48 PM R5 complained of burning and penile pain. Orders were received to change and flush R5's urinary catheter and obtain a urine sample for culture and sensitivity. R5's catheter was changed and R5 did not have any urinary output. R5 complained of some discomfort during catheterization. There are no documented nursing notes again until 1/17/23 at 2:00 PM when R5 was transferred to the emergency room for vomiting and complaints of lower abdominal pain. R5's medical record does not document R5's urine output was recorded daily or each shift in January 2023. There is no documentation that the facility collected a urine sample before R5 was transferred to the emergency roiagnom on [DATE]. R5's Hospital Summary of Care dated 1/17/23 documents R5 presented to the emergency room for vomiting. R5's urinary catheter balloon was found to be inflated within the urethra, and could be the cause of R5's abdominal pain. R5's urinary catheter was repositioned/replaced and a urine specimen was collected. R5 was given intravenous fluids and intravenous antibiotics, and was discharged back to the facility. R5's Encounter Diagnoses are listed as Recurrent Urinary Tract Infection, Malfunction of urinary catheter, and Systemic Inflammatory Response Syndrome. R5's computed Tomography of the abdomen dated 1/17/23 at 5:18 PM documents R5's (Urinary) catheter is malpositioned with the balloon inflated within the urethra. Small amount of air within the urinary bladder which is likely related to the (urinary) catheter. R5's Urine Culture dated 1/18/23 documents the urine contained greater than 100,000 colony forming units/milliliter of Staphylococcus aureus (bacteria). On 4/24/23 at 8:59 AM V6 Licensed Practical Nurse (LPN) stated on 1/16/23 R5 had signs of urinary tract infection and V6 notified R5's physician. V6 changed R5's catheter and there was a minimal amount of urine returned. V6 stated there was not enough urine to collect a urine specimen. V6 stated R5 had some discomfort during catheterization, but R5 had been pulling on R5's catheter prior to catheterization. The next day R5 still had urinary tract infection symptoms, complained of abdominal pain, and V6 transferred R5 to the hospital. V6 was not aware that R5's urinary catheter balloon was found to be within R5's urethra. On 4/25/23 at 12:25 PM V2 Interim Director of Nursing (DON) stated urinary catheter output should be monitored and documented every shift on the output monitoring log. V2 stated if there is no urine output then the physician should be notified. On 4/25/23 at 12:40 PM V17 Nurse Practitioner stated the nurses should be monitoring residents with urinary catheters for signs of drainage, blood, and odorous urine. Urine output should be monitored and recorded at least once per shift. If there is no urine output for 6-8 hours, then they should notify the physician. If notified of decreased urine output soul recommend a bladder scan, palpation of the bladder, adjusting the catheter placement, and assessing for pain prior to transferring the resident to the hospital. These are interventions/treatments that could be performed and possibly prevent hospitalization . Decreased urine output could be a sign of a blockage or catheter malfunction. Urine stasis could contribute to the development of urinary tract infections. 2.) On 4/23/23 at 8:26 AM R8 stated staff provide R8's urinary catheter care, but was unsure how often the catheter tubing is cleaned. 04/26/23 10:21 AM V8 Certified Nursing Assistant (CNA) and V27 CNA transferred R8 from the recliner into bed with a full mechanical lift. During the transfer, R8's urinary drainage bag was hooked onto the mechanical lift sling and was positioned above R8's bladder. Urine backflowed from the urinary drainage bag tubing towards the catheter tubing. R8's urine contained white sediment. V8 cleansed R8's catheter tubing in a downward motion and raised R8's urinary drainage bag in the air, above R8's bladder. R8's urine in the drainage bag tubing backflowed into R8's urinary catheter tubing/bladder. R8's MDS dated [DATE] documents R8 is cognitively intact and requires extensive assistance of one staff person for toileting. R8's Care Plan revised 6/13/22 documents R8 has a suprapubic catheter (inserted through the abdomen) with interventions that include the use of tubing with anti-reflux valves, position the drainage bag below bladder level to prevent reflux, empty collection bag at least each shift and record urine output. R8's April 2023 Physician's Orders document an order for urinary catheter care to be completed every shift. R8's April 2023 Treatment Administration Record (TAR) does not document catheter care was administered on 16 shifts between 4/1/23 and 4/23/23. There is no documentation that urine output is documented each shift. On 4/26/23 at 10:35 AM V8 CNA stated the urinary drainage bag is suppose to be kept below the level of the resident's kidneys. V8 stated the CNAs are to do catheter care at least every shift and the urine output is reported to the nurse to document. V8 stated the CNAs do not document catheter care. On 4/26/23 at 10:45 AM V12 LPN provided the urinary catheter drainage bags that are used for R8. The drainage bag does not contain an antireflux valve. At 10:50 AM V2 DON confirmed R8's urinary drainage bags do not contain an antireflux valve (to prevent urine backflow into the catheter) at the connection port that connects to the urinary catheter. 3.) On 4/23/23 at 8:50 AM R39's urinary catheter tubing contained yellow urine with white sediment. R39 stated the CNAs perform R39's catheter care. R39's April 2023 Physician's Orders includes orders to perform catheter care every shift. R39's April 2023 TAR does not document catheter care was administered 16 shifts between 4/1/23 and 4/23/23. There is no documentation that R39's urine output is documented each shift. On 4/25/23 at 12:20 PM V4 LPN stated catheter care is documented on the Medication/Treatment Administration Record. V4 confirmed there is no documented urine output recorded for R8 and R39 for April 2023. On 4/26/23 at 9:45 AM V2 Interim DON stated the nurses should initial the Treatment Administration Record and document refusals by circling the initials and recording the refusal in nursing note. The facility's Intake and Output policy revised December 2021 documents the CNAs obtain urine output every 8 hours and report the output to the nurse to document on the intake and output record. 41970 4.) 04/26/23 08:59 AM R10's Physician Order Sheet (POS) dated April 1-30, 2023 documents medical diagnoses of Dysuria, Amnesia, Hypertension, Atrial Fibrillation, Chronic Kidney Disease Stage 3, Neuropathy and Macular Degeneration. R10's Cognitive assessment dated [DATE] documents R10 as cognitively intact. R10's Care Plan does not document updated interventions for R10's 4/19/23 medical diagnosis of Dysuria. R10's V23 Urology Progress Note dated 4/19/23 documents Chief complaint: Dysuria. Dysuria started a couple of days ago. Facility states there was blood in (R10's) incontinence brief. (R10) has burning and frequency of urination for two days with no abdominal pain no back pain, nausea, vomiting, fever or chills. Orders placed this encounter: Nitrofurantoin Monohydrate/Macrocrystals (Macrobid) 100 milligrams (mg) capsules and Phenazopyridine (Pyridium) 100 mg tablet. R10's Nurse Progress Note dated 4/19/23 at 3:06 PM documents (R10) out of facility earlier this shift with son, who transported (R10) to Urology appointments. (R10) had complained of frequency and discomfort. New order received from urologist. Macrobid and Pyridium therapy. Orders transcribed in Medication Administration Record (MAR) and communicated to oncoming nurse. R10's Medication Administration Record (MAR) dated April 1-30, 2023 documents a physician order dated 4/19/23 Macrobid 100 mg twice daily for seven days which was signed out as administered 4/20/23-4/26/23. This same MAR documents a physician order dated 4/19/23 100 mg three times per day for two days which was signed out as administered on 4/20/23-4/21/23. Facility Emergency Kit (Ekit) Contents Report documents Macrobid 50 mg capsules as being contained in EKit. On 04/23/23 at 1:36 PM R10 stated I was prescribed an antibiotic at (V23's) Urology office for my Urinary Tract Infection (UTI). R10 stated They (facility) let me wait an entire day before they (facility) gave me my antibiotic. (V23) Urologist told me I had a bad infection and needed treated immediately. I never had a problem with UTI's before I came in here (facility). But they (staff) make me wait to get changed so I just sit in pee. It is no wonder I got an infection. On 4/26/23 at 9:15 AM V12 Licensed Practical Nurse (LPN) stated (V20) (R10's) family member took (R10) to a Urology appointment on 4/19/23. (R10) came back with orders for Macrobid 100 milligrams (mg) twice daily for seven days and Pyridium 100 mg twice daily for two days. I worked day shift that day and I remember there was some kind of delay for (R10's) Macrobid and Pyridium because (R10) is private pay so her family gets all of her medications. I never received (R10's) medications from the family before I left that day. The night shift nurse may have, but I did not. The facility has a box which emergency kit that has the Macrobid in it but since (R10) is private pay, we (staff) are not supposed to use medications from the emergency box for private pay residents. On 4/26/23 at 9:35 AM V20 (R10's) family member stated (R10) made her own Urology appointment and then called me and asked me to take her. (R10) uses a wheechair so I came in to the facility and talked with them (staff). They (facility) took (R10) to the Urology appointment and I followed behind in my car. (V23) Urologist ordered two pills for (R10's) Urinary Tract Infection (UTI). One pill was an antibiotic and the other was for pain for (R10's) UTI. (V24) facility van driver drove (R10) back to the facility after her appointment. (V24) van driver had one of the bottles of pills with her to take back to the facility. After (V24) van driver got back to the facility, they (facility) called me and said that (V23's) office only filled one of the prescriptions and that they (facility) couldn't give one of the pills without the other. So I drove back to the clinic and had the other prescription filled. (V24) facility van driver met me back at the clinic so I didn't have to drive all the way across town again. I gave the pills to (V24) facility van driver. I did all that so that (R10) could get both of her medications started that same night of the appointment with (V23) Urologist. On 4/26/23 at 9:40 AM V21 Registered Nurse stated V21 worked night shift the evening of 4/19/23. V21 RN stated I have no knowledge of any pills being brought to the facility for (R10). Normally after hours the North hall nurse would answer the door and if there were any medications left for any of my residents, the north hall nurse would let me know and I would have to check them in. I don't remember if there were any medications brought to me but I don't think that they were. On 4/26/23 at 9:45 AM V10 Registered Nurse (RN) stated I remember that next morning when I came in I heard about (R10) being started on the Macrobid and Pyridium. There was some talk about the family having brought it in since (R10) is private pay so I checked the medication cart for her hall and the Macrobid and Pyridium were both in bottles sitting in the top drawer. The facility does keep the Macrobid in the emergency box but since (R10) is private pay we (staff) would have the family bring the medication in since they (family) would have to pay for it. We (staff) are not supposed to use the emergency box medications for private pay residents. I would if I had to but the family did bring in both medications the evening of 4/19/23. I am not sure why (V21) RN did not start those medications. V10 RN stated There is not a Urinalysis or Culture for (R10) but I can look in the hospital systems records to try to find out about those. On 4/26/23 at 10:45 AM V1 Administrator stated (V24) facility van driver should not be transporting medications for residents. (R10's) Macrobid and Pyridium should have both been delivered to facility by a pharmacy. On 4/26/23 at 2:00 PM V2 Interim Director of Nurses (DON) stated the facility did not follow up on R10's Dysuria that was treated with Macrobid (antibiotic). V2 stated there is no way to know if the antibiotic is working or not without having a Urinalysis or Culture and Sensitivity completed. V2 stated the facility should have followed up with (V23's) Urology office but did not.

Based on observation, interview and record review the facility failed to follow a Physician's Order and weigh a resident daily to monitor for fluid overload for one of one resident (R103) reviewed for Edema in the sample list of 39. This failure resulted in R103 being hospitalized for five days for Congestive Heart Failure exacerbation. Findings include: The facility's Laboratory Tests policy with a review date of 9/27/17 documents, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. R103's Physician's Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses of Congestive Heart Failure and Left Lower Extremity Cellulitis. This POS documents an order to weigh once daily and notify Physician if a three pound weight gain in one day or five pounds in one week. R103's Minimum Data Set, dated dated dated [DATE] documents diagnoses including Atrial Fibrillation, Heart Failure and Hypertension. R103's Treatment Administration Sheet (TAR) dated 3/1/23 through 3/31/23 documents an order dated 2/3/23 to weigh once daily and notify Physician if a 3 pound gain in one day or a 5 pound gain in one week. There are no weights recorded on this TAR from 3/1/23 to 3/31/23. R103's TAR dated 4/1/23 through 4/30/23 documents the same order with a start date of 2/3/23 to weigh once daily and notify the Physician if there is a 3 pound weight gain in one day or a 5 pound gain in one week. This TAR has no weights documented from 4/1/23 to 4/23/23. The facility's Monthly Weight Grid for May 2022 through April 2023 documents R103's weight in March 2023 was 119 pounds and then R103's weight in April 2023 was 146.6 pounds. R103's Nurse's Notes dated 4/6/23 at 6:00 PM documents R103 had a doctor's appointment and documents R103 was admitted to the hospital following the appointment and the note is signed by V6 Licensed Practical Nurse. R103's Cardiology Office Visit note dated 4/6/23 documents R103 stated that R103's legs felt much more swollen than when R103 discharged from the hospital. V30 Cardiology Advanced Practice Registered Nurse documents that R103 has orders for the facility to notify the Physician if R103's weight increases 2-3 pounds in 25 hours or 5 pounds in one week. V30 documents there has been no encounters where the extended care facility has notified them of any weight gain. V30 documents R103's weight was 135 pounds on 2/2/23 and on this day (4/6/23) it was 142 pounds. V30 documents the physical exam for R103 demonstrates +(plus) 2-3 edema to lower legs and a skin tear with oozing of serous fluid to the right anterior lower leg. V30 documents R103 appears fluid overloaded. Oxygen was 73% (percent) on arrival. R103 has worsening peripheral edema and dyspnea (shortness of breath) on exertion. Send R103 to the emergency department for diuresis and further evaluation. R103's hospital discharge orders dated 4/11/23 documents R103 was admitted since 4/6/23 and documents orders to weigh daily and monitor blood pressure, look for signs and symptoms of heart failure such as shortness of breath, swelling of feet and legs and swollen or tender abdomen. Call provider if symptoms develop or if you gain more than 3 pounds in a day or 5 pounds in a week. R103's Nurse's Notes dated 4/11/23 documents R103 arrived at the facility at 5:02 PM and R103's admitting diagnosis was Acute Exacerbation of Congestive Heart Failure. On 4/25/23 at 11:44 AM, V22 Restorative Certified Nursing Assistant stated that V22 completes the weekly and monthly weights but the daily weights are supposed to be completed by the floor Certified Nursing Assistants (CNA). On 4/26/23 at 2:21 PM, V1 Administrator in Training stated that V22 Restorative CNA is supposed to complete the daily weights and V2 Interim Director of Nursing stated that if there is an order for daily weights they should be getting completed.

Based on observation, interview and record review the facility failed to provide adequate nutrition, identify significant weight loss, complete dietary assessments, intervene and follow up with the physician and dietician for residents. These failures affect four (R5, R28, R45, R1) of four residents reviewed for weight loss and nutrition from a total sample list of 39. These failures resulted in significant weight losses for R5, R28 and R45. Findings include: 1.) R28's diagnosis include: falls, dementia, hypertension, gastroesophageal reflux, Osteoporosis, hiatal hernia, Barretts esophagus. On 4/22/23 at 12:45PM, after R28 had left the dining room, her plate was observed to have more than 90 percent of her food left on the plate. On 4/23/23 at 12:47PM, R28 was sitting at lunch with plate in front of her with no one attempting to assist her to eat. V28 Certified Nursing Assistant (CNA) gave R28 one bite of dessert and then said, She doesn't eat well for us. Usually her husband comes to feed her, and then V28 CNA left the table. On 4/23/23 at 1:30PM, after residents had left the dining room, V5 Dietary Manager confirmed that R28 had only bite eaten from her plate. On 4/24/23 at 8:33AM, R28 was sitting at a dining room table with 3 other residents with a full plate of food. Staff are walking beside resident without assisting R28. R1, R28's table mate, began to feed R28. R28 continued to eat what R1 fed her. On 4/25/23 at 11:45AM, V13 Dietician said that she did not know anything about R28's weight loss until 4/24/23 when the facility dietary manager called her to inform her of R28's weight loss. V13 Dietician said that she had not completed an assessment on R28, had never been a part of a weight meeting, and had not sent any recommendations for R28. V13 Dietician said that prior to the current dietary manager, the facility would not communicate with her about resident dietary needs. Now, V5 dietary manager is communicating with me well, but she just started. The facility provided monthly weight grid document's R28's weights as the following in pounds: October 2022: 176.5, November: 178.6, December 2022: 178.2, January 2023: 170.0, February 2023: 167.10, March 2023: 160.10, and April 2023: 152.5. The above weight losses are calculated at a 10.29 percent weight loss from January 2023 to April 2023 and a 13.6 percent weight loss from October 2022 to April 2023. R28's undated care plan documents that R28 demonstrates dependency on a caregiver to assist with eating. The facility, Resident Weight Monitoring Policy dated 3/19 documents that if there is an actual significant weight change, the resident, the power of attorney for health care, the physician and the dietician will be notified. The food service manager and interdisciplinary team will review the resident's weights and nutritional status and make recommendations for intervention. The dietician shall review and document all significant weight changes along with any recommended nutritional intervention in the dietary progress notes, in the medical record monthly. Significant weight changes are reviewed in the weekly weight committee meeting. The weight committee will also identify any trend of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. On 4/25/23 at 12:00PM, V13 Dietician stated, With (R28's) significant weight loss, we might have been able to prevent it. If she needs assistance with feeding, that needs to occur and I also need to be made aware of these residents so that I can intervene before the weight loss. With the system that they have had in place, I didn't know who needed to be seen and who didn't. 32853 2.) R45's Physician Order Sheet (POS)dated 4/1/23 through 4/30/23 documents diagnoses including Physical Deconditioning, Diabetes Type 2, End Stage Renal Disease, Hiatal Hernia and Gastroesophageal Reflux. This POS documents Diet Orders of No Added Salt, Carbohydrate Controlled Diet, Regular Consistency, Fortified Milk Shake Twice Daily and 1500 ml (milliliters)/day Fluid Restriction. The facility's Monthly Weight Grid May 2022 through April 2023 documents R45's weight for February 2023 as 154.2 pounds, March 2023 as 139.4 pounds and April as 127.6 pounds. This indicates a 9.6% weight loss in 30 days and a 17.25% weight loss in 60 days. R45's medical record documents a Dietary Services Communication form completed by V13 Dietician documents R45 has experienced a significant weight loss times three months and documents R45 was refusing meals and supplements. This form documents Dietary Recommendations that V13 discussed with R45 and R45 agreed to take a (liquid protein supplement) 90 ml (milliliter) twice a day and add a grape nutritious juice. This form is dated 3/19/23 and signed by V13. This form has a place for the Physician to approve and sign and that is blank. R45's Medication Administration Record dated 4/1/23 through 4/30/23 and R45's Treatment Administration Record dated 4/1/23 through 4/30/23 do not document an order for a liquid protein supplement or a grape nutritious juice. On 4/24/23 at 4:05 PM, V8 Dietary Manager stated that V8 has never seen the Dietary Services Communication dated 3/19/23 for R45 signed by V13. On 4/25/23 at 12:03 PM, V13 confirmed that V13 made these recommendation and that they should have been sent to the Physician to get an order and then should have been implemented. V13 stated that V13 filled out the communication form and put in the Director of Nurse's box as requested by the Director of Nursing. R45's Dietary meal tray card documents R45 should have a Fortified Milk Shake at lunch and dinner. On 4/23/23 at 1:04 PM, R45 had R45's meal tray in R45's room. R45 had a pork chop, stuffing, sweet potatoes, roll, two bowls of chicken noodle soup, lemon pie, applesauce, saltine crackers, lemonade and water. There was no Fortified Milk Shake on R45's tray. On 4/24/23 R45 went to dialysis after breakfast. R45 did not receive a Fortified Milk Shake with the breakfast tray this day. R45 will not be in the facility for lunch so R45 will not receive a Fortified Milk Shake at lunch on this day. On 4/26/23 at 2:21 PM, V2 Interim Director of Nursing stated that staff should be following Dietician recommendations. 40385 3.) The facility's Weight Report dated May 2022 - April 2023 documents R5's weights as follows: August 192 lbs. (pounds), September 195.2, October 184.2 (5.6% loss in 1 month), November 186, December is not recorded, January 171.4, February 161.6 (13.12% loss in 3 months/15.83% loss in 6 months), March 164.4, and April 164. R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment, R5's current weight is 160 pounds, and R5 has not had a significant weight loss within the last month or last 6 months. R5's undated Care Plan problem area for Nutrition, documents the following: R5 is at risk for altered nutritional status and/or weight loss. R5 has had a decline with significant weight loss within the last 6 months and is on a No Added Salt Diet. The following undated interventions are listed as provide diet as ordered, refer to the Physician's Order Sheet (POS) for diet order, honor food preferences and dislikes, offer snack at bedtime and record amount consumed, monitor weights monthly or per the Registered Dietitian's (RD) recommendation, report significant weight changes to the physician and RD, follow the RD's recommendations, and assess current diet tolerance related to recent nausea/vomiting/diarrhea. R5's medical record does not document that R5's additional significant weight loss after October 2022 was reported to the physician and RD. There are no completed nutritional/dietary assessments after 6/23/22. R5's medical record does not document R5's weights between 10/12/22 and 12/31/22. R5's Physician Notification of Weight Change dated 10/12/22 documents R5 diet was regular and No Added Salt. The physician was notified of the one month weight loss of 5.64% loss and the interdisciplinary team recommended to continue to monitor R5's weights weekly for 4 weeks. R5's April 2023 Physician's Orders documents R5's diet as No Added Salt, thin liquids, and may have meal of the month on special occasions. There is no documentation that R5 has nutritional supplements/fortified foods as part of R5's diet. On 4/24/23 at 8:39 AM R5 was eating in the main dining room. R5's meal tray did not include any supplements/fortified foods. R5's dietary card does not document R5's diet includes supplements or fortified foods. On 4/24/23 at 3:48 PM V2 Interim Director of Nursing (DON) stated when there is significant weight loss we notify the RD and physician and document the notification in the nursing notes. Nutritional interventions and the RD's recommendations are implemented. On 4/24/23 at 4:00 PM V2 stated the RD's recommendations are submitted to V2 by electronic mail and nursing follows up on getting approval from the physician to implement the recommendations. An order is then written and transcribed onto the POS and nutritional interventions are documented on the care plan. V2 reviewed R5's POS and Care Plan and confirmed there are no documented nutritional supplements or nutritional interventions to address R5's significant weight loss. On 4/25/23 at 12:25 PM V2 stated V2 was unable to locate any documentation of follow up, notification, and interventions to address R5's significant weight loss after October 2022. On 4/25/23 at 2:05 PM V2 stated V2 provided all of the weights that V2 could locate for R5 within the last year and confirmed there were no weights documented in R5's medical record between October 2022 and December 2022. On 4/24/23 at 3:52 PM V5 Dietary Manager stated the RD comes to the facility twice per month. V5 stated nutritional assessments are completed quarterly and annually. R5 had a Urinary Tract Infection and was hospitalized around the time of R5's significant weight loss noted in October. The RD emails us the nutritional recommendations. The recommendations are placed in the resident's medical record. V5 gives the RD recommendations to the DON to review with the physician and implement the RD's recommended nutritional supplements. We did a weight review on R5 in January, and I thought we added a frozen nutritional supplement and nutritional juices. On 4/24/23 at 4:15 PM V3 Care Plan Coordinator stated significant weight loss is documented on the MDS and confirmed R5's January 2023 MDS does not identify R5's significant weight loss. On 4/25/23 at 11:53 AM V13 RD stated the facility has been inconsistent with reporting resident weight loss. The Dietary Manager is suppose to send V13 a list of residents to see at each visit and V13 expects to be notified of significant weight loss noted for 30, 90, and 180 days. V13 was not given a notification to evaluate R5 after November 2022. V13 stated V13 last evaluated R5 on 11/24/23 and completed a nutritional assessment at that time. V13 recommended a high calorie nutritional shake to be given three times daily with meals. V13's assessments are documented in the dietary section of the resident's medical record, and there have been issues with documentation being removed or missing from the records. Nutritional assessments are completed annually, quarterly, and with any significant weight changes. V13 is not always notified when the resident's annual assessment is due. V13 stated V13 would expect the health shakes to have been continued until R5 either refused them or R5's weight increased. V13 would recommend weekly weight monitoring if the resident is trending weight loss. V13 confirmed if R5's nutritional recommendations were implemented it could have prevented additional weight loss. The facility's Resident Weight Monitoring policy dated as revised March 2019 documents weights are obtained monthly and reviewed by the Dietary Manager and DON by the 8th of the month. Monthly weights are recorded on the monthly weight report in the progress notes section of the resident's medical record. Significant weight loss of 5% or more in one month, 7.5% or more in 3 months, and 10% or more in 6 months are reported to the physician and dietitian. The resident's weights and nutritional status is reviewed by the dietary manager, interdisciplinary team, and dietitian, and interventions are recommended/implemented. The dietitian documents review, weight changes, and recommended nutritional interventions monthly in the dietary progress notes. Nursing is responsible to report the nutritional recommendations to the physician to obtain orders.

Failures at this level require more than one deficient practice statement. These failures resulted in an Immediate Jeopardy. A. Based on observation, interview and record review the facility failed to provide targeted interventions to prevent repetitive burn injuries for R1, a resident with a history of tremors and burns from hot liquids. This failure resulted in a second degree burn on R1's left forearm. This failure affects one (R1) of three residents reviewed for accidents and supervision in a sample list of 9 residents. The Immediate Jeopardy began on 1/6/23 when the facility failed to implement interventions to prevent R1 from burning himself. V1 Regional Director of Clinical Operations was notified of the Immediate Jeopardy on 1/25/23 at 12:55PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 1/25/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: a) R1's diagnoses include: Parkinson's disease, Dementia, Schizophrenia, Congestive Heart Failure, Benign Prostatic Hypertension, Severe Bipolar Affective Disorder with Psychosis, and Dysphasia. R1's physician order for medications for tremors include: Carbi-Levodopa 25/100 four times daily and Rasaginine Mesylate 1 milligram daily (both taken since 8/29/22) On 1/24/23 at 12:05 PM, V7 Certified Nursing Assistant stated, Oh yes, (R1) has tremors when he eats and drinks. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as moderately cognitively intact, requiring set up and supervision for meals. On 1/5/23 at 2:45 PM, R1's change of condition report documents R1 spilled hot chocolate on his clothing resulting in reddened skin on his right arm and pain. On 1/6/23, the facility quality committee minutes document that R1 is having tremors and recommended interventions including using reusable cups, ice to cool drink and a sipping cup lid. R1's care plan dated 1/6/23 documents interventions of a sipping cup lid for drinks, a regular coffee cup and ice to cool down the drinks. On 1/24/23 at 9:30 AM, V2 Wound Nurse stated, On 1/10/23 early in the morning, R1 showed me the burn on his arm. He told me that he got burned from the hot chocolate at dinner but that he couldn't remember if anyone was around when it happened. He could not tell me if he told anyone. He just kept saying the Parkinson's, the Parkinson's. No one would [NAME] up to knowing when it happened. It had to have happened at supper (on 1/9/23). I didn't talk to the nurse on duty that night and I didn't document my interviews. I got an order from the doctor for treatment and had the medicine in hand 4 hours after I was made aware of the burn. I was horrified by the size and tissue damage. I know that they temperature checked the hot liquids that morning after they heard about the burn. On 1/10/23 at 6:55 AM, R1's change of condition report documents that R1 presented to V2 wound nurse with a burn on his left forearm measuring 8.2 centimeters by 2.8 centimeters with an unknown depth. The physician was notified and orders were received to cleanse the wound with normal saline, apply Silvadene ointment and cover daily. On 1/10/23 V6 Nurse Practitioner made an urgent visit to evaluate R1's burn. V6 Nurse Practitioner's Note documents that R1 has a partial thickness burn covered in eschar with a few blisters. The Note documents (R1) does have some tremors, this could have been how he spilled the hot chocolate. Spoke with nursing staff about more safety measure regarding hot liquids due to his tremor and high risk of injury. On 1/24/23 at 9:25 AM, R1 received wound care to his left forearm burn. The area was observed to have a burn pattern splatter mark approximately 8 centimeters in length by 3 centimeters in width with a deep purple and red coloring surrounding the open scab area that was the size of half a dime. The wound was cleansed by V2 wound nurse and then Silvadene ointment was applied and covered. R1 stated, It hurt but it doesn't now. It was hot! On 1/24/23 at 12:00 PM, V2 wound nurse stated, We ordered a sipping lid, but there weren't any available in the facility. So no, on 1/9/23 and 1/10/23, R1 didn't have the lid yet. I can't say if they put ice in his drink that night, but it still burned him. On 1/24/23 at 9:50 AM. V5 Dietary Manager stated, I tempted the water for the hot chocolate that morning of the (second) burn (1/10/23) and it was 176 degrees (Fahrenheit). On 1/30/23 at 1:00 PM, V11 Regional Administrator stated that hot drinks should be served at no more than 140 degrees Fahrenheit for safety. On 1/24/22 at 9:55 AM, the hot chocolate water was temperature checked by facility staff measuring 172.6 degrees Fahrenheit. On 1/24/23 at 12:00 PM, R1 was sitting in the dining room at a table by himself, across the room from the nurse's station. On 1/24/23 at 12:06 PM, V2 wound nurse/director of nursing stated, (R1's) interventions weren't put into place like they should have been and I really don't like (R1) sitting so far from the nurse's station when he eats. On 1/24/23 at 2:42PM, V4 Physician stated, I was not aware of the first burn. They should have told me about it. I was aware of the second burn and the way it was described to me, it was a second degree burn. They should have implemented interventions to prevent another burn. It was potentially preventable. The immediate jeopardy that began on 1/6/23 was removed on 1/25/23 when the facility took the following actions to remove the immediacy. 1. On 1/10/2023 all staff were in-serviced on emergency care for burns, food temperatures, and newly acquired skin conditions by V1 Regional Director of Clinical Operations. 2. Residents no longer allowed drinking coffee/hot chocolate in their rooms when in bed. They must be upright at an over bed table or dining room table. Confirmed by V1, V12 Regional Administrator and direct care staff. 3. All residents will be supervised while consuming a meal on a hall tray, room tray or dining room tray. Confirmed by V1, V12 and direct care staff. 4. On 1/25/2023 all staff were in-serviced on emergency care of burns, food temperatures, staff expectations on room/hall trays, and notification of change in conditions, newly acquired skin conditions, comprehensive care planning, and the care needs notice by V1 Regional Director of Clinical Operations. 5. On 1/25/23, V2 Director of Nursing and V12 Regional Administrator were in-serviced on Incident Investigations by V1 Regional Director of Clinical Operations. 6. R1's orders and care plan were updated to include lidded cups for all drinks for safety. Completed on 1/10/23. 7. The facility initiated the use of the Care Need notice for care plan revisions to better communicate changes to the care plan to direct care staff. Completed on 1/10/23 and ongoing. 8. The quality assurance team will conduct random rounds to ensure residents and staff are following the room tray/hall tray and dining room observations. Confirmed by V1 and V12. Daily meetings will be held. 9. V12 Regional Administrator or designee will educate new staff members and new residents on the room tray/hall and dining room tray expectations. As needed. 10. V12 Regional Administrator or designee will in-service staff on emergency care of burns, food temperatures, staff expectations on room/hall/dining room trays, newly acquired skin conditions and notification of change in conditions weekly x 4 weeks and then monthly times 3 months starting 1/31/2023 11. As part of ongoing quality improvement V12 Administrator and/or V2 Director of Nursing will conduct random temperature audits of hot drinks being served from the dietary department to determine if hot beverages are being served in the normal range. To begin on January 31, 2023. 12. Dietary staff will be randomly testing hot liquid temperatures and using ice to decrease the temperature in liquids found hotter than 140 degrees. Started on 1/30/23. B. Based on observation, interview and record review the facility failed to prevent a burn for R2, a resident with known hand weakness, resulting in a burn on R2's hand. These failures affect one (R2) of three residents reviewed for accidents and supervision from a total sample list of 9 residents. Findings include: b) R2's undated face sheet documents diagnoses including: Chronic Obstructive Pulmonary Disease, Weakness, Chronic Embolism and Thrombosis of deep veins, End Stage Renal Disease requiring Hemodialysis, Non-Hodgkin's Lymphoma, Anemia, Vitamin D deficiency, Peripheral Vascular Disease, Coronary Artery Disease, and Hypertension. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as cognitively intact requiring supervision for eating and drinking. R2's admission prescreen for violence dated 11/22/22 documents, Resident is weak in the hands and arms. He does have weakness in his legs and can't stand for long period of time. He has to use the left hand to control his right hand to eat. He can't write. R2's Dietary Notes dated 12/14/22 document, Family talked with administrator. At home, (R2) worked with cups with handles. They also asked for grips to be added to his silverware like he had in the hospital. Occupational Therapy agrees and also recommended an edged plate to help keep food from hitting the floor. No interventions to prevent burns were put into place from admission until 1/6/23. R2's quality meeting note dated 1/6/23 documents that on 1/5/23 R2 was drinking hot coffee from a foam cup and put a finger through the cup. R2's physician order dated 1/5/23 documents an order for triple antibiotic ointment and bordered gauze for the wound. R2's wound tracking documents on 1/5/23 a 1.4 centimeter by 1.1 centimeter by .1 centimeter right index finger burn. On 1/25/23 at 2:40 PM, R2 stated that he put his finger through the foam cup and the coffee burned his right index finger leaving it with a blister. R2 said that he has neuropathy and that the coffee also spilled on his lap but it didn't burn him through his clothes. R2 stated that this happened in the dining room and that he usually reminded staff that he used a regular cup, but that they gave him the foam and he didn't want to complain. On 1/25/23 at 2:45 PM, R2 demonstrated where the burn occurred on the right index finger. A scab the size of a dime was seen with redness around the area of the scab. R2's care plan, dated 1/9/23 documents interventions to prevent future burns including using a mug with a handle. Occupational therapy documented an order for R2's coffee cups to have a lid with a straw for all drinks on 1/20/23.

Based on observation, interview and record review the facility failed to complete pressure ulcer treatments as ordered, complete weekly pressure ulcer monitoring, thoroughly assess pressure ulcers upon admission, obtain treatment orders for a newly identified wound and have documentation of identification of a new wound for two of four residents (R5, R4) reviewed for pressure ulcers in the sample list of nine. This failure resulted in R5's unstageable pressure ulcer deteriorating and increasing in size. Findings include: The facility's Pressure Sore Prevention Guidelines policy with a revised date of January/2018 documents, Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. The facility's Aseptic Wound and Skin Treatment Procedure with a revised date of January/2018 documents, Purpose: To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. Document procedure on treatment sheet. 1.) R5's Physician's Order Sheet dated 11/1/22 through 11/30/22 documents diagnoses including Skin Picking, Advanced Dementia, Neuropathy, Obesity and Diabetes. R5's Physician's Order dated 11/30/22 documents a treatment order for the left heel to cleanse with normal saline, pat dry, apply calcium alginate, cover with a foam dressing, secure with rolled gauze and change daily. R5's Physician's Order dated 11/30/22 documents a treatment order for the right buttock to cleanse with normal saline, pat dry, apply calcium alginate, cover with a bordered foam dressing and change daily. R5's Physician's Order dated 11/30/22 documents a treatment order for the right heel to cleanse with normal saline, pat dry, cover with a foam dressing and change three times a week. R5's Treatment Administration Record dated 12/1/22 through 12/31/22 documents an order to apply skin protective wipe every shift and documents three shifts, 10:00 PM to 6:00 AM, 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. There are not signatures indicating this treatment was completed at all in December. This Treatment Administration Record documents an order for the right heel to cleanse with normal saline, pat dry, apply three times a week and documents to be completed on the 10:00 PM to 6:00 AM shift and is to be completed on 12/2/22, 12/5/22, 12/7/22 and 12/9/22. This treatment is not signed out as completed on 12/5/22. On 12/6/22 at 1:55 PM, V12 Licensed Practical Nurse removed R5's left heel protector boot and the dressing that was on the left foot was dated 12/3/22. The dressing had drainage soaking through. V12 confirmed the date was 12/3/22 and was supposed to have been changed on 12/5/22 but was not and confirmed there was drainage soaking through the dressing. R5's medical record contains Wound Evaluations from V18 Wound Physician. R4's Wound Evaluation dated 10/26/22 documents the Unstageable Left Heel wound measured 4.5 cm (centimeters) x (by) 8 cm. There is no other wound measurements or assessments until 11/16/22, 21 days later. R5's Wound Evaluation dated 11/16/22 documents the Unstageable Left Heel wound measured 6.5 cm x 10 cm x 0.1 cm and wound progress is documented as Deteriorated. On 12/6/22 at 2:35 PM, V3 Regional Administration confirmed that R5's chart did not contain a thorough assessment of R5's wounds on admission. V3 stated V3 could only find the depth of R5's Left Ischium wound and no other measurements or characteristics. 2.) R4's Physician's Order Sheet (POS) dated 12/1/22 through 12/31/22 documents diagnoses including Left Ischium Stage Four Pressure Ulcer, Cellulitis of Left Lower Extremity, Diabetes Type 2, Infected Wound and Chronic Kidney Disease. R4's POS documents treatment orders dated 11/30/22 for the Left Ischium to cleanse with normal saline, pat dry, pack with rolled gauze soaked in 1/4 strength bleach solution, cover with abdominal pad and change twice a day; the Sacrum to cleanse with normal saline, pat dry, apply calcium alginate, cover with foam dressing and change daily; the right ankle to cleanse with normal saline, pat dry, apply calcium alginate, cover with foam dressing and change three times a week; the left heel to cleanse with normal saline, pat dry, apply foam dressing and change three times a week; the left anterior leg to cleanse with normal saline, pat dry, apply calcium alginate, cover with an abdominal pad and change three times a week; the right anterior leg to cleanse with normal saline, pat dry, apply calcium alginate, cover with a silicone foam bordered dressing and change three times a week. R4's Nursing Admission assessment dated [DATE] at 8:15 PM does not document a thorough assessment of all of R4's wounds. The area on the left Ischium has no measurements for width or length. The depth is measured at 7 centimeters but no other characteristics are identified. R4's Treatment Administration Record (TAR) dated 11/18/22 through 11/30/22 documents R4 daily skin check was not signed off as completed on 11/22/22 and 11/30/22. This TAR documents R4's Right Ischium treatment was not signed off as completed on the evening shift of 11/22/22 and 11/23/22 and both shifts on 11/30/22. R4's TAR documents R4's Left Lower Extremity treatment was not signed off as completed on 11/30/22. R4's TAR documents R4's Left Heel treatment was not signed off as completed on 11/30/22. R4's TAR documents R4's Right Leg and Right Foot treatment was not signed off as completed on 11/22/22 and 11/30/22. R4's TAR documents R4's Right Heel treatment was not signed off as completed on 11/22/22 and 11/30/22. R4's TAR documents R4's Left Ischium treatments was not signed off as completed on 11/22/22 both shifts, 11/23/22 both shifts, 11/24/22, 11/25/22, 11/26/22, 11/27/22 on the evening shift and 11/30/22 on both shifts. R4's TAR documents R4's Left Buttock treatment was not signed off as completed on 11/22/22, 11/23/22 and 11/30/22. R4's TAR dated 12/1/22 through 12/31/22 documents R4's Left Ischium treatment was not signed off as completed on 12/5/22 on the evening shift. On 12/5/22 at 4:00 PM, R4 stated that the nurses do not change R4's dressing as they are ordered to be changed. R4 stated the dressings were not changed last night (12/4/22) and had not yet been changed this day (12/5/22). R4 stated R4 really wants the wounds to heal so that they do not have to be treated when R4 goes home. R4's Physician visit with V17 R4's Physician on 11/22/22 documents R4 was concerned that R4's dressings have not been changed consistently since R4 was admitted to the facility. On 12/6/22 at 8:15 AM, V8 Licensed Practical Nurse (LPN) completed dressing changes for R4. When V8 removed R4's incontinent brief and there was a new open area on the right buttocks approximately 0.5 cm (centimeters) circular shape. V8 stated that V8 noticed that area yesterday and left a message for V18 Wound Physician regarding this new area but V8 stated V8 has not received a reply back. V8 confirmed there is no treatment order for this area and V8 did not complete a treatment for this area. V8 left this new area open and put a clean incontinence brief on R4. R4's Minimum Data Set (MDS) dated [DATE] does not document any of the wounds that R4 had on admission. On 12/7/22 at 10:45 AM, R4 stated that the nurses miss doing some of R4's treatments. On 12/7/22 at 1:00 PM, V8 LPN confirmed there is still no treatment orders for R4's new wound on R4's buttocks. V8 stated that V18 Wound Physician will be back to the facility on [DATE]. The facility's Resident Council Meeting Minutes dated 9/23/22 documents concerns regarding wound not being done. On 12/7/22 at 1:45 PM, V3 confirmed the nurse are to sign their initials on the Treatment Administration Record when they complete a treatment. V3 confirmed the Treatment Records are not complete.

Based on observation, interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 being admitted to a local hospital with chest incision and right lower leg infection requiring intravenous antibiotic medication. Findings include: R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Emergency Department notes dated 5/31/22, document R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge transfer orders dated 5/26/22, document R1 going to a Skilled Nursing facility on this day with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation in R1's Nursing notes for R1 admission. The only Nursing Notes in R1's medical record are on 5/28/22 at 2:40 PM, 5/29/22 at 3:30 PM, 5/29/22 2-10 PM, 5/30/22 at 1:40 PM, 5/30/22 at 10:00 PM, 5/31/22 at 4:00 AM, and 5/31/22 at 10:50 AM. R1's Medical Administration Record (MAR) dated 5/26/22, documents no medications were given to R1 on this date. The medications include: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)],Certrizine, [MEDICATION(S)],[MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] Sulfate, and Testosterone not given 5/27/22 through 5/31/22. R1's MAR documents an order on 5/29/22, for [MEDICATION(S)] 300 milligrams (mg) by mouth three times a day for 7 days. This medication was not given on on 5/29/22. This medication was observed to be in the facility's convenience box in the medication room on 8/4/22 at 11:30 AM, having 6 capsules available for use. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An order on 5/30/22 was given to discontinue [MEDICATION(S)] (due to allergy) and start [MEDICATION(S)] 100 mg by mouth twice a day for 7 days. R1's MAR documents [MEDICATION(S)] only being given on 5/31/22 at 1200 noon. [MEDICATION(S)] was also observed in the convenience box on 8/4/22 at 11:30 AM, having 6 capsules available for use. R1's discharge orders from 5/26/22 document orders for a fluid restriction of 2 liters or less in 24 hours, which there is no documentation of this order being carried out 5/26/22 through 5/31/22. There are no dietary/nutrition notes in R1's chart. Another order from R1's discharge orders documents to walk a minimum of three times a day. On 8/9/22 at 9:27 AM, V8 Physical Therapy Assistant (PTA) stated R1 walked 175 feet one time on 5/29/22 and walked 25 feet one time on 5/30/22. An order from R1's discharge orders documents to use the incentive spirometer 10-15 breaths every 1-2 hours, there is no documentation of this being done 5/26/22 through 5/31/22. These discharge orders also document wound care for chest tube care - wash daily and cover with dry dressing, examine wounds everyday; chest incision - use clean washcloth, wipe down chest incision once with soap and water, use another clean washcloth and rinse incision starting at the top and going down incisions, pat dry with clean towel; leg incision - clean each leg incision separately, start with lowest incision, wipe each incision from top to bottom, dry incisions with clean washcloth, leave open to air unless drainage, apply gauze 4 x 4 to any incisions where skin touches groin or draining, change everyday as needed, also apply 4 x 4 or absorbent cloth between and under breasts. There is no documentation in R1's chart documenting these orders were carried out. There is no Treatment Administration Record (TAR) in R1's medical record so no documentation of any treatments being completed. R1's Nursing Notes dated 5/31/22 document, R1 was sent to the Emergency Department (ED) on 5/31/22 at 10:50 AM due to R1 experiencing discomfort with right lower extremity with redness, swelling, and warmth. On 8/4/22 at 10:21 AM, V4 Nurse Practitioner, stated no one saw R1 from 5/26/22 until 5/31/22. V4 stated R1 should have been seen within 1-2 days especially the reason R1 was at the facility (post-coronary artery bypass graft). V4 stated R1 should have been seen before 5/31/22 by myself (V4) or the doctor V5. V4 stated R1 needed to be sent to the ED due to R1's sternum surgical area looking infected and had drainage. V4 stated V4 did not look at R1's legs at that time. V4 stated V4 did not do any type of note in R1's chart about what was going on with R1. R1's ED notes dated 5/31/22, document: patient had triple bypass and mitral valve repair on 5/19/22, discharged to long term care facility on 5/26/22, sent to ED for concern for infection at the surgical sites, patient had wound care nurse see R1 over the weekend and there was concern for infection in R1's lower midsternal surgical wounds, prescribed [MEDICATION(S)] on 5/29/22 but has yet to receive any antibiotic, patient does have redness to the right leg and redness with some drainage from the abdomen, R1 and wife V6 noted over the weekend wound was draining and saturated through R1's shirt, R1 notes R1 has some redness to right medial calf where graft was performed. R1's hospital notes dated 5/31/22, document R1 admitted to the hospital with [MEDICATION(S)] intravenously. R1's Hospital notes from 6/3/22 document R1's right lower leg has a [CONDITION(S)] Oxytoca infection and receiving [MEDICATION(S)] and [MEDICATION(S)] and [MEDICATION(S)] due to positive swab of right lower leg. These hospital notes also document R1's right lower leg was cleaned with [MEDICATION(S)] and using a scalpel, the surgical site was opened and old sutures removed, small amount of murky fluid drainage present, wound cleaned and packed with saline wet to dry dressing and plan for wound vac placement on 6/4/22. R1's Hospital Discharge Summary dated 6/14/22, documents R1 being in the hospital from 5/31/22 through 6/14/22 with positive blood cultures growing two different organisms and needing two antibiotics, [MEDICATION(S)] and ceftnizone, wound cultures growing [CONDITION(S)] Oxytoca in right lower leg surgical site, transitioned to [MEDICATION(S)], placed on wound vac and went home with antibiotic and wound vac on 6/14/22. On 8/4/22 at 11:30 AM, V2 LPN, stated there is no treatment sheet or as needed (PRN) sheet for R1 that V2 can find. V2 stated if it wasn't charted, it wasn't done. V2 stated there is a convenience box in the medication room where there are several antibiotics and other medications for immediate use. V2 stated there is no nursing note for R1's admission and there was no complete assessment done including a body assessment. V2 stated it doesn't look like the treatment orders for R1 were clarified and they were not even being done because there is no TAR sheet to even document they were being done. On 8/8/22 at 8:45, V2 stated the Treatment Administration Record for R1 shows treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/22 at 2:40 PM, V1 Administrator stated it looks like there was a failure all around for R1's admission and V1 cannot tell who did the original admission. On 8/4/22 at 3:25 PM, R3's wound dressing was observed with no date, time, or initials on bandages. At this same time R3 stated R3's wound dressings are not changed every day. On 8/4/22 at 3:34 PM, R2 right leg wound dressing is soaked through to the linens on R2's bed, no date, time, or initials on bandages. At this same time R2 stated R2's wound dressings do not get changed everyday. The facility's Resident Council Meeting Minutes notes dated 5/20/22, document nurses not doing treatments. The facility's undated Nursing Documentation Guidelines Policy, documents three day documentation on every shift is required on all new admissions, MD should be notified after one missed treatment or one missed medication, be aware of facility policies and procedures on draining wounds; skin, wound, and pressure ulcer documentation - regular observations of skin surfaces, the progress, deterioration of any new problems; medication administration - the date, time, and initials of the person administering the medications is to be documented on the Medication Administration Record and PRN (as needed) sheets; fluid intake documentation - the amount of fluid consumed at each meal and between meals; treatment documentation - date and time each treatment administered, name and initial of person administering treatments, treatments should be documented on the Treatment Administration Record (TAR). The facility's undated Admissions Policy documents each resident shall have a complete physical examination within 72 hours after admission, The facility's Conformance with Physician Medication Orders Policy dated Reviewed 9/27/17, documents all medications shall be given as prescribed by the physician at the designated time. The facility's Medication Administration Policy date Revised 11/18/17, documents medications must be prepared and administered within one hour of the designated time, check medications against the resident's allergy list, and document any medication not administered for any reason on the back of the MAR with the date, the time, the medication and dosage, and reason for omission and initials.

Based on interview and record review the facility failed to provide supervision and implement fall interventions for one of three residents (R1) reviewed for falls in the sample of six. This failure resulted in R1 falling out of bed and sustaining a fracture of the right upper extremity. Findings include: R1's Physician Order Sheet dated June 2022 documents R1 is diagnosed with Muscle Spasms, Congestive Heart Failure, Anxiety, [CONDITION(S)], Dyspnea, [CONDITION(S)], Functional [CONDITION(S)], [CONDITION(S)], and is Legally Blind. R1 is prescribed the anticoagulant [MEDICATION(S)] 2.5 milligrams twice daily for [CONDITION(S)]. R1's Fall Risk assessment dated [DATE] documents R1 is at High Risk for falls in part due to R1's altered mental status, R1's need for assistance with elimination, R1's use of assistive devices for transfer, R1's medications, and R1's impaired hearing, joint pain, and previous fractures. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is severely cognitively impaired and she is totally dependant of at least two staff for transfers. The Incident Investigation Form dated 5/24/22 documents on 5/24/22 R1 was found on the floor beside her bed. R1 complained of pain and was sent to the emergency room for further evaluation. R1's Diagnostic Computed Tomography Report of the Right Humerus dated 5/24/22 documents R1 sustained an acute fracture of the distal Humerus related to acute trauma (fall). On 7/11/22 at 2:20 PM V6 Licensed Practical Nurse stated around midnight on 5/24/22, R1 was found by V6 and V9 Certified Nurses Assistant. R1 had rolled out of bed and was lying on the floor beside her bed. V6 stated the bed was not in the low position and there was no fall mat under R1 or beside her bed. V6 confirmed R1 was a high fall risk and should have been in a low bed and should have had a fall mat beside her bed. On 7/11/22 at 3:09 PM V9 Certified Nurses Assistant stated she found R1 on the floor by her bed around midnight on 5/24/22. V9 stated R1 is a high fall risk and can be confused. V9 stated R1 was supposed to have a fall mat by her bed but it was not there at the time of her fall. V9 stated R1 should've also been a low bed however her old bed broke and she was moved to a different bed that could not be lowered all the way down. V9 confirmed when R1 fell out of bed on 5/24/22, R1's bed was not in the low position. On 7/11/22 at 3:30 PM V1 Administrator confirmed R1 is a high fall risk, has altered mental status, is on an anticoagulant, and requires assistance for transfers and mobility. V1 confirmed that prior to R1's fall on 5/24/22, R1 was moved to a new bed because her bed no longer worked. V1 stated the bed that R1 was moved to was an older bed and it could not be lowered down to the floor. V1 confirmed R1 should be in a low bed and should have a fall mat by her bed. V1 confirmed its possible that if R1 would've rolled out of a low bed onto a fall mat, she might not have sustained a fracture. V1 confirmed both of those fall interventions should have been in place at the time of R1's fall on 5/24/22.

Based on observation, interview, and record review the facility failed to implement resident centered interventions to prevent new/worsened pressure ulcers, failed to prevent cross contamination of Stage lll and Stage lV pressure ulcers during a residents incotinence care and failed to document weekly wound assessments for five residents (R17,R27,R32,R34, R21) of five residents reviewed for pressure ulcers in a sample list of 26. This failure caused development of new Stage ll pressure ulcers for three (R32, R17, R27) the five residents. Findings include: 1. R32's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/1/22 at 9:26AM V12, Certified Nurse's Aide (CNA) and V13 Certified Nurse's Aide (CNA) assisted R32 to bed from her wheelchair with a sling type mechanical lift. As R32 was lifted urine poured on the wheel chair and floor. V12 rolled R32 in bed and her slacks were soaked with urine. V12 and V13 did not provide R32 with incontinence care at this time. V12 placed R32's blankets on R32 and both CNA's left the room. On 3/1/22 at 10:00AM when asked if V12 had noticed the urine on R32 V12 stated she had and would provide incontinence care for R32. R32's adult diaper was heavy with foul smelling urine and she was soaked through to the bed sheets. R32 was observed to have two dime size Stage II pressure ulcers to the right and left side of R32's coccyx. V12 stated I will let the wound nurse know. On 3/1/22 at 10:30AM V13 stated I did see the urine dripping on the wheel chair, but (V12) was taking care of (R32) and I thought she would clean (R32). On 3/2/22 at 10:15AM R32 stated I could use a diaper I am wet and dirty. V12 stated she was going to get supplies. On 3/2/22 at 11:00AM V15, Licensed Practical Nurse (LPN) stated (R32) doesn't have any treatments ordered except barrier cream. I wasn't aware she had any open areas. V15 stated she would call and get a treatment order. No wound assessment was documented. On 3/2/22 at 11:05AM V12 returned with V8, Certified Nurse's Aide (CNA) to provide incontinence care for R32. In addition to the stage II pressure ulcers on R32's right and left coccyx R2 also had a Stage II pressure uler to her right gluteal cleft and a pin point Stage II pressure ulcer to her left second toe. 2. R27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's Care Plan last updated 11/16/21 documents R27 is at high risk for pressure ulcers. On 3/1/22 at 2:00PM R27 stated his butt hurt. V4, Licensed Practical Nurse (LPN) wound nurse assisted R27 to roll to his side. R27 was incontinent of urine and being provided care. R27 had three dime sized pressure ulcers to his left buttock. On 3/1/22 at 2:00PM V4 stated I work the floor so I don't have time to get all my wound care done. (R27) was healed and now he's open again. 3. R17 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 Wound Evaluation and Summary dated 2/27/22 documented R17 has a 1. Stage IV pressure ulcer to the right medial ischium full thickness, of greater than 437 days duration 2. A Stage III Pressure Ulcer on his right lower Medial Ishium of greater that 227 day duration. and 3. A shearing wound to the right thigh that is new. The wound physician ordered a calcium alginate dressing covered with an abdominal pad for the Stage III and the Stage IV and house barrier cream to the shearing wound. On 3/1/22 at 11:45AM V12, Certified Nurse's Aide (CNA) removed R17's adult diaper to provide incontinence care. There were dressings in place to the Stage III and StageIV sites. V12 removed the dressings and discarded them. She then used the same wash cloth she had used to clean the rectal area and ran it over the two wounds. She did not notify the nurse to come in and properly cleanse the wound and reapply the ordered dressing. R17 had been laying on, the Yshaped tubing to R17's urinary catheter under his right buttock. There was a new Stage II pressure area in the shape and size of the tubing on R17's right buttock. V12 replaced the adult diaper over the wounds. On 3/1/22 at 1:30PM R1 stated The nurse never did come back in and put the bandage on my bottom. On 3/1/22 at 2:00PM V12 stated I guess I should have left the dressing alone. and let the nurse change it. No wound measurements or assessments for R17 documented from 12/5/21 until 12/30/21. No wound measurements or assessments for R17 documented from 12/30/21 until 1/12/22. No wound measurements or assessments for R17 documented from 1/20/22 until 2/13/22. No wound measurements or assessments for R17 documented from 2/13/22 until 2/27/22. 4. On 2/27/22 R21's physician wound evaluation and management summary documents a 0.5 centimeter by 0.3 centimeter stage two pressure wound of the right buttock with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/28/22 R21's nurse's notes document R21 complaining of bottom pain. R21's treatment administration record dated February 2022 documents skin checks and assessments to be done daily. These checks were not done daily but rather 10 of 28 days. On 2/28/22 at 8:02AM V4 Licensed Practical Nurse/Wound Nurse stated R21 did not have any open areas to the coccyx and no treatment other than barrier cream was being put on R21's coccyx. On 3/2/22 at 8:15AM V4 Licensed Practical Nurse/Wound Nurse performed pericare on R21 A dime sized open area on the right buttock was covered in thick liquid feces and urine. 5. R34's February 2022 Treatment Administration Record documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/28/22 V4 Licensed Practical Nurse stated that R34 did not have any open areas on R34's bottom. On 3/1/22 at 2:00PM R34 was toileted and a nickel sized stage two pressure ulcer was on R34's sacrum. On 3/1/22 at 1:00PM V4 Licensed Practical Nurse/Wound Nurse stated V21 Physical Therapy Assistant had made V4 LPN aware of R34's wound earlier that day. On 3/2/22 at 8:45AM V4 Licensed Practical Nurse (LPN) stated V4 LPN hadn't had time to perform the treatment and place the dressing on R34 yet and that additional interventions should have been put in place to prevent further skin breakdown. On 3/2/22 at 8:50AM, when asked about not knowing about open areas on the residents, V4 Licensed Practical Nurse/Wound Nurse stated, Honestly, we just don't have the staff to make sure everything is done the way that it should be. The facility policy revised date 1/18 documents that a wound will be documented on the treatment or wound record and that when a pressure ulcer is identified, additional interventions must be established and noted on the care plan in an effort to prevent worsening or reoccuring pressure ulcers. Additionally, staff on every shift and as needed will provide skin care. The facility 's policy documents the expectation of preventative skin care through repositioning, careful washing, rinsing, drying and observation.

Based on observation, interview, and record review the facility failed to ensure R3 was not subjected to a physical restraint and assessed for appropriate and necessary use of a physical restraint. As a result R3 sustained a right ankle fracture attempting to get free from a physical restraint. R3 is one of one resident reviewed for accidents on the sample list of 26. Findings include: On 3/1/22 at 11:00 AM, R3 was sitting at a dining room table. R3's wheelchair (wheels) was locked. R3 was pushing down on the wheelchair arms and attempting to stand but could not do so due to chair placement against the table. R3 was also pushing against the table and could not push backwards. R3 sat at this table until after lunch (12:30 PM), R3 continued to push against the table and attempted to stand unsuccessfully. R3 demonstrated no ability to unlock the wheelchair that forced R3 to remain at the table. R3 was identified to have the ability to independently self-propel R3's wheelchair while in the seated position. R3's radiology report dated 1/31/22 documents a right lateral mallelor (ankle) fracture. R3's Investigation Final Report dated 2/8/22 documents on 2/1/22, R3 complained of right ankle pain and had bruising to the right ankle. This report documents an x-ray was obtained which showed a right ankle fracture. This report documents V18, R3's Physician determined the fracture was caused from R3 rolling the ankle when attempting to move the wheelchair or when attempting to ambulate. On 3/2/22 at 10:00 AM, V1 Administrator stated it was determined that R3 rolled the right ankle when attempting to push self up and away from table. V1 stated R3's wheelchair is locked (by staff) so R3 can not move away from the table due to fall precautions. V1 stated R3 will push, rock, and attempt to stand while at the table. V1 stated the physician determined the cause of the fracture was from R3 rolling her ankle when attempting to move away from the table. R3's current medical record as reviewed on 3/1/22 had no documented evidence of a completed physical restraint assessment or any record related to medical symptoms warranting the use of, or being treated by physically restraining R3, with locked wheelchair wheels.

Based on observation, interview, and record review, the facility failed to complete a thorough fall investigation and implement fall interventions for one (R1) of three residents reviewed for accidents in the sample of three. The facility failed to ensure a floor mat was in place per R1's care plan resulting in R1 sustaining a right pubic rami fracture during a fall. Findings include: The facility's Fall Prevention policy revised 11/10/18 documents: 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or AIM (Assess Intervene and Monitor) for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nursing Assistant) assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R1's Physician's Orders dated 12/18/21-12/31/21 document R1's diagnoses include Functional [CONDITION(S)], Legally Blind, [CONDITION(S)], and a history of Left and Right Hip Fractures. R1's Minimum Data Set, dated dated dated [DATE] documents R1 has moderate cognitive impairment, and is dependent on one staff person for bed mobility and at least two staff for transfers. R1's Fall Risk assessment dated [DATE] documents a score of 18 indicating R1 is high risk for falling, and R1 uses a full mechanical lift for transfers. R1's Care Plan with a start date of 6/18/19 documents: (R1) has risk factors that require monitoring and intervention to reduce potential for self injury. This care plan documents an intervention dated 8/21/21 to keep R1's bed in low position when R1 is not eating, R1 has had increased confusion. R1's care plan documents an intervention dated 9/21/21 to have a fall mat beside R1's bed. R1's AIM for Wellness form documents on 12/14/21 at 4:45 PM R1 was found lying on R1's back on the floor next to R1's bed. R1 hit R1's head and complained of right hip pain. R1 was confused and believed R1 was at R1's family member's house. R1 was transferred to the local hospital. There is no documentation in R1's nursing notes or AIM for Wellness form that R1's bed was in low position, or fall mat was in place at the time of R1's fall. R1's Medical History and Physical Note dated 12/15/21 at 2:55 AM documents: R1 admitted to the hospital on 12/14/21. R1 fell reaching for a glass of water. R1 hit R1's head, has right leg shortening, and has previous right hip surgery. R1's diagnosis is documented as fall with acute closed right pubic rami fracture without hematoma. R1's Abdomen/Pelvis CT (Computed Tomography) dated 12/14/21 at 9:40 PM documents: Acute minimally displaced fractures of the right superior and inferior pubic rami and right parasymphyseal pubis. No associated hematoma. The facility's Final Report dated 12/21/21 and signed by V1 Administrator documents: R1 had an unwitnessed fall and was found on the floor of R1's bedroom. R1 told staff that R1 had sat on the edge of R1's bed, attempted to grab a bottle of water, and fell forward from R1's bed. R1 had a bump on R1's forehead and was sent to the local hospital for treatment. The facility was notified R1 had a right pubic ramus fracture. The facility interviewed staff working at the time of R1's fall. V4 and V6 CNAs had assisted R1 to bed prior to the fall. V7 Licensed Practical Nurse (LPN) had been in R1's room prior to the fall, gave R1 a bottle of water and a snack, and positioned R1's tray over R1's bed. This report does not document the position of R1's bed or if a floor mat was in place prior to or at the time of R1's fall. The root cause of R1's fall is documented as R1 had an increase in R1's positioning ability. The facility believes R1 pushed R1's overbed tray table away and later attempted to retrieve R1's water. A bed alarm was initiated as R1's fall intervention. There is no documentation in R1's medical record that a bed alarm was implemented subsequent to this incident. On 12/29/21 at 10:46 AM, R1 was lying in bed and R1's bed did not contain an alarming device. There was a fall mat on the floor beside R1's bed. R1 said, recently had a fall and broke R1's right hip. At the time of R1's fall, R1 had sat R1's self up on the side of the bed to attempt to reach a water bottle that was on an overbed table across R1's room. R1's socks slid across the floor and R1 fell from the bed onto the floor. At 11:25 AM, R1 was sitting in R1's wheelchair in R1's room. R1's bed did not contain a bed alarm. R1 stated, doesn't use a bed alarm. R1 was unsure if the floor mat was a new intervention or if it was in place at the time of R1's fall. On 12/29/21 at 1:23 PM, V3 CNA stated: R1's fall interventions include placing the call light within reach and encouraging to call for assistance. R1 had been having some confusion thinking R1 is working, so educating R1 to use the call light didn't always stick. R1 never previously tried to sit R1's self up on the side of the bed before, and R1's last fall was about 5 or 6 months ago. R1's fall was unusual in the fact that R1 sat R1's self up on the side of the bed. R1 uses two people for bed mobility and transfers. R1 would use the bed controls to adjust R1's bed height. We had stopped giving the controls to R1 and had been using a floor mat prior to R1's fall. On 12/29/21 at 1:46 PM, V5 CNA stated, CNAs do not use a worksheet. Fall interventions are discussed at shift report at the beginning of each shift. V5 was not working at the time of R1's fall but regularly provides care for R1. V5 stated, R1 had been using a fall mat beside R1's bed for the last couple of months. R1 hasn't used any type of bed alarm. On 12/29/21 at 2:01 PM V4 CNA stated: At the time of R1's fall, V2 and V4 were walking up the hallway. V4 saw R1's overbed table was tipped over and R1 was on the floor. Initially V4 stated, there was a floor mat on the floor. Then V4 stated no, now that I (V4) think about it, I (V4) don't think there was a floor mat in place. I (V4) think that was something that was implemented after R1's fall. V3 and V4 stated, fall interventions are discussed as part of a shift huddle at the beginning of each shift. V3 knows resident fall interventions by looking at the care plan and attending the morning meetings where falls are discussed. On 12/29/21 at 10:50 AM, V2 Wound Nurse/Licensed Practical Nurse was asked about R1's 12/14/21 fall. V2 stated: It was close to supper time and V2 and V4 CNA's were coming down the hall and noticed R1's overbed table was tipped over. R1 was lying on the floor with R1's head on a pillow near the foot of R1's bed, and R1's feet near the head of the bed. R1 said, I was trying to reach my water. V4 and V6 CNAs had been in R1's room about 30 minutes before the fall and had scooted R1 up in bed and given R1 water. V7 LPN had also been in R1's room to give R1 medications and a bottle of water prior to R1's fall. R1 said, R1 was not trying to get out of bed, and R1 had sat R1's self up on the side of the bed. When R1 went to push R1's self back, R1's feet slid on the floor, and R1 was wearing regular socks. At 11:29 AM, V2 stated: The new post fall intervention for R1's fall was a floor mat beside the bed. R1 does not use a bed alarm and one was not used after R1's fall. At 1:34 PM, V2 stated, at the time of R1's fall, there was not a fall mat on the floor. R1's bed was low to the floor. Falls are discussed in the morning meeting and management is updating the resident care plans with fall interventions. V2 has been assisting since the facility does not currently have a Director of Nursing. At 3:00 PM, V2 stated, staff are expected to look at the resident's care plan to determine fall interventions. Care plans are kept at the nurse's station and available for staff to review. The facility does not use a CNA worksheet to document fall interventions. On 12/29/21 at 1:40 PM, V1 Administrator stated: R1's post fall intervention for R1's 12/14/21 fall was to have a bed alarm, but the bed alarm did not work for R1 so we implemented a floor mat. V1 Confirmed R1's care plan documents a fall intervention for the use of a floor mat on 9/21/21. On 12/29/21 at 2:10 PM, V1 stated, V1 had no additional documentation to provide for R1's fall investigation or that a bed alarm was implemented after R1's fall on 12/14/21.

Identified failures required more than one deficient practice statement. A.) Based on observation, interview and record review the facility failed to follow facility policy and local health department guidance to restrict employees with COVID-19 (Human Coronavirus infection) symptoms from working and exposing residents and employees to infection. This failure resulted in all residents residing in the facility being unnecessarily exposed to an infectious disease by symptomatic employees. The facility also failed to follow facility policy and local health department guidance to promptly separate symptomatic COVID-19 (Human Coronavirus infection) infected residents away from non-infected residents for four of 35 residents (R4, R7, R8, and R11) reviewed for infection control in the sample of 35. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on November 17, 2020, the facility remained out of compliance at a severity level two. The facility is in the process of re-educating key management personnel and direct care staff regarding appropriate COVID-19 infection control measures. Findings include: The facility's COVID-19 Control Measures policy revised 10/1/20 documents to implement droplet and contact precautions when a resident is suspected of having fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, or loss of taste and/or smell. This policy documents to place symptomatic residents in a private room until test results are received, and if a private room is not available cohort residents who have tested positive for COVID-19. This policy documents to wear a facemask/N95, gloves, gown, and goggles or face shields when entering a droplet precaution isolation room. This policy documents Restrictions for Health Care Personnel 1. Educated all employees if having symptoms of a respiratory infection, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell not to report to work and to contact their regular provider. 2. Initiate screening at entryway of facility for symptoms of COVID-19 and/or fever. This policy documents that residents who are cared for by a healthcare professional with known or suspected COVID-19 should be restricted to their rooms and cared for using all the recommended COVID-19 PPE (Personal Protective Equipment) for 14 days following the last known exposure and tested if they develop symptoms. The facility's COVID-19 Cohorting of Residents policy dated 8/26/20 documents residents with COVID-19 should be transferred to the facility's designated COVID-19 area. This policy documents residents who have had exposure should not room share with residents who are unexposed. This policy documents residents who have had exposure should be transferred to a private observation room, or room share with other exposed residents within a designated observation area. The facility's undated floor plan documents North hall rooms are designated COVID-19 isolation rooms, East hall rooms E1 and E2 are the designated observation rooms, East hall rooms E3-E5 and South hall rooms S1-S16 are Zone 2 (asymptomatic unit.) a.)1.) On 11/4/20 at 8:47 AM there was a sign posted at the entrance to the facility documenting the facility had positive COVID-19 in the facility. On 11/5/20 at 9:29 AM V4, Certified Nursing Assistant (CNA), stated V4 worked on the south/east halls on 11/1/20 from 10:00 PM until 2:45 AM. V4 stated V4 had not been feeling well with symptoms of fatigue, chills, nausea, and diarrhea prior to reporting to work on 11/1. V4 stated V4 reported V4's symptoms to V5, Registered Nurse (RN), at the beginning of V4's shift, and V4 had documented V4's symptoms on the employee symptom screening form. V4 stated V5 asked V4 to continue working that night and V5 told V4 to take Tylenol (fever reducing medication.) V4 stated V5 sent V4 home around 2:45 AM after V4 had vomited twice. V4 confirmed V4 provided direct resident care to asymptomatic residents who resided on the south hall (R1-R4, R7-R14, R16, R17) and residents (R19-R21) who resided in the east rooms. V4 stated on 11/1 V4 was not wearing any eye protection while providing care to the residents. V4 stated V4 also worked on the COVID-19 unit on 11/3/20 at 10:00 PM with symptoms of nausea, and V4 reported V4's symptoms to V2 DON. V4 stated V2 sent V4 home around 11:00 PM when V4's COVID-19 positive test results were reported to the facility. On 11/5/20 at 12:56 PM V5, RN , stated V4 had reported to V5 on 11/1/20 that V4 wasn't feeling well, and was fatigued and tired. V5 stated V5 gave V4 Tylenol to take. V5 stated V5 sent V4 home after V4 vomited twice. V5 stated if staff report symptoms of COVID-19 they are to be sent home. V4's Timecard documents V4 worked on 11/1/20 from 10:15 PM until 2:45 AM, and 11/3 from 10:15 PM until 11:15 PM. V4's Employee, Vendor Consultant COVID Screening Questionnaire documents on 10/31 V4 had no symptoms of COVID-19. V4's Questionnaire does not document symptom screening was completed on 11/1/20, and on 11/3 V4's temperature is documented but the symptom screening was left blank. V4's Nasopharyngeal Swab test collected on 11/2/20 and reported 11/3 at 11:03 PM documents V4 was positive for COVID-19. The facility's Daily Assignments dated 10/30/20 and 11/3/20 document V4 worked night shift and documents iso (isolation) next to V4's name. The facility's Daily Assignment dated 11/1/20 documents V4 worked night shift with V5 and does not document iso next to V4's name. The facility's Room Roster dated 11/3/20 documents R1-R4, R7-, R14, R16, and R17 resided on the South hall and R19-R21 resided on the East hall. The facility's undated Covid Positive Employees list documents a total of 15 employees have tested positive for COVID-19 since 10/14/20. The facility's undated Covid Positive Residents list documents a total of 25 residents have tested positive for COVID-19 since 10/21/20. R1-R4's COVID-19 tests dated as collected 10/26/20 and reported 10/28 documents R1-R4 were negative for COVID-19. R1-R3's and R7-R9's COVID-19 tests dated as collected 11/2/20 and reported 11/3 documents R1-R3 and R7-R9 tested positive for COVID-19. R10's, R11's, R13's, R14's, and R17-R20's COVID-19 tested dated as collected 11/2/20 and reported on 11/3 document R10, R11, R13, R14, and R17-R20 tested negative for COVID-19. On 11/5/20 at 10:12 AM V2, Director of Nursing (DON), stated the facility follows CDC (Centers for Disease Control and Prevention) and the state and local health departments' guidance for COVID-19. V2 stated employees are to complete the COVID-19 symptom screening questionnaire at the beginning of their shift. V2 stated if employees have any symptoms of COVID-19 they are not allowed to work and are given instructions to be tested and follow up with their physician. V2 stated the employee is to remain off work until COVID-19 test results are received. V2 stated if the test is negative and COVID-19 symptoms have improved the employee can return to work. V2 stated V2 was not aware of V4's COVID-19 symptoms on 11/1 and confirmed V4 should not have been allowed to work. V2 stated V2 worked with V4 on 11/3, and V4 told V2 that V4 had an upset stomach and believed it was due to something V4 ate. V2 confirmed V4 was not sent home from work until around 11:00 PM on 11/3 when V2 received V4's positive COVID-19 test result. V2 stated the facility tries to dedicate employees to work on the COVID-19 unit, and employees who work on the South Hall provide care to all residents residing on the East and South halls. On 11/6/20 at 2:38 PM V2 stated the facility's schedule documents iso next to the employee's name who is assigned to work the COVID-19 isolation unit, and if the employee does not have iso next to their name they are assigned to the South/East rooms. On 11/6/20 at 2:48 PM V1 ,Administrator , stated V1 was unable to locate any additional documentation to provide for V4's COVID-19 symptom screening questionnaires that were requested for 11/1-11/3/20. V1 stated the room roster dated 11/3 is the same for 11/1 and 11/2. V1 stated R12 and R16 who resided on the South hall have also tested positive for COVID-19. On 11/6/20 at 11:47 AM V8, ( County Health Dept. COVID-19 Lead Investigator), stated V8 has noticed an influx in COVID-19 positive cases in both residents and staff of the facility. V8 stated V8 has been providing COVID-19 guidance from CDC and IDPH (Illinois Department of Public Health) regularly to the facility. V8 stated the facility should be conducting employee COVID-19 symptom screening at the beginning and middle of the shifts. V8 stated if an employee has COVID-19 symptoms, they should not be allowed to work, and the employee should be sent to be tested for COVID-19. V8 stated employees should be wearing an N95 mask and face shield or goggles when providing care to asymptomatic residents during an outbreak. V8 stated that allowing V4 to work with COVID-19 symptoms (who tested positive on 11/3) and provide direct resident care unnecessarily exposing unexposed staff and residents would contribute to the spread of COVID-19 within the facility. a.)2.) On 11/4/20 at 9:09 AM R4 was in R4's room located on the South hall. There was a sign on R4's door indicating R4 was on isolation and an isolation cart was outside of R4's room. R11's room was located on the south hall with the door closed, there was no isolation signage posted or an isolation cart locate outside of R11's room. On 11/5/20 at 8:15 AM V6 Licensed Practical Nurse stated R7 returned from the hospital and was placed in a room with R4. V6 stated R7 had a cough on 11/2 and 11/3 during second shift when V6 worked. V6 confirmed R7 and R4 shared a room until 11/3. V6 stated V6 had given R7 a mask to wear, but R7 refused to wear the mask. V6 stated the nurses were monitoring residents for elevated temperatures, but V6 told the nurses that we (nurses) should be monitoring for other COVID-19 symptoms besides a fever. V6 stated R8 and R11 shared a room until 11/3 and were not on isolation. The facility's Room Roster dated 11/3/20 documents R4 and R7 share a room and R8 and R11 share a room. R7's Nurse's Note dated 10/30/20 at 1:00 PM documents R7 stayed in bed and had a nonproductive cough. R7's nursing note dated 11/3/20 documents R7 was coughing with liquids. R7's COVID-19 test with a collected date 11/2 and reported date 11/3/20 documents R7 tested positive for COVID-19. R7's Physician order [REDACTED]. There is no documentation in R7's medical record that R7 was transferred to an observation room or placed on contact and droplet precautions. R4's Physician order [REDACTED]. R4's Nurse's Note dated 10/28/20 at 5:30 PM documents R4 readmitted to the facility into the same room as R7. This note documents R4 was treated at the hospital for Aspiration Pneumonia. R4's Nursing Note dated 11/1 at 7:00 PM documents R4 had wheezing bilaterally to R4's lungs. R4's COVID-19 test with collection date 11/2/20 and reported date 11/3/20 documents R4 is negative for COVID-19. R8's COVID-19 assessments document as follows: on 10/28/20 and 10/29/20 R8 had increased lethargy. On 10/30/20 and 11/1/20 R8 had a cough. On 11/1/20 R8 had wheezing to R8's lungs. On 11/2/20 at 1:35 PM, R8 had a nonproductive cough and diminished lung sounds. On 11/3/20 R8 had a nonproductive cough and an oxygen saturation (measurement of oxygen level in the blood) of 85 percent. R8's COVID-19 test with collected date 11/2 and reported 11/3 at 11:05 PM documents R8 was positive for COVID-19. There is no documentation in R8's medical record that R8 was transferred to an observation room or placed on droplet/contact isolation. R11's Physician order [REDACTED]. R11's medical record documents R11 had no observed or reported symptoms of COVID-19. R11's COVID-19 test with collected date 11/2 and reported date 11/3 documents R11 tested negative for COVID-19. On 11/5/20 at 10:12 AM V2, DON, stated V2 worked night shift on 11/3 and received R7's and R8's COVID-19 positive test results. V2 stated R7 and R8 were transferred to rooms located on the COVID-19 unit during the night shift on 11/3. V2 confirmed R7 had been sharing a room with R4, and R8 had been sharing a room with R11 prior to 11/3. V2 stated V2 was not aware that R7 or R8 had COVID-19 symptoms prior to testing positive on 11/3. V2 stated nurses are to report to V2 when residents have COVID-19 symptoms, and the symptomatic residents are to be placed on droplet/contact isolation in a private room. V2 confirmed R4 and R11 would be considered to be exposed to COVID-19 and should also be placed on contact/droplet precautions. On 11/6/20 at 2:48 PM V1 stated the room roster dated 11/3/20 is the same for 11/1 and 11/2. V1 stated R12 and R16 who resided on the South hall have also tested positive for COVID-19. On 11/6/20 at 11:47 AM V8, County Health Dept. COVID-19 Lead Investigator stated V8 has noticed an influx in COVID-19 positive cases in both residents and staff of the facility. V8 stated V8 has been providing COVID-19 guidance from CDC and IDPH (Illinois Department of Public Health) regularly to the facility. V8 stated the facility should be monitoring residents for COVID-19 symptoms and residents who have COVID-19 symptoms should be housed in a separate location away from residents who are COVID-19 negative and placed on isolation. V8 stated residents that shared a room with a COVID-19 positive resident would be exposed and should be transferred to a location away from COVID-19 negative residents and placed on isolation. An Immediate Jeopardy situation was identified on 11/5/20. The Immediate Jeopardy was identified to have begun on 10/28/20 when R8 had COVID-19 symptoms and was allowed to remain in a shared room with R11 who was COVID-19 negative, exposing R11 to COVID-19 infection. The facility also allowed V4 CNA to work in the facility on 11/1/20 with symptoms of COVID-19 infection thereby exposing multiple staff and residents to COVID-19 infection. On 11/10/20 at 1:50 PM V1 was notified of the Immediate Jeopardy situation. The Employee, Vendor Consultant COVID Screening Questionnaire for V28 ,CNA, documents on 11/11/20 at 6:00 AM and 10:00 AM, and 11/12/20 at 6:00 AM V28 had COVID-19 symptoms of new or worsening cough, sore throat, headache, new loss of taste/smell, and runny nose/nasal drainage. V28's COVID Screening Questionnaire documents V28 had muscle pain on 11/12/20 at 6:00 AM. The The Employee, Vendor Consultant COVID Screening Questionnaire for V29 CNA documents on 11/11/20 at 10:00 PM V29 had COVID-19 symptom of sore throat. The Employee, Vendor Consultant COVID Screening Questionnaire for V6 Licensed Practical Nurse (LPN) documents on 11/11/20 at 8:00 PM and 11/12/20 at 2:00 PM V6 had COVID-19 symptoms of runny nose or nasal drainage. The Employee, Vendor Consultant COVID Screening Questionnaire for V27 LPN documents COVID-19 symptom screening was completed on 11/8-11/10/20, but does not document COVID-19 symptom screening was completed for 11/11/20. V28's Time Card documents V28 worked on 11/11/20 from 6:00 AM until 2:00 PM and on 11/12/20 at 6:00 AM. V29's Time Card documents V29 worked on 11/11/20 from 10:15 PM until 6:00 AM on 11/12/20. V6's Time Card documents V6 worked on 11/11/20 from 2:00 PM until 10:30 PM. V27's Time Card documents on 11/11/20 V27 punched in at 2:00 PM. The facility's Daily Assignment dated 11/11/20 documents V28 worked first shift on the south hall (where asymptomatic and COVID-19 negative residents reside), V6 worked second shift on the south hall, V27 worked second shift on the north hall, and V29 worked third shift on the south hall. The facility's Daily Assignment dated 11/12/20 document V28 was scheduled to work first shift on the north hall and V6 was scheduled to work 2nd shift on the south hall. The facility's Room Roster dated 11/12/20 documents R19 and R21 reside on the east hall, and R4, R6, R14, R17, R24-R26, and R29 reside on the south hall. On 11/12/20 at 11:50 AM V10,LPN stated V10 worked with V28 on first shift on 11/11/20. V10 stated V28 provided direct resident care on the south/east halls on 11/11, and on the north hall this morning (11/12/20.) V10 stated V28 left the facility sometime this morning after V28 received a phone call that V28's child was ill. V10 stated V28 had not reported V28's symptoms to V10 on 11/11 and 11/12/20. V2 DON stated V2 was not aware that V28 had COVID-19 symptoms on 11/11 and 11/12. Both V2 and V10 stated that V28 should not have been allowed to work in the facility with COVID-19 symptoms. On 11/12/20 at 12:55 PM V1 Administrator stated V28 had worked (today) (11/12) and left the facility between 8:30 AM and 9:00 AM. On 11/12/20 at 1:58 PM V2 stated employees conduct self screening for COVID-19 symptoms and complete the screening questionnaire at the beginning of their shift. V2 stated the forms are not turned into anyone, and they are placed in the binder at the nurse's station. V2 stated V1 is responsible for reviewing employee COVID-19 symptom screening. V2 stated V2 was unable to locate V27's COVID-19 symptom screening questionnaire for 11/11/20. On 11/12/20 at 11:05 AM V1 confirmed V1 had not reviewed COVID-19 symptom screening questionnaires dated 11/11 and 11/12/20 for V28, V27, V29, and V6. On 11/12/20 at 3:25 PM V1 verified between 11/11 and 11/12/20 V27-V29, and V6 had documented symptoms of COVID-19 and worked in the facility providing resident care while having symptoms of COVID-19. V1 stated that part of the problem may be that staff are self screening for COVID-19 symptoms, and the facility will need to adjust their policy for conducting employee COVID-19 symptom screening. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 11/17/20 at 11:55 AM V1 stated in-services on COVID-19 Control Measures, Contact/Droplet Precautions and Screening Process were completed with all employees by 11/17/20. Completed by V1 Administrator. 2.) On 11/17/20 at 11:55 AM V1 confirmed V1 and V2 reviewed all employee COVID-19 screening questionnaires daily by 11/17/20. 3.) On 11/12/20 at 9:40 AM signs documenting COVID-19 Reminders/Practices were located at the nurses stations and time clocks. On 11/12/20 at 10:04 AM V1 stated all employees received the COVID-19 Reminders/Practices handout during the in-service on 11/10/20 and the handout was also mailed with employee paychecks on 11/10/20. Completed by V1 Administrator. 4.) On 11/12/20 at 10:04 AM V1 confirmed all Department Supervisors were in-serviced on 11/10/20 on employees displaying signs and symptoms of COVID-19 can not work and must be sent home, and V1 is to be notified immediately. Completed by V1 Administrator. 5.) On 11/12/20 at 10:04 AM V1 stated the facility's Immediate Jeopardy Removal Plan was provided to and reviewed with V30 Medical Director. Completed by V1 Administrator. 6.) On 11/12/20 at 10:04 AM V1 and V2 confirmed observations and monitoring of employee and resident COVID-19 symptoms are reviewed during the facility's daily morning Quality Assurance meetings. Completed by V1 Administrator and V2 Director of Nursing. 7.) On 11/12/20 at 9:32 AM V2 stated V2 had completed COVID-19 symptom assessments on 11/10/20 of the COVID-19 negative residents. V2 stated V2 reviewed COVID-19 symptom assessments for COVID-19 negative residents on 11/12/20, and V2 will continue to conduct random reviews. V2 stated R5 had symptoms of COVID-19 during night shift on 11/11 into 11/12, and R5 was transferred into a private observation room and placed on isolation. On 11/12/20 at 9:19 AM R5 was in a private observation room with signage posted on R5's door indicating R5 was on contact and droplet precautions. B) Based on observation, interview, and record review the facility failed to ensure an employee was properly wearing a face covering to contain potential respiratory pathogens. This failure has the potential to affect all residents residing in the facility. The facility also failed to implement Transmission Based Precautions for a resident exposed to COVID-19, ensure employees and visitors apply and remove Personal Protectitive Equipment (PPE), properly store isolation garbage and linen containers, post isolation signage, and complete COVID-19 symptom monitoring per the facility's policy for 24 of 35 residents (R1-R8, R10, R18, R22-R35) reviewed for infection control in the sample of 35. Findings include: The facility's COVID-19 Control Measures policy revised 10/1/20 documents when a resident is placed on Contact or Droplet Precautions signage will be posted on the door. This policy documents staff will remove PPE and perform hand hygiene when leaving the resident's room and after direct contact with potentially contaminated surfaces. This policy documents for contact precautions wear gloves and a gown if potentially coming into contact with contaminated surfaces in the resident's room, and for droplet precautions wear a facemask/N95, gloves, gown, goggles or face shields when entering the resident's room. This policy documents to obtain resident vital signs and pulse oximetry twice daily, and residents will be monitored for symptoms of COVID-19 including fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, and loss of taste/smell. The facility's Contact Precautions policy reviewed on 12/7/18 documents Resident Transport: Limit the movement and transport of the resident from the room to essential purposes only. The facility's Droplet Precautions policy reviewed on 12/7/18 documents Resident Transport: Limit the movement and transport of the resident from the room to essential purposes only. If transport or movement is necessary, minimize resident dispersal of droplets by masking the resident and follow the cough Hygiene Etiquette Protocol. The facility's Visitation Guidelines dated 10/27/20 documents Purpose: To provide different means of visitation based on the facility's structure the facility will restrict indoor visitation based on the facility's structure and residents' needs, utilizing the Core Principles and best practices to reduce the risk of COVID-19 transmission. This policy documents Core Principles include hand hygiene and use of Alcohol Based Hand Rub, face coverings/masks, social distance of at least 6 feet, and provide education to visitors on infection control precautions. This policy documents that visitors should be monitored for compliance with following the facility's Core Principles, wear required PPE during the visit, and be instructed on the proper disposal of PPE and hand hygiene before and after the visit. This policy documents visitors should go directly to the resident room and not walk around different hallways in the facility. This policy documents The facility with the cooperation of the visitor can allow personal contact during a visit only if it can be done following appropriate infection prevention guidelines and for a limited amount of time (i.e. (for example) N95, gown, gloves, face shields/goggles.) b.1) On 11/4/20 at 1:55 PM V16 Cook was working in the kitchen. V16 was wearing a surgical mask below V16's nose, only covering V16's mouth. V16 confirmed V16's mask was below V16's nose, and stated if V16 wears the mask covering both V16's nose and mouth it makes it hard for V16 to breathe. On 11/5/20 at 10:12 AM V2 DON stated nondirect care staff such as kitchen staff should be wearing surgical masks covering both their nose and mouth. V2 stated V16 has been told before to wear V16's mask covering V16's nose and mouth. The Daily Roster dated 11/4/20 documents 32 residents reside in the facility. b.2) The facility's undated Covid Positive Residents list documents R3, R5-R8, R18, and R22-R35 tested positive for COVID-19 between 10/21/20 and 11/2/20. The facility's Daily Roster dated 11/4/20 documents R5, R6, R18, and R22-R35 reside on the North Hall, the facility's designated COVID-19 unit. On 11/4/20 at 8:47 AM there were COVID-19 unit signs posted on the double doors to the facility's North hall. On 11/4/20 at 12:12PM V25 (R18's Family Member) was standing in the hallway of the COVID-19 unit wearing a gown, gloves, goggles, and a surgical mask over top of a cloth mask. V25 was talking to R3 and R5 in the hallway and standing within 6 feet of R3 and R5. On 11/4/20 at 12:20 PM V25 left the COVID-19 unit while still wearing the (potentially contaminated) surgical/cloth masks, gloves, and gown worn on the COVID-19 unit and in R18's room. V25 stated V25 was visiting R18 and stated the facility had not provided education to V25 on when to change PPE or perform hand hygiene. V25 stated V25 was wearing the PPE that the facility had given to V25 and that V25 was not sure when V25 was suppose to remove V25's PPE. V25 proceeded to the exit of the facility and was instructed by the surveyor to remove V25's PPE and perform hand hygiene. On 11/4/20 at 12:05 PM V18 CNA (Certified Nursing Assistant) was working on the North hall. V18 was going in and out of resident rooms while wearing V18's goggles (eye protection PPE) on top of V18's head. V18 was observed leaving a resident room wearing a gown, gloves, N95 (respirator mask PPE), and surgical mask to obtain items from the clean linen cart located in the hallway. V18 did not change gloves and perform hand hygiene upon leaving the resident's room, prior to obtaining items from the cart. On 11/4/20 at 12:10 PM V26 CNA was wearing a gown, N95 mask, surgical mask, gloves, and goggles on the North hall. V26 was observed leaving a resident room wearing gloves, and carrying supplies into another resident room while wearing the same pair of (potentially contaminated) gloves. V18 left a resident room carrying trash with gloved hands into resident room N15. On 11/4/20 at 12:25 PM V18 was passing meal trays into resident rooms on the North hall. V18 did not change V18's contaminated gloves and perform hand hygiene between entering each resident rooms. V18 then used the phone located on the wall while wearing the same pair of gloves used to pass meal trays. V26 carried a bag of garbage while wearing gloves into room N15, and left the room without changing gloves or completing hand hygiene prior to entering another resident room. On 11/4/20 at 12:18 PM V18 stated V25 was visiting R18 who was actively dying. V18 stated any staff or visitors on the COVID-19 unit are to wear a gown, gloves, goggles, and a surgical mask over top of an N95 mask. V18 stated the North hall's isolation soiled linen and garbage containers are located in the same room where R1 and R35 reside. On 11/5/20 at 10:12 AM V2, DON (Director of Nursing), stated the facility has not been allowing indoor family visits, except for residents who are actively dying. V2 stated visitors are to call the facility to schedule a visit. V2 stated visitors should be instructed to come to a certain door, given gown, gloves, N95 mask, surgical mask, and either a face shield or goggles, and should be instructed on to remove PPE and perform hand hygiene upon leaving the COVID-19 unit. V2 stated staff working on the COVID-19 unit should wear a surgical mask covering an N95 mask, gown, goggles or face shield, and gloves into resident rooms and when on the unit. V2 stated staff should be changing gloves and performing hand hygiene between each resident and upon leaving a resident room. V2 stated isolation garbage and soiled linen containers on the COVID-19 unit should be stored near the double door entrance to the unit, and V2 was not aware that the soiled linen and garbage containers were located in a room where residents reside. On 11/6/20 at 11:47 AM V8, County Health Department COVID-19 Lead Investigator stated the facility has been advised against allowing indoor family visits. V8 stated any staff or visitor on the COVID-19 unit should be wearing an N95 mask, eye protection, gown and gloves and all PPE should be removed upon leaving the unit and hand hygiene performed. V8 stated staff should be changing gloves between each resident. b.3) The Room Roster dated 11/3/20 documents R3 and R10 share a room, R4 and R7 share a room, and R11 and R8 share a room on the South hall. The Daily Roster dated 11/4/20 documents R1, R4, R10, and R11 reside on the South hall. R1's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R1 tested positive for COVID-19. R3's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R3 tested positive for COVID-19. R10's COVID-19 test collected 11/2/20 and reported on 11/3 documents R10 was negative for COVID-19. R7's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R7 was positive for COVID-19. R4's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R4 was negative for COVID-19. R8's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R8 was positive for COVID-19. R11's COVID-19 test collected on 11/2/20 and reported on 11/3/20 documents R11 was negative for COVID-19. On 11/4/20 at 9:09 AM R1's, R4's, R8's and R10's rooms were located on the South hall. There was no isolation signage posted on R4's, R8's and R10's door, and there were no isolation carts outside of R8's and R10's rooms. There were droplet and contact isolation signs posted on R4's door and an isolation cart was outside of R4's room. There was an isolation cart located outside of R1's door and there was no isolation signage posted on R1's door. On 11/4/20 at 9:24 AM V9 Licensed Practical Nurse (LPN) 9:24 AM stated R1 is on isolation and has to be moved today due to testing positive for COVID-19. At this time V14 Minimum Data Set Coordinator posted signs for Contact and Droplet Precautions on R1's door. On 11/4/20 at 11:28 AM V3, Housekeeper was cleaning R1's room on the South hall, R1 and R1's belongings were no longer in the room. V3 was wearing gloves, a surgical mask over top of an N95 mask, and a face shield. V3 was not wearing an isolation gown. V3 was wiping down the mattress, bed railings, and mopping the floor. V3 was observed leaving the room and while wearing the same pair of contaminated gloves worn to clean R1's room obtained items from the housekeeping cart located in the hall. V3 left R1's room at 11:35 AM and pulled the door closed while wearing the same gloves used to clean R1's room. V3 then removed V3's gloves and washed V3's hands. On 11/4/20 at 2:45 PM V12, Housekeeping Supervisor, stated after a resident transfers to the COVID-19 unit their room is cleaned from top to bottom and their belongings are bagged up. V12 stated housekeeping staff should wear gown, gloves, goggles, and an N95 mask to clean the room. V12 stated V3 should have been wearing a gown while V3 cleaned R1's room and removed V3's gloves upon leaving the room prior to closing the door. On 11/5/20 at 10:12 AM V2 stated V2 received R3's, R7's and R8's COVID-19 positive test results around 11:00 PM on 11/3/20. V2 stated R3, R7, and R8 were moved that night to the COVID-19 unit. V2 confirmed that R10 had been residing with R3, R4 had been residing with R7, and R11 had been residing with R8 prior to R3, R7, and R8 testing positive for COVID-19 .V2 confirmed R4, R10, and R11 reside on the South hall, the facility's designated area for asymptomatic or COVID-19 negative residents. V2 confirmed R10 and R11 were not placed on isolation. V2 stated when a resident's room mate tests positive for COVID-19 they are considered to be exposed and should be moved to an observation room and placed on isolation. V2 stated R3, R11, and R10 will be moved to observation rooms and placed on isolation. V2 stated residents should have Contact and Droplet Precaution sings posted on the (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement pressure relieving interventions, failed to measure wounds weekly, failed to report development of and changes in pressure ulcer condition to the physician, and failed to request pressure ulcer treatment orders for one of three residents (R5) reviewed for pressure ulcers in the sample of nine. This failure resulted in the deterioration of R5's Stage II Sacral Pressure Ulcer wound to a Stage III Sacral Pressure Ulcer wound. Findings include: R5's Skin Risk assessment dated [DATE] is to have a pressure relieving cushion to R5's wheelchair. R5's Pressure Ulcer Risk assessment dated [DATE] documents R5 is at a high risk for pressure ulcers. R5's Care Plans dated 5/24/18 document R5 has a Stage II Pressure Ulcer to the coccyx which is actually the sacral area per wound documentation. These care plans document to use a pressure reducing wheelchair cushion and uses a mechanical lift for transfers. These care plans also document staff are to assess wound per policy and notify the physician of acute changes or delayed healing. R5's Weekly Wound Tracking sheet dated (MONTH) 24, (YEAR) documents R5 has a Stage II Pressure Ulcer to the sacrum that is center (facility) acquired with measurements of 2cm (centimeters) by 1cm with no drainage. There is no additional documentation of R5's sacral pressure ulcer measurements for May. R5's Weekly Wound Tracking sheet dated (MONTH) (YEAR) documents R5's Stage II Pressure Ulcer to the sacrum that is center acquired with measurements including mild drainage for 6/4/18, 6/11/18 and 6/20/18 from the pressure ulcer, which was not documented on the Wound Tracking sheet dated (MONTH) 24, (YEAR). There is no documentation R5's Physician was notified of the changes in drainage of R5's Stage II Pressure Ulcer to the sacrum. This Weekly Wound Tracking sheet for (MONTH) (YEAR) also documents R5's Stage II Pressure Ulcer to the sacrum measurements on 6/20/18 of 1.4cm by 0.8cm. R5's Weekly Wound Tracking sheet dated (MONTH) (YEAR) does not document any wound measurements for R5's Stage II Pressure Ulcer to the sacrum on 7/11/18. The next measurements documented for this wound are on 7/17/18, which now documents the pressure ulcer as a Stage III, and has increased in size, measuring 2.5cm by 5cm. R5's Treatment Administration Records (TAR) do not document any weekly wound assessments or measurements for R5's Sacral Pressure Ulcer for (MONTH) (YEAR), (MONTH) (YEAR) or (MONTH) (YEAR). These records do not document any treatments for R5's Sacral Pressure Ulcer. The only treatment documented is for EPC (Extra Protective Cream) to the coccyx for (MONTH) (YEAR) and (MONTH) (YEAR). There is documentation of treatment with barrier cream to the sacrum dated 6/20/18. R5's Nurse's Notes document notes dated 5/18/18 and 7/15 but there is no documentation of R5's Stage II Pressure Ulcer wound to the Sacrum. On 7/24/18 at 12:45pm and 7/25/18 at 9:20am, R5 was up in the wheelchair in the dining room with the mechanical lift sling positioned under R5 on top of the pressure relieving cushion. On 7/25/18 at 2:50pm, V3, Director of Nursing (DON) stated V3 would expect staff to follow the facility policy and measure and document pressure ulcer wound assessments weekly and notify the physician's of development of or changes in pressure ulcers. V3 stated if an open wound is over a bony prominence, then it is a pressure ulcer wound. V3 stated R5's wound on the sacrum was a pressure ulcer. V3 stated the facility changed who was responsible for wounds in (MONTH) or (MONTH) of (YEAR) and there has been a decline in documentation of wound assessments/measurements. V3 stated there should not be anything, including a mechanical lift sling, placed between the pressure relieving cushion and the resident. V3 stated the sling may increase moisture to the area of pressure concern as well as cause pressure related wounds. The facility's Decubitus Care/Pressure Areas policy dated (MONTH) 2007 documents the policy is to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of the pressure ulcer once identified. This policy documents the pressure area will be assessed and documented on the Treatment Administration Record (TAR) and all areas on the TAR will be completed including documentation of size, stage, site, depth, drainage, color and odor. This policy also documents the pressure area documentation must occur upon identification and at least once each week on the TAR and the assessment must include wound characteristics and treatment and response to treatment.

Based on interview and record review the facility failed to implement preventative fall interventions and failed to maintain effective fall interventions for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 incurring a fracture of cervical fourth and fifth spinal vertebrae. Findings include: The February 2016 Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R1 with severe cognitive impairment. This MDS, Section G0300, Balance During Transitions and Walking is scored, after observation of reviewer, as not steady and only able to stabilize with staff assistance. The Care Area Assessment Summary dated 11/23/15 documents, (R1) is at high risk for falls due to balance issues, staff will observe and assist with all transfers ensuring he has his balance before moving. R1'sCare Plan for falls dated 10/6/15 documents reasons R1 is at risk for falls including R1 is known to attempt to get up from chair unattended. Interventions placed include use of a personal fall alarm on 11/15/15, application of anti-rollback wheelchair brakes to R1's wheelchair on 11/13/15, and on 11/25/15 the anti-rollback wheelchair brakes were discontinued to the wheelchair secondary to improved posture while in chair. Interview with E3 (Director of Nursing) on 2/25/16 at 12:45pm and review of the facility Incident Log and Situation Background Assessment and Request Forms (SBAR), October 2015 through February 16, 2016, identified R1 with falls without injuries on 10/13/15, 10/20/15, 11/13/15, 11/15/15, 11/25/15, 11/28/15, 12/14/15, 12/16/15, 12/18/15, 12/29/15, 1/4/16, 1/8/16. There were falls with injuries on 1/21/16 (steri strips for forehead abrasion) and 2/15/16 (Fracture of the cervical spinal fourth and fifth vertebrae). On 2/25/16 at 12:45pm E3 stated R1 was found on the bedroom floor after falling on 11/25/15 by E6 (Nursing Assistant). On 2/25/16 at 1:59pm, E6 stated R1 was supposed to have a personal fall alarm on but at the time E6 discovered R1 on the floor an alarm was not sounding. The SBAR dated 12/14/15 documents R1 was found on the floor in front of the recliner. On 2/25/16 at 12:45pm E3 stated R1 got up unassisted and was found on the floor by E7 (Nursing Assistant) after a fall on 12/14/15. On 2/25/16 at 2:04pm, E7 stated when E7 entered the room and found R1 the personal fall alarm was not sounding. On 2/25/16 at 2:28pm, E3 stated R1's personal fall alarm was to be utilized both in bed and in the chair. The SBAR dated 1/4/16 documents, (R1) tried to stand on own and fell to the floor on bottom. On 2/25/16 at 12:45pm E3 stated when a fall occurs the resident is to be evaluated for a new intervention to prevent further falls. E3 confirmed E3 was the manager who monitors and analyzes falls and an evaluation for an intervention was not done after the 1/4/16 fall. The SBAR dated 1/21/16 documents R1 as standing up in the hallway and lost balance causing R1 to fall to the floor. The January 2016 Physician order [REDACTED]. E3 stated R1 fell from the wheelchair and after this fall a physical therapy evaluation was ordered. E3 further stated, It doesn't appear (R1) was evaluated. On 2/25/16 at 2:45pm, E8 (Physical Therapist Assistant) stated R1 was last evaluated and treated in November 2015. The SBAR dated 11/13/15 documents R1 had his head laying on the dining room table asleep when the wheelchair wheel went back and R1 fell to the floor. On 2/25/16 at 12:45pm E3 stated the anti-rollback wheelchair brakes were added after this fall because E3 was leaning forward in the chair at the time of this fall. E3 stated the anti-rollback wheelchair brakes lock the wheelchair wheels so the wheelchair does not roll back when a resident stands up but when a resident sits down the wheelchair is not locked. E3 stated the anti-rollback wheelchair brakes were removed on 11/25/15 after R1's posture improved with therapy. E3 stated a formal assessment is not completed for the reduction of preventative fall devices. A review of October and November 2015 Physical Therapy notes did not identify R1 with inadequate posture while seated. physician progress notes [REDACTED]. The Fall Risk assessment dated [DATE] and 1/22/16 documents R1 at high risk for falls due to cognitive deficits, loss of balance while walking and standing, and requiring assistance to stand; loss of sitting balance is not marked as a deficit for R1. The Physician order [REDACTED]. The SBAR form 2/15/16 documents at 4:20pm E5 (Nursing Assistant) saw R1 fall. R1 had a red bump on the right side of the forehead and R1 was unable to recall how he fell . R1 is documented as sent to the emergency room for evaluation. The (2-15-16) handwritten statement, completed by E5 documents, (R1) trying to reposition himself back in his chair, while trying to do so chair when backward and (R1) fell on to the floor on (R1's) right side hitting (R1's) head . The Quality Assurance Fall Analysis form dated 2/15/16 documents R1 was witnessed attempting to scoot himself back in the chair when R1 pushed up on the arms of the wheelchair the wheelchair rolled back. On 2/25/16 at 2:21pm, E5 stated E5 was assisting another resident when E5 seen R1 trying to scoot back in the wheelchair and the wheelchair went backwards, behind R1 causing R1 to fall and hit head on the floor. E5 stated the wheelchair brakes were not locked when R1 fell . On 2/25/16 at 2:45pm, E8 Physical Therapy Assistant stated R1 was not able to stand independently, had poor cognition and would try to rise from the wheelchair unassisted. E8 stated anti-rollback wheelchair brakes prevent the wheelchair from rolling back to prevent residents from falling. On 2/25/16 at 2:04pm, E7 Nursing Assistant stated R1 would frequently attempt to stand up while holding onto the dining room table. E7 stated when R1 was at the table wheelchair brakes were kept locked to keep the wheelchair from rolling back. On 2/25/16 at 2:28pm, E3 stated R1 was able to unlock brakes. R1's Computerized Tomography (CT) Cervical Spine report dated 2/15/16 documents the indication for completion of this test is back pain after falling out of a wheelchair. The impression documents, Acute fracture at the C4-5 (Cervical Vertebrae) .with displacement . On 2/25/16 at 2:50pm, Z1 (R1's Physician) stated R1 was impulsive with actions and due to dementia R1 had poor safety awareness. Z1 stated she was not aware of the number of falls R1 incurred since admission to the facility but confirmed R1 had a fall 2/15/16 which resulted in a fracture of R1's cervical spinal fourth and fifth vertebrae. Z1 stated she didn't recall being notified the anti-rollback wheelchair brakes being removed from R1's wheelchair. Z1 stated she could not state if it was incorrect or correct for the facility to remove the anti-lock wheelchair brakes despite R1 frequently attempting to rise from the wheelchair unassisted and incurring falls from the wheelchair for this reason. The facility's Fall Prevention policy, revised 9/3/15, states the facility is to provide for resident safety and to minimize injuries related to falls .If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident .All falls are reported and discussed during the morning Quality Assurance meetings and any new interventions will be written on the care plan .Fall prevention interventions include personal alarm, pressure alarm for bed/chair, and Physical therapy referral.

A. Based on observation, interview, and record review, the facility failed to thoroughly investigate circumstances related to a fall and failed to assess the risk for entrapment and falls in the use of an air flow mattress and side rails for one of four residents (R13) reviewed for side rails in the sample of 14. These failures put the resident at risk for further falls with injury and entrapment, strangulation, or suffocation if she became lodged between the mattress and the rails. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 05/22/12, the facility remains out of compliance at a severity level two as the facility is in the process of evaluating the effectiveness of new safety interventions for R13. Findings include: R13's Physician order [REDACTED]. R13's Minimum Data Set ((MDS) dated [DATE] and 03/12/12 document that R13 is severely cognitively impaired, has no impairment of upper extremity range of motion, has impairment of one lower leg's range of motion (due to amputation), is unable to balance without human assistance, and requires extensive assistance with bed mobility. R13's Admission Fall Risk assessment dated [DATE] documents that R13 was at high risk for falls. R13's Interim Care Plan dated 09/14/11 documented R13's high risk for falls but did not document any safety precautions to be implemented by staff, nor did it direct the extent of assistance required for R13's bed mobility or transferring. The Investigation Report for Falls dated 09/18/11 documents that on 09/18/11 at 2:15pm R13 was found lying on her left side on the floor,"left arm pinned under the left side of her body, screaming in pain with any body movement, and head in a pool of blood." The Emergency Department Report dated 09/18/11 documents that R13 received 15 sutures to the left temporal laceration. On 05/22/12 at 12:05pm, E10, Licensed Practical Nurse (LPN), stated that on 09/18/11 when she responded to R13's fall, bilateral full side rails were raised on the bed with the air flow mattress. E10 confirmed this statement on 05/22/12 at 3:50pm. The Investigation Report for Falls dated 09/18/11 fails to document use of side rails at the time of R13's fall, but does document the following interventions to be implemented: 15 minute checks, side rails, and "family requested possibly low bed." The Investigation Report for Falls documents the root cause of the fall to be "Resident attempted to change position and was unaware of her limitations." On 05/22/12 at 4:16pm Z1, family member, stated that R13's fall was caused by R13 hallucinating and trying to feed her dog. Z1 stated that to her knowledge side rails were not being used at this time (9/18/11) for R13. The Investigation Report for Falls dated 09/18/11 and R13's MDS dated [DATE] do not document R13's hallucination. On 05/22/12 at 1:05pm R13 raised her right leg, left stump, and both arms upon command while in bed. The Facility investigation failed to demonstrate knowledge of R13's hallucinations, an assessed ability of R13's purposeful movement, and the appropriateness of R13's full side rails used in conjunction with an alternating air mattress. The Side Rail Assessments dated 09/13/11, 09/19/11, and 03/13/12 do not address the use of full side rails in conjunction with an alternating air mattress. Use of the low bed was not implemented. On 05/15/12 at 1:00pm R13 was lying on a standard height bed on an air flow mattress with bilateral three-quarter side rails in use. The side rails extended from R13's axilla to her ankle. The side rails extended four inches above the height of the mattress. On 05/22/12 at 1:15pm, the foot and head of the air mattress was compressed (with the resident lying in the bed) to the bottom structure of the bed, approximately four and one-half inches using one hand. This compressible space was confirmed on 05/23/12 at 2:00pm with E5, Maintenance Supervisor. Including this compressible space and the four inch extension of the side rails above the mattress, there is an eight and one-half inch space along the side rails on both sides of the bed in which R13 could be entrapped or wedged. This compressible space has the potential to cause entrapment or wedging of R13's limbs, head, neck, or chest between rails and the mattress, or spaces between side rails and the foot board of the bed and cause serious injury or death. On 05/15/12 at 1:00pm and 3:30pm when R13 was positioned to her right and left sides, there was no padding between R13, the rail, and the mattress to prevent entrapment. On 05/16/12 at 9:15am, 11:15am, 1:30pm, and 3:45pm, there was no padding between R13, the rail, and the mattress to prevent entrapment. On 05/17/12 at 9:00am, 12:00pm, and 1:30 pm, there was no padding between R13, the rail, and the mattress to prevent entrapment. On 05/22/12 at 1:05pm there was no padding between R13, the rail, and the mattress to prevent entrapment. On 05/22/12 at 1:05pm R13 demonstrated that she had the ability to raise her right leg, left stump, and both arms (purposeful movement). The four inches the raised side rails extend above the mattress could enable R13 to place her leg on the rail and roll over the side of the bed onto the floor and injure herself. On 05/22/12 at 2:10pm, an Immediate Jeopardy was identified to have begun on 09/18/11 when facility staff failed to thoroughly investigate circumstances related to a fall with injury and failed to assess and mitigate the risk for entrapment and falls in the use of an air flow mattress and side rails for R13, who was assessed as a high fall risk on admission (09/14/11). E1, Administrator, was notified of the Immediate Jeopardy on 05/22/12 at 2:30pm. The surveyor confirmed though observation and interview that the facility took the following actions to remove the Immediate Jeopardy: 1. R13 was moved to her reclining chair at approximately 2:45pm on 05/22/12 upon notification of the Immediate Jeopardy. 2. R13 was reassessed for side rail usage on 05/22/12. 3. Hospice was contacted on 05/22/12 at 2:45pm to provide a high low bed with half side rails for R13 and air mattress. These were delivered on 05/22/12 at 6:10pm. R13 was placed in the bed in a low position. B. Based on observation, interview, and record review, the facility failed to implement safety measures for five of eight residents (R7, R11, R12,R13, R18) reviewed for falls during personal care and transfers and failed to fully conduct an investigation of falls to prevent recurrent falls. Findings include: 1. On R11's May 2012 Physician order [REDACTED]. R11 was admitted on [DATE] and the initial Minimum Data Set (MDS) on 2-8-12 identifies R11 as independent with Bed Mobility; Supervision/set up help for transfers, toileting and personal hygiene; and Supervision/1 person physical help for ambulation on the unit. The " Investigation Report For Falls" dated 2-22-12 documents R11 had a fall on 2-22-12 at 4:00 pm without injury from the wheelchair with the intervention added for a mobility monitor in the wheelchair. The "Quality Care Reporting Form" dated 3-23-12 at 4:00pm documents R11 attempted to stand during an activity and the wheelchair rolled back allowing R11 to fall. The intervention was to add anti roll back brakes to R11's wheelchair. The "Quality Care Reporting Form" dated 4-21-12 at 8:30pm documents R11 had a fall from her bed and the investigation indicated R11 had a Urinary Tract Infection. The Investigation Report dated 4-21-12 for R11's fall indicates the mobility alarm was on and working. The intervention indicates the facility would add 15 minute checks. The "Quality Care Reporting Form"dated 5-8-12 documents R11's fall at 3:30pm from bed resulted in an injury to the right side of her head above the right eye and the right cheek was red. R11 also had a skin tear on the right hand near the first digit and a slight bruising noted on the right knee. R11 was sent to a local hospital emergency room and admitted for testing. According to Nurses Notes on 5-10-12 ". . .upon palpation to right forehead area states pain when touched, continued edema (below knee left extremity), multiple bruises over body none open." On 5-22-12 at 9:20am E2, Director of Nursing (DON), stated the bed (pressure) alarm was implemented for R11 at the initial admission per her daughter's request. On 5-15-12 at 1:46pm E7, Licensed Practical Nurse, (LPN) E7 stated R11 is not usually compliant with the alarms. E7 described R11 as removing the clip alarm and removing the battery case so staff have to hide it from R11. On 5-17-12 at 11:55am E13, CNA stated R11 requires minimal assist to hold her just in case. E13 stated R11 is forgetful and said mentally she is about the same as she was at the time of the fall on 5-8-12. E13 verified she was the CNA taking care of R11 up to 2:00pm on the day of the fall. E13 stated R11 had a bed alarm and a chair alarm both on and staff had to hide them because she would turn them off. On 5-17-12 at 5:05pm E12, LPN stated she was working the second shift on 5-8-12 and heard R11. E12 stated " I heard Help." E12 stated she ran to R11's door and it was shut, no alarms were activated. E12 stated R11 had the pressure alarm in the bed and the one clipped to the wheelchair. E12 stated R11 had been in bed but was found sitting on the floor close to and leaning up against the bed. E12 stated "(R11) can take the (alarm) device with her so we try to hide them. I found the device (bed) and tried it and it wasn't turned on. I turned it on and tried it and it worked." On 5-20-12 at 9:40am E2, DON (regarding the investigation of R11's fall on 5-8-12) stated she had interviewed E21, CNA assigned to R11 at the time of the falls who wrote out a statement indicating R11 had been checked every 15 minutes while sleeping with the (personal safety alarm) attached to her clothing. E2 stated the alarm device was found on R11's nightstand and R11 had taken off the personal alarm. The "Investigation Report For Falls" indicated "bed alarm and alarm attached to resident". E2 was asked if she had interviewed E12, the nurse who first entered the room and tried the alarm devices. E2 stated "No, I interviewed the nurse assigned to that hall and the CNA. I obtained statements from both. They are attached." E2 verified the only new intervention added after this fall was a fall mat according to the Investigation Report. E2 stated they did change out the type of chair alarm to be a pressure alarm device. The Investigation Form does not document results of the "Root Cause Analysis" of R11's fall on 5-8-12 to help them identify what interventions would be effective to help prevent future falls. At this time E2 stated "On this form we wrote (indicating Quality Care Reporting Form) "attempting to get out of bed." 2. R13's Physician order [REDACTED]. R13's Minimum Data Set ((MDS) dated [DATE] and 03/12/12 document that R13 is severely cognitively impaired, has impairment of one lower leg's range of motion (due to amputation), is unable to balance without human assistance, requires extensive assistance with bed mobility, and is always incontinent. On 05/15/12 at 1:35pm while assisting with incontinence care, E15, Certified Nursing Assistant (CNA), pulled R13 over to the side of the bed and hit R13's head on the wall. R13 yelled "Ouch!" On 05/15/12 at 1:36pm E15 stated R13 should have been repositioned in bed in order to avoid hitting R13's head when turning her and asked E14, CNA, to assist her with repositioning R13 before continuing on with incontinence care. 3. R12's POS dated May 2012 documents the following Diagnoses: [REDACTED]. R12's MDS dated [DATE] documents that R12's balance is unsteady at all times and that she requires human assistance to stabilize. The MDS dated [DATE] also documents that R12 requires limited assistance with bed mobility and transferring. On 05/15/12 at 10:40am R12 was lying in her bed with bilateral bed bolsters and bilateral full side rails. On 05/17/12 at 11:58am, the bilateral side rails were raised on R12's bed. On 05/17/12 at 12:07pm, E16, CNA, confirmed that the rails on R12's bed were raised. On 05/17/12 at 12:07pm, E16 stated that the bilateral full side rails are used to keep R12 in bed because she will try to get up and toilet herself and fall. E16 stated that bilateral full side rails are used in addition to bilateral bed bolsters because "(R12) will climb over the side rails." E16 also stated at this time that the bilateral full side rails were implemented after one of R12's falls. On 05/23/12 at 1:00pm, E17, CNA, confirmed that she sometimes uses the bilateral full side rails to keep R12 in bed and prevent falls. The Investigation Report for Falls documents that R12 fell [DATE], 03/25/12, 04/12/12, 04/20/12, and 04/23/12. R12's Fall Risk Assessments dated 03/24/12, 03/25/12, 04/12/12, 04/20/12, and 04/23/12 document that R12 was at high risk for falls. R12's Side Rail assessment dated [DATE] documents the recommendation that no side rails be used with R12's bed. R12's POS dated May 2012 did not include an order for [REDACTED]. R12's Care Plan addressing Risk for Fall dated 03/24/12 and updated 04/12/12, 04/20/12, and 04/23/12 documents the following interventions: resident educated to use the call light when needing to transfer, bed alarm, medication review, medication reduction, urinalysis and culture, basic metabolic profile, complete blood count, nonskid footwear, staff educated on all interventions, resident turns off alarms, and bed bolsters. Side rails are not listed as an intervention on the Care Plan. On 05/17/12 at 11:55am, E2, Director of Nursing (DON) stated that the side rails on R12's bed were zip-tied down to make them inoperable. On 05/23/12 at 12:30pm E5, Maintenance Supervisor, stated that when he removed the bilateral full side rails from E12's bed after 05/17/12, the rails were not zip-tied down to make them inoperable. According to State Operations Manual, Appendix PP (revised 01/07/11), the Food and Drug Administration in a Safety Alert entitled "Potential Hazards with Restraint Devices," side rails can increase resident safety risk resulting in increased incidence of falls or head trauma due to falls (1992). The facility failed to identify and prevent bilateral full side rails being raised on R12's bed when she was in bed, even when contraindicated by the Side Rail assessment dated [DATE]. R12's Care Plan for Fall Risk interventions dated 03/24/12 and updated 04/12/12, 04/20/12, and 04/23/12, and the Investigation for Falls Report's new interventions to prevent falls dated 03/24/12, 03/25/12, 04/12/12, 04/20/12, and 04/23/12 also contraindicated side rail use. The Facility's undated Fall Prevention Policy does not address the use of side rails. . 4. R7's POS includes the [DIAGNOSES REDACTED]. R7's MDS of 3-7-12 identifies bed mobility, dressing, ambulation on/off the unit, and personal hygiene as extensive assistance with one person physical assist. This MDS identifies R7's transfer needs as extensive assistance with two plus persons physical assistance. The "Quality Care Reporting Form" dated 3-10-12 documents R7's fall on 3-10-12 at 6:25am without injury. The "Investigation Report for Falls" dated 3-10-12 indicates the CNA was in the room with R7 sitting in bed. The report states R7 began sliding and CNA eased her to the floor. This form identifies the cause of the fall as "Inadequate footwear. " On 5-23-12 at 9:40am E2, DON stated the investigation for R7's fall on 3-10-12 included the statement from E23, CNA ". . .went to get (R7) dressed. I sat her on the side of the bed. She started sliding so I eased her to the floor." On 5-23-12 at 9:40am E2, DON stated " I spoke to the CNA, (E23), she said she sat the resident up at the side of the bed to put on her shoes. She didn't know why she did that. She only had on regular socks and they slide on this floor. " According to the Investigation Report for Falls dated 3-10-12 the intervention identified to prevent future falls was for R7 to have footwear before getting out of bed. This intervention was verified with E2, DON on 5-23-12 at 9:40am. 5. R18's May POS includes the [DIAGNOSES REDACTED]. R18's MDS of 4-20-12 identifies bed mobility, transfers, ambulation on/off unit, dressing, toileting, and personal hygiene as limited assistance with one person physical assist. The "Quality Care Reporting Form" dated 4-9-12 documents R18 had a fall at 3:15pm with identified bruises and pain to Right upper arm and right hip. The review indicates "(R18) impulsive on walk to dine program fell did not inform anyone. (Wheelchair) alarm (added)." Nurses Notes on 4-9-12 of x-rays indicated no additional injuries were received. The "Investigation Report For Falls" dated 4-9-12 only indicates there is a "mobility alarm on the bed" and that R18 has "Aphasia". Everything else is marked "unknown" under Prompts and Observations. The section marked for the cause of the fall states " unaware of limits - Stroke (right) body CVA unsteady gait, not seeking assistance." The only interview documented was from the attending nurse asking yes/no questions of R18, indicating R18 fell in his room without anyone present. On 5-23-12 at 9:30am E2, DON stated (regarding the investigation of R18's fall on 4-9-12) "(R18) was observed up earlier walking by himself in the hall. He did not have bruises then, they were found on his upper arm, you could see the one just below his shirt sleeve. It was reported by his wife when she came in." E2 verified this information was not in the report. E2 also verified that she did not interview any other staff to see if they noticed any bruising or redness earlier in the day when helping with R18's care.

Based on observation, record review and interview, the facility failed to maintain 3 of 4 designated exits free of snow and ice, preventing a clear pathway for egress of residents in the event of a fire or need for evacuation. This failure placed all 49 residents at risk. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 2-10-11, the facility remains out of compliance at a Severity Level 2, as the facility continues to monitor the effectiveness of staff education. Findings include: A modified tour was conducted at 8:00 A.M. on 2-10-11 to ensure that the 4 emergency exits had clear pathways to public way. The Dietary Manager, E3 was present during the tour. E3 stated she was the only supervisor in the facility at that time. According to the facility floor plan and posted evacuation route, the facility has 4 designated emergency exits to be used during emergencies for evacuation: the West (main entrance), the South (lounge), the Northeast (East resident corridor), and the Northwest (North resident corridor and service corridor). The West exit is the main front entrance and was cleared to the parking lot/ public way. The remaining three exits were not cleared to allow passage of residents to the parking lot/public way. 1. The South emergency exit door could only be opened approximately 12 inches The snow and ice had not been attempted to be removed from in front of the door or off of the sidewalk. The distance between the South exit and parking lot/public way is approximately 30 feet. The encrusted snow and ice had accumulated approximately 5 to 6 inches on the sidewalk making it impassable to the parking lot/public way. 2. The Northeast exit door is located in the back (East) resident room corridor. The exit door was able to be opened and the immediate 4 foot by 4 foot concrete pad was free of snow and ice. The sidewalk that continues on from the concrete pad had 2 inches or more encrusted snow and ice on it. This sidewalk extends approximately 120 feet from the Northeast exit door to the east side of the free standing laundry building. Approximately 20 feet of this sidewalk from the Northeast exit door had been cleared, but the width of the cleared area was only 21 inches, preventing passage of wheelchairs. From the laundry building one would need to continue down another 20 feet of sidewalk, past a dumpster to the parking lot. The sidewalk between the laundry building and the dumpster was clear and passable up to the dumpster,but the distance from the dumpster to the parking lot/a public way had not been cleared. Snow was piled up approximately 12 inches between the dumpster and the parking lot. 3. The Northwest exit door opened to the cleared shared path with the Northeast exit. The sidewalk was cleared from the door to the dumpster. Snow was piled up approximately 12 inches and the path did not open into the parking lot, a public way. The facility's "Snow Removal & Ice Treatment Procedures" policy states, "Snow removal must start as soon as possible. In other words, we do not wait until the snow stops to begin.....6. Facility staff will clear a path from all emergency exits to a public way and insure those paths remain unobstructed in a width allowing for the safe transfer of all residents in the event an evacuation is necessary." The "Facility Data Sheet" listed 49 residents in the facility. On 2-10-11 the Activity Director, E5 provided a list of residents that use and or are depended on wheelchairs for mobile. Thirty-eight of the forty-nine residents use wheelchairs. In addition, two residents use larger or bariatric wheelchairs. The residents' wheelchairs vary in width from as small as 26 inches to 33 inches. The observed wheelchairs had narrow 1 inch wide tires. The residents in wheelchairs would be difficult to evacuate over the snow and ice. In addition, non wheelchair residents would be at risk for falling on the snow and ice. The Maintenance Director, E4 on 2-10-11 at 9:05 A.M. was asked about the snow and ice remaining on the sidewalk and lack of clear path to a public way. E4 stated the facility's snow blower was not functioning. E4 stated, "I have been working on it a little bit each day." E4 stated, "The walks have not been cleared since before the snows." E4 did not recall the day or date the walks were cleared to a public way. The Administrator, E1, on 2-10-11 at 11:10 A.M. was asked how long the snow and ice has been on the sidewalks. E1 stated, "It was since last Wednesday (2-2-11)." An Immediate Jeopardy was identified on 2-10-11. E1, Administrator, was notified of the Immediate Jeopardy on 2-10-11 at 9:40 A.M. The Immediate Jeopardy situation was identified to have begun on 2-2-11 when staff failed to remove snow and ice from the emergency exits following the winter storm on 2-1-11 and 2-2-11. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2-10-11 at 4:45 P.M. facility Maintenance staff had removed the snow and ice from all emergency exits and walkways to a public way. 2. On 2-10-11 Regional and Corporate staff conducted an inservice with the Administrator, Maintenance Staff and interdisciplinary team. This covered the Snow Removal and Ice Treatment Procedure, resident risks and environmental hazards, physical plant hazards, the Environmental Supervisor job description, grounds policy, Maintenance services and the disaster plan.

Based on record review and interview the facility failed to provide a safe transfer of one resident (R3) by using a sit to stand lift the resident was not capable of using which resulted in (R3) falling, sustaining an Anterior Inferior Left Shoulder Dislocation. The facility also failed to supervise (R1) during toileting by leaving (R1) unattended on the toilet which resulted in (R1) falling and having additional swelling and pain to the left ankle that was already fractured from a previous injury. R3 and R1 are two residents in a total of 3 sampled for falls . Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] shows that R3 is severely impaired in cognitive skills for daily decision making, is totally dependent on two staff members for transfers and activities of daily living. The same MDS continues to show that R3 has limitations in range of motion with impairment on both sides of the body to include upper and lower extremities. The facility form titled "Fall Risk Assessment" dated 6/19/10, 9/17/10 and 11/9/10 shows R3 to be at high risk for falls. The facility form titled "Investigation Report for Falls" dated 11/4/10 under the section titled "What was the resident doing or trying to do at the time of the fall?"states " (R3) was being transferred from wheelchair to the bed using a sit to stand lift, improper transfer." The report continues under section titled "Root Cause Analysis" states "(R3) could not hold onto the sit to stand lift or stand properly for transfer." Nurses Notes dated 11/4/10 at 5:45 PM documents " (R3) complains of left arm pain upon touch, .....new orders received for x-ray of left arm...." Nurses notes on 11/5/10 documents that X-ray report shows an Anterior Dislocation of the Left Humeral Head. Hospital report titled "Report of Operation" dated 11/7/10 for R3 states that the preoperative [DIAGNOSES REDACTED]. E1, Administrator on 1/28/11 at 12:30 PM confirmed that R3 was improperly transferred using a sit to stand lift and received a left shoulder fracture due to the incident. E2, Director of Nurses confirmed the same information on 2/3/11 at 2:30 PM. 2. The POS dated January 2011 lists the following [DIAGNOSES REDACTED]. The MDS dated [DATE] shows that R1 is severely impaired in cognitive skills for daily decision making, requires extensive assistance with all activities of daily living to include transfers, toileting and personal hygiene. The same MDS continues to shows that R1 has limitations in range of motion with impairments on both sides of her body to include upper and lower extremities. The facility form titled "Fall Risk Assessment" dated 9/3/10, 11/1/10, 11/4/10 and 1/21/11 shows R1 to be at high risk for falls. Nurses Notes dated 12/22/10 at 2 PM for R1 shows that R1 complained of left ankle pain and slight swelling . A new order was received for an x-ray to be done. The X-ray report dated 12/22/10 under the section titled "Findings" states "A fracture of the distal fibula is noted..... Soft tissue swelling is present. Conclusions...Distal fibular fracture." According to the facility's" Investigation Report for Falls" dated 12/22/10 the cause of the injury was undetermined. An additional facility report titled "Investigation Report for Falls" dated 12/29/10 for R1 states under the section titled "Root Cause Analysis" states "Dementia, unstable gait, poor balance. Left alone on toilet." The same report under section titled "What new intervention was implemented to prevent any further falls" states to continue 15 minute checks by staff and " Do Not Leave Resident on Toilet by herself." Nurses Notes dated 12/29/10 at 5:10 AM states that R1 complains of pain when moving left ankle and CNA (Certified Nurses Assistant) will not leave R1 unattended while using the restroom and R1 cannot remember to use call-light. Nurses Notes dated 12/29/10 at 10:20 PM states that a new order was received for elastic wrap to left ankle, re-wrap twice a day, keep left ankle elevated, apply ice pack to left ankle for 10 minutes four times a day times two weeks and give Ultram 50 mg (milligrams) one tablet every 4 to 6 hours for pain. E2, Director of Nurses on 2/3/11 at 12:25 PM stated that there was no alarm on R1 when she was using the toilet and the CNA left R1 unattended on the toilet.