Every finding on record at La Bella of Aurora

Based on observation, interview, and record review, the facility failed to serve the correct protein entrees as planned per the facility approved menu.This applies to all 50 residents receiving regular, mechanical soft, low concentrated sweets, and no added salt diets in the facility. The findings include: Facility Daily Census, dated 4/24/26, shows the facility census was 58 residents.Facility Diet Type Report, dated 4/25/26, shows 7 residents received pureed diets, 1 resident had physician orders for NPO (Nothing By Mouth) and the rest of the residents received either regular, mechanical soft, low concentrated sweets or no added salt diets.On 4/25/26 at 10:29 AM, R1 (Resident Council President) stated residents were served very small entree portions such as small squares of fried fish at meals.On 4/25/26 at 11:45 AM, during lunch service, R2, R4, and R5 were served a bowl with mostly rice and few pieces of cut sausage and a few beans. There were no salt or pepper packets on the meal trays or table. On 4/25/26 at 12:20 PM, V8 (Cook) was serving 4 fluid ounces of jambalaya into bowls and serving them to residents. A test tray was obtained, and the sausage/chicken/beans were removed from the jambalaya mixture. The sausage/chicken/beans were weighed in the presence of V1 (Administrator) and the proteins weighed less than 1 ounce. V4 (Food Service Manger) stated the protein in the dish should weigh 2 ounces, and V8 should have served two - 4 fluid ounce scoops of jambalaya to each resident. On 4/25/26 at 1:05 PM, V4 stated she expected the cook to review the meal item recipes at meals to determine what serving sizes and serving utensils were to be used to serve menu items.Facility Recipe Card - Jambalaya, shows the entree served at lunch was to be served with an 8-ounce spoodle (one cup) and was to provide 2 ounces of protein. Diet spread sheet Week 4 Day 28 Saturday showed all residents receiving oral diets other than pureed diets received the regular portion of Chicken Sausage Jambalaya which was to be served with an 8-ounce spoodle (1 cup total). Facility Menu Planning Requirements document, dated 2020, shows, Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served. Menus are planned in advance and are varied for the same day of consecutive weeks. Cycle menus are to be planned for a minimum of one week or based upon specific state regulations. Cycle menus are reviewed semi-annually and consideration is given to resident input. Planned menus take into consideration cultural backgrounds and food habits of residents. Regular and therapeutic menus are planned by a nutrition professional in accordance to the community's approved diet manual. The planned menus are reviewed and approved by a registered dietitian (RD). Facility Standardized Recipes document, dated 2020, shows, Standardized recipes will be used for all menu items. Each standardized recipe will include the following: Serving Sizes. Menu Diet Spreadsheets/Portion Serving Communication Tool document, dated 2020, shows, Diet spreadsheets are based on the planned menu and reflect serving portions for regular and therapeutic diet orders offered in the community. 2. On 4/25/26 at 10:29 AM, R1 (Resident Council President) stated the facility did not serve the menus as planned and often ran out of foods such as apple juice, butter, cereal, cheese, ham, and other items. R1 stated the residents complained and discussed the concerns at resident council meetings and no resolutions were provided.On 4/25/26 at 12:10 PM, R7 (Resident Council [NAME] President) stated the facility was often out of food items, the food was served in small portions, and the facility was often out of condiments at meals. R7 stated the residents complained during meals, and the residents voiced concerns at resident council meetings, but R7 stopped speaking up because there were no resolutions to the concerns from the facility. On 4/25/26 at 11:03 AM, R2 stated the facility often did not serve the planned menu or ran out of foods while serving the meal items. R2 stated the facility was also often out condiments such as sugar, salt, pepper, ketchup, mustard, and mayonnaise. R2 stated the facility was out of cheese once or twice a week. R2 also stated the facility ran out of juice for meals.On 4/25/26, R4 and R5 both stated the facility food service often runs out of condiments including salt and butter and also ran out of substitution menu items such as ham and cheese.On 4/25/26 at 11:45 AM during lunch, R6 had coffee on his tray and stated he always puts sugar in his coffee. R6 stated was not served sugar for his coffee and had to borrow sugar packets from R2, who saves the packets he does not use at meals, because the facility often runs out of sugar packets. R6 stated the facility often did not have ketchup or mustard at meals.On 4/25/26 at 12:00 PM, V10 (Certified Nursing Assistant/CNA) stated the residents complain the facility runs out of condiments. On 4/25/26 at 12:28 AM, V12 (CNA) stated the facility often ran out of condiments at meals.On 4/25/26 at 2:34 PM, V11 (CNA) stated the facility did not always follow the planned menus and sometimes the facility was out of juice at meals when it was to be served per the planned menu. On 4/25/26 at 11:58 AM in the kitchen during meal service, V8 (Cook), V7 (Food Service Worker), and V9 (Cook Aide) all stated the facility was out of butter packets for residents for at least a week and out of salt and pepper packets for a few days. V9 stated the facility was out of cucumbers, tomatoes, and onions at that time. On 4/25/26 at 1:43 PM with V1 (Administrator) present, V4 stated the chef salad on the substitution list was served with lettuce, American cheese, and deli meat (ham or turkey). V4 stated the chef salad only included tomato or cucumber if those items were being served on the menu that week and were in stock in the kitchen, but V4 did not order those items to have them available for substitution salads. On 4/25/26 at 11:27 AM with V1 (Administrator), V4 (Food Service Director) stated the facility was out of packets of sugar, salt, pepper, and butter for residents. At 12:20 PM, V4 stated the facility had no brown sugar available. At 1:05 PM, V4 stated condiments are not specified on the written menu but should automatically be served as part of the facility menu.

Based on interviews and record reviews, the facility failed to offer residents a variety of appealing meal substitutions based on resident preferences per facility policy.This applies to all 57 residents receiving oral diets at the facility.The findings include: Facility Daily Census, dated 4/24/26, shows the facility census was 58 residents.Facility Diet Type Report, dated 4/25/26, shows one resident had physician orders for NPO (Nothing By Mouth).Facility Alternate Menu, undated, showed residents were offered the following substitutions if they were unsatisfied with their menu items served at meals: 1. Deli Sandwich; 2. Grilled Cheese; 3. Chef's Choice Salad with Italian or Catalina dressing; 4. White/Wheat/Rye Bread.On 4/25/26 at 10:29 AM, R1 (Resident Council President) stated residents were frustrated with the lack of meal substitution variety and were complaining at meals and during resident council meetings with no resolutions. R1 stated many residents do not like the food served at the facility and the meal substitution offered at the facility was limited to grilled cheese or sometimes grilled ham sandwiches. R1 stated if they receive a ham sandwich, they are told they cannot have cheese on the sandwich. R1 stated the facility stopped offering hamburgers and pizza as meal substitutions and the residents were still upset their choices were so limited. R1 stated she reported her concerns to V4 (Food Service Manager) but no improvements were made.On 4/25/26 at 12:10 PM, R7 (Resident Council [NAME] President) stated the residents have complained during meals and at resident council regarding the lack of available substitution choices at meals. R7 stated the facility only provided grilled cheese sandwiches if the residents did not like what they were served. R7 stated the facility previously offered a variety of choices as substitutions including pizza or hamburgers and not just grilled cheese sandwiches. R7 stated she stopped speaking up because voicing her concerns resulted in no resolutions and she gave up trying. R7 stated the residents have complained about the food and lack of substitutions for some time and continued to only receive grilled cheese sandwiches as substitutions.On 4/25/26 at 11:03 AM, R2, R4, and R5 all stated they and many residents did not like the food served at the facility. The residents stated the available menu substitutions were very limited, and typically there were only grilled cheese sandwiches available for substitutes. The resident stated the facility sometimes had a ham sandwich available but would serve it without cheese. On 4/25/26 at 2:34 PM, V11 (Certified Nursing Assistant/CNA) stated the residents complain they don't like the facility food and have very limited meal substitutions available. V11 stated the residents previously had more substitution choices but residents were currently only offered grilled cheese sandwiches. On 4/25/26, V12 (CNA) stated the facility food did not look the best and residents only had grilled cheese sandwiches as substitutions that were offered.On 4/25/26 at 9:06 AM, V2 (Licensed Practical Nurse) stated the residents at the facility frequently complain they do not like their meals, ask for meal substitutions, and complain they do not have food choices when they do not like their meals.On 4/25/25 at 9:30 AM, V3 (Registered Nurse) stated residents complain they do not like the food served at the facility and complained they wanted more variety of meal substitutes at resident council meetings.On 4/25/26 at 12:00 PM, V10 (CNA) stated the residents complain they have a lack of variety of substitutions at the facility during meals. V10 stated the residents are only offered grilled cheese as substitutes when they request a substitute for meals. Facility Resident Council Meeting Minutes, dated 3/5/26 and 4/9/26, both show the residents complained the facility menus lacked variety. On 4/25/26 at 10:10 AM, V4 (Food Service Manager) stated she took hamburgers and pizza off the resident meal substitution menu because beef was too expensive and pizza was not affordable. V4 stated when she recently received her budget, she changed the alternate/substitution list to include only deli sandwiches or grilled cheese. V4 stated the residents were most likely upset because they were no longer offered hamburgers on the substitution menu. On 4/25/26 at 1:43 PM with V1 present, V4 stated the chef salad on the substitution list was served with lettuce, American cheese, and deli meat (ham or turkey). V4 stated the chef salad only included tomato or cucumber if those items were being served on the menu that week and were in stock in the kitchen, but V4 did not order those items to have them available for substitution salads. V1 stated American cheese was utilized to make all 3 of the entrees offered on the substitution list including the grilled cheese sandwich, deli sandwich, and chef salad. V4 stated the same deli meat was used to make the deli sandwiches and chef salads on the substitution list. V4 stated she changed the substitution menus after she reviewed her budget and removed hamburgers, hot dogs, and pizza. On 4/25/26 at 11:58 AM during lunch service, V8 (Cook), V7 (Food Service Worker), and V9 (Cook Assistant), stated the facility did not have cucumbers, tomato, or onions available in the kitchen. There were cooked grilled cheese sandwiches sitting in a steamtable pan on the serving line. V8 stated upon request, he will cook a grilled ham and cheese sandwich as a substitute. Facility document other Menu Selections, dated 2020, shows, Other Menu Selections may be available and offered, per facility standards, to offer additional choice and variety at meals. In the event the planned main meal is not accepted or refused, foods from other Menu Selections may be offered. Procedure: 1. A list of Other Menu Selections is created and available based on the community preferences, consisting of both hot and cold meal items for both the lunch and dinner meals. 2. The list of Other Menu Selections contains a variety of food options including entrees and sides. 3. At a minimum, the Other Menu Selections list is reviewed by a resident committee for proposed changes twice per year.

Based on interview and record review, the facility failed to prevent diversion of resident's money by a staff member.This applies to 1 of 3 residents (R3) reviewed for misappropriation of funds in the sample of 11.This failure resulted in psychosocial harm when R3 stated she feels terrible and bothered when the staff member took her hard-earned money without her consent. The findings include:R3 was admitted to the facility on [DATE]. R3 had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, generalized muscle weakness, unspecified lack of coordination, and anxiety disorder, based on the face sheet.R3's quarterly MDS (Minimum Data Set), dated February 6, 2026, showed the resident was cognitively intact.On March 6, 2026, at 2:04 PM, R3 was sitting on her bed inside her room. R3 was alert and was able to answer questions. R3 stated she had a car accident sometime in July 2025 and since admission at the facility, there were several suspicious transactions in her bank account. R3 stated her bank sent the statements, and she noticed her bank card is being used by someone here at the city where she currently resides (city where the facility is located) and she did not recognize the charges. During the same interview, R3 stated after her car accident, she had no place to store her car while she was residing at the facility. R3 also stated V4 (Receptionist) was storing her car for her at her (V4) place. R3 stated she told V4 that she could use the car if she needed it to pick up her kids or get groceries. According to R3, while V4 was using her car, V4 went 10 miles over the speed limit and V4 received a ticket. Since V4 did not have any money to pay for the ticket, R3 stated she paid for it, however, she does not remember how much.On March 6, 2026, at 3:22 PM, the above information shared by R3 was brought to the attention of V1 (Administrator) and V2 (Director of Nursing).On March 9, 2026, at 12:35 PM, during an over the phone interview, V4 (Receptionist) stated she was suspended from the facility starting March 6, 2026. V4 stated from August 2025 through March 6, 2026, she was storing R3's car at the back of her house and V1 (Administrator) and V9 (Social Worker) were aware of it. V4 stated on the afternoon of March 6, 2026, after being told that she was suspended, the facility had R3's car towed to the facility's parking lot. According to V4, I just wanted to help [R3], then R3 wanted to pay for storing the car at her property. V4 stated R3 decided to keep the car at her property because eventually the resident wanted to use her car when she got discharged from the facility. V4 stated R3 told her that she could use the car when she needed it. V4 admitted R3 had given her a total of $1,490.00 from January through February 2026. According to V4, the $1,490.00 payments were made by R3 using her (V4) phone-based application (an application that enables her to accept credit card payments). V4 was asked how those transactions were made. V4 stated randomly, R3 would tell her she wanted to give some money for storing the car, so she (V4) would accept the money by using the phone-based application. R3 would enter the amount she wanted to give on the phone-based application then R3 would tap the credit card on the phone, and the credit card would be charged paid to V4. V4 was asked to account for the $1,490.00 that she received from R3. According to V4, out of $1,490.00, the $500.00 was for the release of R3's car from the impound. V4 stated while driving R3's car, she received a speeding ticket and the car was impounded. She (V4) showed R3 the ticket and told the resident she was working on paying for the $500.00 ticket so the car could be released, but R3 offered to pay for it, and since R3 was the owner of the car, the resident also had to sign the documents for the car to be released. Per V4, the remaining $990.00 was given to her by R3 randomly, as payment for storing the resident's car. V4 stated she did not know she cannot receive any money or other financial compensation from the residents.On March 9, 2026, at 1:14 PM, R3 was sitting on her bed. In the presence of V1 (Administrator), R3 stated since V4 was keeping her car at her property, she offered V4 to use her car if she needed to pick up her kids, shop, or do groceries. According to R3, she remembered giving money to V4 for cleaning the car because according to V4 her friend offered to clean it. R3 added she also remembered giving money to V4 at least twice for gas, which she claimed was not much, possibly between 20 to 50 dollars, and she also gave some money to V4 possibly around Christmas time. R3 stated the money was sent through the phone. R3 denied giving money to V4 through the phone as payment for storing her car. During the same interview, R3 expressed she had suspicion that V4 might be the one using her bank card, but she could not be certain.On March 9, 2026, at 1:50 PM, V9 (Social Worker) stated she was aware V4 (receptionist) was keeping R3's car at her property and thought V4 was just being helpful. V9 was not aware V4 was receiving money from R3 for storing the car, nor was she aware R3 had to pay for the release of the resident's car from the impound because V4 had the driving ticket.On March 9, 2026, at 1:57 PM, V1 (Administrator) was informed V4 (receptionist) admitted to receiving money from R3 in the amount of $1,490.00 for storing the car at her property and for the release of R3's car that was impounded because of a speeding ticket that was incurred by V4. V1 stated he was aware V4 was keeping R3's car at her property. According to V1, V4 told him that she has space to keep the car and since R3 was residing at the facility, she (V4) can keep it until such time. V1 commented he thought V4 was doing it out of the goodness of her heart. V1 was not aware V4 was receiving money from R3 for storing the car and was also not aware R3 paid for the release of the car from the impound because of V4's driving ticket. During the same interview, V1 stated the facility staff, including V4, had received an in-service regarding abuse, which included the prohibition of accepting and/or receiving money or financial assistance from any resident.On March 9, 2026, at 3:15 PM, R3 stated she used to be a bank auditor and an accountant, I know how to account for my money and other people's money. According to R3, if someone from the facility was taking money from her without her consent, she would feel terrible and bothered because she had worked her whole life for her money. R3 stated, I might lose sleep over it.The facility's policy regarding abuse, neglect, and exploitation, with implementation date of October 1, 2025 and last reviewed/revised on March 6, 2026, showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The facility's policy regarding prohibition on staff requesting or accepting money, gifts or financial assistance from residents or resident representative, with implementation date of October 1, 2025 and last reviewed/revised on March 6, 2026, showed the purpose of this policy is, To protect residents from financial exploitation and ensure compliance with resident rights by prohibiting staff from requesting or accepting money, gifts, loans, or financial assistance from residents or their family members, representatives or visitors. The policy showed under the policy statement that, Employees, contractors, volunteers, students, and agency staff are strictly prohibited from requesting, borrowing, soliciting or accepting money, gifts, or any form of financial assistance from residents or their family members, representatives, or visitors. This policy supports the facility's commitment to preventing financial exploitation, abuse, and misappropriation of resident property and ensuring residents are protected from undue influence or coercion. The same policy showed in-part, under prohibited conduct, Staff members shall not: . 4. Accept gift cards, checks, or electronic payments (e.g., CashApp, Venmo, Paypal).

Based on interview and record review, the facility failed to ensure dressing changes were done as ordered (R1), and failed to ensure weekly wound assessments and documentation of the assessments were completed, for 2 of 5 residents (R1, R4) reviewed for non-pressure wound care in the sample of 6.This failure resulted in R1's wound getting a maggot infestation, and the wound dehiscing and getting infected. R1 was sent out to a local emergency room, diagnosed with osteomyelitis, requiring two intravenous (IV) antibiotics to prevent sepsis, surgical intervention, and critical care hospital admission. This failure resulted in an Immediate Jeopardy.The Immediate jeopardy began on 7/3/2025 when the facility failed to do the dressing change as ordered and failed to assess R1's surgical site and document an assessment. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/16/2025 at 12:16 PM. The surveyor confirmed by observation, record review, and interview, that the Immediate Jeopardy was removed on 7/17/2025, but noncompliance remains at Level Two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include: 1. R1's admission Record, provided by the facility on 7/10/2025, showed she had diagnoses including, but not limited to, transient cerebral ischemic attack (stroke), atherosclerotic heart disease, aneurysm of the ascending aorta without rupture, myocardial infarction (heart attack), cellulitis of unspecified part of limb, and hypertension.R1's Discharge Instructions from a local hospital, dated 6/26/25, showed Wound Care: Dressing to be left in place until seen in the office next week. Do not get wet. R1's 7/1/2025 notes from the follow up appointment showed Wound cleansing and dressings. Dry protective dressing. Do not get wet. The document showed V4 (LPN) clarified the order to be done every other day.R1's Order Summary Report, provided by the facility on 7/10/2025, showed an order, dated 7/1/2025, for Wound #3 right toes area of great toe, 2nd toe, 3rd toe. Wound cleansing and dry protective dressing to be changed every other day. R1's July 2025 Treatment Administration Record (TAR) showed no treatment was documented as being completed from 7/2/2025-7/6/2025.The facility's weekly Skin Condition Report, dated 7/4/2025, showed R1 had arterial ulcers to her right posterior leg, right medial great toe, right second toe and her right third toe. V3 said the measurements on the form were taken from notes from the wound clinic R1 goes to.R1's Progress notes from 7/1/2025-7/5/2025 do not document any dressing change to the surgical site on R1's right foot/toes area. The progress notes only show RLE ((right lower extremity) wound documentation, which was a different wound on R1's right posterior lower leg. There was no documentation of a dressing change or assessment to R1's right foot surgical site until 7/6/2025 at 8:20 PM where it showed, Resident noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care. MD (doctor) made aware and gave orders to send resident out for further eval (evaluation).R1's progress note, dated 7/6/2025 at 9:20 PM, showed R1 was noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care, Doctor made aware and gave orders to send resident out for further evaluation. when an excessive amount of drainage and larvae were found on R1's right foot surgical wound and she was sent to a local hospital. R1's progress notes from 7/1/2025-7/6/2025 do not show any documentationR1's 7/6/2025 Emergency Department Physician Report from a local hospital showed, Right foot with multiple toe amputations, extensive wound at distal tip with sutures, wound dehiscence, necrotic tissue, copious maggots cleaned from wound, mild surrounding erythema with warmth. the notes showed, admission is required due to the severity of the right foot wound infection with suspected osteomyelitis, need for IV antibiotics, and risk of clinical deterioration. The notes showed Critical Care Statement: Given the patient's presentation with a right foot wound infection and osteomyelitis, which carried a high-risk for rapid clinical deterioration due to potential progression to severe sepsis or septic shock. The emergency room doctor provided 40 minutes of critical care time exclusive of other billable procedures. this time was spent in direct patient care involving high-complexity medical decision making and required constant attendance to prevent sudden, significant deterioration in the patient's condition. The Podiatry Consultation Physician's Report, dated 7/7/2025, showed R1 had surgery approximately two weeks ago due to amputation of the first, second, and third digits of the right foot. This was due to gangrenous changes due to severe peripheral arterial disease. Patient was seen in the office for follow-up and incision site looked good with the wound edges well coaptated and sutures in place. Patient presented to the emergency room last night with dehiscence of the wound and maggots in the wound. The physician debrided the wound and the maggots out. The notes showed R1 was started on IV antibiotics and admitted for further workup. V6's operative notes on 7/8/2025 showed R1, was placed under general anesthesia, the sutures were still in place, however they were not holding any skin or flaps at this time. The sutures were all removed. the wound base and wound edges were debrided back to healthy tissue .several dead bodies of maggots were noted .bony exposure is noted in the wound site. A wound was also noted on the medial aspect of the first metatarsal phalangeal joint area that was likewise debrided .Surgery site was dressed and covered .The area was anesthetized, and patient was extubated .Patient will continue antibiotics.On 7/9/2025 at 3:46 PM, V7 (R1's Power of Attorney/POA) said, (R1) had surgery on 6/25/2025 to amputate her toes. After a brief hospital stay, she returned to the facility. She had a follow up with the surgeon on 7/1/25. The doctor said it was healing nicely on her 7/1/2025 follow up appointment, and everything was okay at that point. V7 said he had not heard any updates from the facility until Sunday night (7/6/2025) after R1 was sent out to the hospital. V7 said the facility staff were supposed to look at her wound every two days. V7 said, Someone from the emergency room (ER) called me on 7/6/2025 and told me (R1) was at the hospital and there were maggots in her surgical wound. (V4, Licensed Practical Nurse-LPN) from the facility called me 10 minutes later. By the time I arrived at the hospital, the emergency room staff had already gotten the maggots out of her wound. There were three maggots in a specimen cup and at least 10 more in a baggie. The reason for (R1's) toes being amputated was due to poor circulation to her feet. Some days (R1) is coherent, but lately she is not as coherent. V7 said he did not think R1 understands why she is in the hospital and did not feel that R1 would be able to say if the facility was doing the dressing changes as ordered. V7 said he spoke with V1 (Administrator) and V2 (Director of Nursing), and they said the facility was doing the dressing changes as ordered. V7 said R1 had to have her surgical site debrided (surgical removal of non-viable tissue). V7 said, It is just too much. This should not have happened. On 7/10/2025 at 10:48 AM, V2 (DON) was shown R1's July 2025 Treatment Administration Record (TAR). V2 said the dressing change for R1's right surgical site/wound in her toes area is not marked off as being completed 7/2/2025-7/6/2025. On 7/11/2025 at 11:50 AM, V3 (Wound Nurse) said the wound clinic provided notes regarding wounds for R1. V3 said the facility got an order to clean the wound and do a dry dressing every other day on 7/1/2025. V7 said he did not do any dressing change or assessment of R1's amputation site. V3 said he did not see any documentation of an assessment being done by any other nurse for R1's surgical site on her right foot in her electronic medical record. V7 said surgical sites should be monitored, assessed, and the assessment should be documented. At 12:51 PM, V3 said, It is important to monitor surgical sites for signs and symptoms of infection, wound dehiscence, a decline, or any changes, and to notify the surgeon of any changes. At 2:11 PM, V3 said the last assessment of R1's right toes, with measurements, was on 6/20/2025. V3 said, When (R1) came back from surgery on 6/26/2025, there was an order to leave covered until her follow up appointment. (R1's) follow-up was on 7/1/2025. The doctor gave an order to cleanse the site and cover with dressing every other day. There was no dressing change completed, no facility assessment, or measurements that I can tell from 7/1/2025-7/6/2025 for (R1's) right foot. V3 said he will do the assessment and dressing change for the residents that are followed by the wound doctor that comes to the facility. He said he does not do the assessments and dressing changes for the residents that go out to wound clinic. V3 provided R1's Skin Impairment/Wound forms for 6/26/2025 and 7/1/2025. V3 said he got the information for the forms from the wound clinic, and did not do the assessments himself. On 7/10/2025 at 3:20 PM, V4 (Licensed Practical Nurse-LPN) said V5 (Certified Nursing Assistant-CNA) told her it looked like the bandage on R1's right foot had some blood on it. V5 said she went in to check it and thought to herself that is not blood. It had a slight odor, and brown drainage was on the sock. V4 said as she was unwrapping the bandage, she saw maggots on the bandage. She notified R1's doctor and he said to send her out to the emergency room (ER) for evaluation. V4 said she worked on 7/1/2025. She called the doctor to verify the treatment orders. V4 said the order was to do the dressing change every other day. V4 said she had not done any assessment or dressing change for R1, because she did not work again until 7/6/2025. V4 said she started her shift at 2:00 PM on 7/6/2025. V4 said she did not recall seeing a date on the dressing, but she was also concerned with what was going on. The color and smell of the drainage is what was concerning me. (R1) was having pain that day. Normally we don't have to give her anything for pain until about 8:00 PM. That day she was having more pain than normal. V4 said as she was unwrapping the bandage to R1's foot, R1 voiced it hurt and pulled back her foot. I had to stop because it was hurting her too much. She was saying 'Oh, Oh, Oh.' V4 said when she saw the maggots, she stopped, called the doctor, and about 15 minutes later, R1 was going out the door. V4 said based on the odor and drainage, she felt it could have been noticed earlier. There was a strong smell and the bandage was saturated. V4 said, It is important to make sure to assess wounds to make sure the wound does not get infected, to notice right away and catch it before it gets bad, and update the doctor, to see if he wants to give any new orders. The earlier you catch something the better.On 7/11/2025 at 2:53 PM, V5 (Certified Nursing Assistant/CNA) said he worked the shift that R1 was sent out to the hospital. He said, I was assisting an agency CNA with (R1) and noticed something on the dressing at the top of her foot, where she had the surgery. It was dark in color, something unusual that you would not see on a sock. It did not really look like blood. It was discolored. I went to (V4) and asked her to check (R1's) foot and then went to assist other residents. V5 said he saw R1 leaving on a stretcher. He went into her room after hearing what happened and checked the linen on her bed. V5 said he saw 8-10 maggots on R1's linen, so he threw her linen away in the garbage. On 7/11/2025 at 3:05 PM, V1 (Administrator) and V2 (Director of Nursing-DON) agreed it is important for the nurses to do an assessment on residents with wounds, at least weekly, even if the resident goes out to the wound clinic. V1 and V2 said unless there is an order not to touch the dressing, it is important the facility nurses assess the resident's wound to monitor and determine if the wound is improving or getting worse, so the doctor can be updated, and new orders can be received if needed.On 7/15/2025 at 10:31 AM, V6 (Wound Clinic Doctor) said R1 had her great toe, second and third digits on her right foot amputated on 6/25/2025. She stayed in the hospital overnight and was sent back to the facility on 6/26/2025. I gave an order to not touch the dressing until her follow-up appointment. When I saw her on 7/1/2025 for the follow-up, the wound was a closed surgical site, no opening, drainage or swelling. It looked very good. V6 said, I gave orders on 7/1/2025 to change the dressing every other day. Keflex was ordered prophylactically to prevent infection. The next time I saw (R1) was the day after she was sent to the hospital (7/7/2025). The stitches were no longer holding the tissue together. It was an open wound. (R1) had the wound cleaned out in the ER due to there being maggots in the wound. On 7/8/2025, I had to take out all the stitches, which were still there, but not holding the tissue in place, debride the wound and flushed it out. Bone was exposed. When bone is exposed to the air, you assume it is infected. Osteomyelitis can occur. V6 said R1 was tested for, and he believes she was diagnosed with, osteomyelitis. The wound was infected and had an infestation of maggots. Two antibiotics were given intravenously (IV) for broad-spectrum antibiotic therapy. It was very serious. Infestation and infection. Infection could get in the blood and the patient could become septic. It is important for the facility nurses to do the dressing changes as ordered. If not done as ordered, it will slow the wound healing and increase the risk of infection. I would expect the nurses to assess the wound during the wound changes, so if there is a problem, they could contact me for guidance on how to proceed. V6 said he has a 24-hour answering service. V6 said, If the facility would have done the dressing changes and monitored the surgical site, it may have prevented the wound from getting infected and infested with maggots, and I would not have had to perform the surgical debridement procedure.On 7/16/2025 at 8:24 AM, V1 (Administrator) said, When (R1) came back from her follow up appointment on 7/1/25, there was some ambiguity about the orders. (V4, LPN) called the doctor and clarified the order. (V4) entered the order into the system wrong. She entered it into other orders (no documentation required), not into the Treatment Administration Record (TAR). When an order is entered into the system like this, the nurses cannot see the order. V1 said he investigated what happened, however, he did not document his investigation. V1 said the order was discontinued on 7/6/2025 and entered in the system correctly. V1 said V3 (Wound Nurse) could have followed up to see what the new orders were after her follow up visit and made sure the treatment was being done as ordered, just like any management team member is expected to do with their department. V1 said he let V2 (DON) know the nurses need training on entering medication orders because that is not acceptable. V1 was asked if the nurses that worked on all three shifts from 7/2/2025-7/6/2025 should have verified the orders for R1 after her follow-up appointment to make sure there was no treatment ordered. V1 nodded yes. On 7/16/2025 at 1:56 PM, V12 (facility's Medical Director) said, Some residents go out for wound care, then come back to the facility. They are here for us to provide medical care. It is important to follow the doctor's orders for wound care. If a resident goes out for wound care and comes back with an order to do dressing changes, the facility nurses should be doing their own wound assessment with every dressing change, document their findings, and notify the physician if there are any changes. The facility's 10/2023 policy and procedure, titled Wound Treatment Management, showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders.1. Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The facility presented an abatement plan to remove the immediacy on 7/16/2025 at 3:34 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 7/17/2025 at 11:29 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 7/17/2025 at 2:37 PM, and the survey team accepted the abatement plan on 7/17/2025.The Immediate Jeopardy that began on 7/3/2025 was removed on 7/17/2025, when the facility took the following actions to remove the immediacy:1. Corrective Actions which will be accomplished for those residents found to be affected by the deficient practice. i. Facility Medical Director was notified of the incident on 7/16/2025 at 2:50 PM. ii. The DON completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy. iii. The DON completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment. iv. The wound nurse assessed all residents with wound and skin conditions to ensure wound treatments were rendered as ordered per MD/NP.2. How the facility will identify other residents having the potential to be affected by the same deficient practice by: The DON and/or designee completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy.The DON and/or designee completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment.The MDS(Minimum Data Set) coordinator and/or designee conducted an audit on every resident with wounds and skin conditions to ensure the care plan reflects their current plan of care. All residents were screened for pressure risk on 7/16/2025, and will be assessed upon admission/re-admission initially, then x 4 weeks, then quarterly. Assessments will be conducted after a change of condition or after any newly identified pressure injury. All residents with wounds and skin conditions treatment orders clarified with medical practitioner and have been changed to AM shift for wound nurse to provide treatments as ordered per MD starting on 7/17/2025. Floor nurses to render wound treatment on weekends and in the absence of wound nurse. Nurse on the floor will render treatment, conduct assessments, and document.A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved. The QAPI (Quality Assurance Performance Improvement) committee reviewed the Skin Assessment and Wound Treatment Management, Quality of Care policies to determine if any revisions needed to be made and determined the policies did not need changes.3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur:The facility initiated in-service training for staff on 7/15/2025 on Skin Assessment and Wound Treatment Management policy. This training will be conducted by the DON and/or designee, is ongoing and will continue with all the new staff upon hiring, and orientation and agency nurses prior to the start of their next shift. The training includes, but is not limited to: A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved.Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and the frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatments will be documented on the Treatment Administration record or in the electronic health record. The effectiveness of treatments will be monitored through ongoing assessment of the wound until healed. Considerations for needed modifications include:a. Lack of progression towards healing. b. Changes in the characteristics of the wound.c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.d. Documentation and Completion of Skin Assessment:Include date and time of the assessment, your name, and position title.Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.)Document type of wound.Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Document if resident refused assessment and why.Document other information as indicated or appropriate. 2. The facility initiated in-service training for staff on 7/16/2025 on Provision of Quality of Care. The training is ongoing and the DON and/or designee will continue with all the new staff upon hiring and orientation and agency nurses prior to the start of next shift.The training includes but is not limited to each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. The facility initiated in-service training for nursing assistants on 7/17/2025 on Skin Audits by Nursing Assistants policy. The training is ongoing, and the DON and/or designee will continue with all the new nursing assistant staff upon hiring and orientation and agency nursing assistants prior to the start of next shift. The training includes, but is not limited to: Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. Skin Conditions that shall be reported include, but are not limited to:Redness, bruising, swelling rashes, hives, blisters (clear or blood filled), skin tears, open areas, ulcers, lesions. Notification shall be made to the nurse verbally or in writing.Notification shall be made to nurse verbally or in writing on any noted soiled or non-intact dressings. The Director of Clinical Excellence scheduled Mandatory All Nursing Staff, DON and Wound Nurse wound care training with (the contracted wound care company that comes to the facility and oversees residents' wounds). DON and/or designee conducted a wound care competency with wound nurse on 7/14/2025 and will conduct one weekly with the wound nurse and nursing staff on all shifts until every staff has participated at least once. This will be ongoing and will continue to be held weekly for two months. Findings will be reviewed at the monthly QAPI committee meeting. 4. Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1. Facility created quality assurance tool Wound Treatment Orders and Assessments will be implemented on 7/16/2025 used by the DON and/or designee to assess all residents and new admissions/re-admissions with wounds and/or skin conditions daily for month and then weekly for 3 months, then quarterly for a year to monitor that the facility is following the policy, and treatments are being completed as ordered, and assessments are being done and completed. Findings will be reported at the monthly QAPI Committee meeting.2. Facility-created quality assurance tool Quality of Care will be implemented on 7/16/2025 and used by the DON and/or designee daily to randomly assess 2 residents daily for a month, then monthly for 3 months, then quarterly for one year to monitor that the facility is following the policy and residents are provided with Quality of Care and Services. The results will be reviewed during the facility's QAPI meetings. Any issues identified will be immediately addressed. On 7/17/2025, a review of the facility's in-service documentation showed all the facility's nurses received the in-service training from the contracted wound care company on 7/17/2025. The Agency nurses, and any new staff will be educated prior to the start of their next shift. The Certified Nursing Assistants working received in-service training on reporting any changes to nurses. The remainder of staff, and any new staff will receive education prior to the start of their next shift. Interviews with staff working on 7/17/2025 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan. 2. R4's admission Record, provided by the facility on 7/16/2025, showed diagnoses including, but not limited to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes. Symptoms include pain, numbness, and slow healing of leg or foot sores), hypertension, congestive heart failure, acquired absence of left leg below the knee, iron deficiency anemia, ischemic cardiomyopathy, acute hematogenous osteomyelitis, chronic obstructive pulmonary disease, and acquired absence of right foot. R4's Order Summary Report, printed by the facility on 7/11/2025, showed an order, dated 7/11/2025, to clean wound on right foot with normal saline. Apply xeroform to wound. Cover with abdominal pad and (rolled gauze) once daily and as needed. The report showed an order, dated 7/11/2025, for a nuclear stress test on 7/21/2025 (a cardiac imaging procedure that assesses blood flow to the heart muscle at rest and during stress. It helps doctors diagnose coronary artery disease and determine the extent of any blockages or damage).R4's care plan, dated 5/20/2025, showed, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.R4's July 2025 TAR showed the dressing changes were being done as ordered. On 7/10/2025 at 9:59 AM, R4 was sitting in his wheelchair in his room. R4's left leg was amputated below the knee. R4's right foot and lower leg was wrapped with rolled gauze. No drainage or odor was observed on R4's dressing. R4 said when he was first admitted to the facility, they missed a couple dressing changes. R4 said the nurses change his dressing every morning now. R4 said the dressing had already been changed at 6:30 AM. R4 said he goes to (a local wound clinic) once a week on Mondays. The doctor said I am making steady progress in healing, especially with my circulatory issues. R4 said since he was admitted to the facility, he has not had any infection or decline in his wound. R4 said he is not sure if the nurses do an assessment of the wound or not. No nurse at the facility has measured it that he is aware of. Sometimes his wound does have drainage, that is why it is wrapped, and he has a boot on his foot. R4 said his wound doctor at the wound clinic said he is pleased with the progress so far considering all R4's circulation issues. R4 said the wound doctor thinks something else may be going on and has ordered a nuclear test be done. R4 said he also has anemia, diabetes, and other issues. R4 said he had the amputations prior to admission. I came to the facility because I could not take care of the wounds. They were very bad.On 7/11/2025, R4's wound assessments from 6/1/2025 through the present were requested from V3. V3 (Wound Nurse) said he did not do weekly assessments on R4 due to R4 going out to the wound clinic for wound care. V3 said the facility nurses change R4's dressing daily as ordered; however, weekly wound assessments are done at the wound clinic. V3 said he gets the information from the wound clinic notes, and uses the information from the wound clinic to fill out the Skin Impairment/Wound Forms on R4. On 7/11/2025 at 1:54 PM, V3 said, I will do measurements and wound assessments for the residents that use (contracted wound company that comes to the facility) when I do rounds with the wound doctor. If a resident is not seen by (the contracted wound company), and goes out for wound care, then we go by the measurements and assessments done by the outside wound clinics. There are 3 residents in the facility with wounds that go out for wound care. (R1), (R4) and (R5) are the residents that go out to wound clinics. At 2:48 PM, V3 said there was not a wound nurse when he first took the job, so he did not really receive any training on how to do the job. V3 said he is still learning things.On 7/15/2025 at 10:00 AM, V3 said, Initially, (R1) was being seen by (contracted wound company) that comes to the facility. (R1) was referred to (a local wound clinic) around the end of April/beginning of May. She had a doppler scan and other tests and was referred to the wound clinic. V3 said, The only trainingI received for the wound nurse position was about 4 hours of training when I took the job. Mostly on paper and laptop. A regional consultant provided some guidance. V3 was asked if he had any specific wound training or certification prior to taking the Wound Nurse position. V3 said he had been a nurse for 20 yrs. Other than that, he said he has not had any specific wound training or certification.V3 provided Skin Impairment/Wound Forms for R4, dated 6/23/2025, 7/1/2025, and 7/8/2025. V3 said he filled out the forms with the information provided by the local wound clinic. V3 also provided wound clinic notes for R4, dated 6/30/2025, 7/7/2025, and 7/14/2025, as well as R4's initial admission assessment form for the local wound clinic. The only other assessment V3 provided was dated 6/12/2025; V3 did assess R4's wound and documented a partial assessment (No measurements. Just the wound bed characteristics). The facility's September 2024 policy and procedure titled Skin Assessment showed. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. The policy showed documentation and Completion of Skin Assessment: A. Include date and time of the assessment, your name and position title. B. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). C. Document type of wound. D. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). E. Document if resident refused assessment and why. F. Document other information as indicated or appropriate.

Based on interview and record review, the facility failed to document a resident's discharge correctly for 1 of 3 residents (R2) reviewed for discharge. This failure resulted in R2 losing his Medicare coverage from [DATE]-[DATE], having to cancel important diagnostic testing and a follow-up appointment with his neurosurgeon, not having CPAP (continuous positive airway pressure) supplies due to lack of medical coverage, and having to spend many hours and days trying to get his Medicare coverage reinstated.The findings include:R2's admission Record, printed by the facility on [DATE], showed he had diagnoses including, but not limited to partial intestinal obstruction, type II diabetes mellitus with hyperglycemia, gastrointestinal hemorrhage, anemia, acute kidney failure, neoplasm of unspecified behavior of bone, soft tissue, and skin, long-term use of non-insulin antidiabetic drugs, hypertension, anuria, and oliguria (reduced urine output or complete absence of urine output). The admission Record showed R2 was discharged to home on [DATE]. R2's progress note, dated [DATE], showed R2 was discharged to home with his wife (V9).R2's Oder Summary Report, provided by the facility on [DATE], showed an order for blood glucose checks daily. The report showed Patient may discharge to home [DATE] with orders for Home Health care services to be provided by (name of home health services company) for PT/OT, Nursing, CNA, and DME (medical equipment) to include a wheelchair. The Report also showed needs appointment in [DATE] for MRI per neurosurgeon.R2's Progress Note, dated [DATE], showed R1 transported home with wife via (transportation service) at 10:15 AM.The facility's Admission, Discharge, and Transfer Report, printed by the facility on [DATE], lists R2 as deceased .On [DATE] at 8:35 AM, R2 said he discharged from the facility to home on [DATE]. R2 said he had to cancel his scheduled MRI (Magnetic Resonance Imaging) and an appointment with his neurosurgeon, due to the facility putting him down as deceased , causing him to lose his Medicare coverage. V9 (R2's wife) was also on the phone and said R2 was not able to schedule any appointments to have his stage 1 pressure ulcer looked at, adding he has a lot of medical issues and needs to see his doctors. V9 said she kept a log of everything and would email IDPH (Illinois Department of Public Health) the specific details of everything they had to do to get the facility's error resolved. On [DATE] at 5:11 PM, V9 sent an email to IDPH that described the difficulties R2 encountered as a result of the facility incorrectly documenting R2's discharge as deceased .On [DATE] at 3:02 PM, V9 sent an email to IDPH with an update showing R2's Medicare account was active as of today. On [DATE] at 5:01 PM, V9 said, The facility error has taken up a lot of our time and has been very stressful on him. R2 agreed. We have been through a lot. (R2) and I have not been able to do anything because they have been on the phone trying to get it taken care of. (R2) was going to ask his neurosurgeon at his next appointment about an order for therapy, but the appointment had to be canceled due to the facility entering (R2) as deceased . Medicare would not cover the cost for (R2's) lancets and glucose test strips because the facility marked him as deceased . (R2) ran out of his CPAP (continuous positive airway pressure) supplies, and had to sleep without his CPAP for about 30 days, because he did not have the supplies. He did have trouble sleeping. R2 agreed. V9 said, (R2) was so mad because the facility was not returning our calls. It was very frustrating. He missed the MRI scheduled for [DATE] and the follow-up appointment on [DATE]. They had to be cancelled due to facility's mistake. (R2) just found out yesterday that it has finally been resolved, and (R2's) Medicare was reinstated. [NAME] departments from the hospital kept calling us and asking when the issue was going to be resolved so they could resubmit their claims. (R2) and I were told the date the facility's error went through the system on [DATE]. If we wanted to schedule any appointment, they would tell us we had to pay up front. We can't afford to do that. That is what we are paying the insurance company for. We felt the facility did not care about us. Like we were not important, like trash. No one should have to go through that.On [DATE] at 1:44 PM, V15 (Regional Business Manager for the facility) said, The nurse that discharged (R2) entered him into PCC (the facility's electronic medical record charting system) as discharged expired. We take that information from PCC, and that is how we enter it for billing purposes. V15 said she was notified on [DATE] that R2 went to make an appointment recently, and that is when R2 and V9 found out about the error. V15 said she was informed R2 missed a neuro appointment and some kind of test for his neuro appointment. V15 said she contacted Medicare and informed them that was an error. V15 said she contacted R2 and V9 to inform them it was corrected and would take about 7-10 business days. V15 said yesterday ([DATE]) was business day 4. V15 said she informed R2 if it has not been corrected by Tuesday, to give her a call and she would take care of it. V15 said, Medicare does not require a death certificate to stop Medicare coverage. Social Security needs one wrong key stroke and it could interfere with the resident's benefits. All the more reason to make sure that the information is entered in correctly. The nurse should make sure when they enter discharge information, they enter the correct information. If the nurse puts something in the system, the Business Office Manager (BOM) does not have access to the clinical side. The facility can put something in place where if someone is listed as expired, that we verify before we enter it into the Medicare billing. We can change how we are doing it to make sure that when a resident is entered as expired or deceased that we (the BOM) verify with the facility that the resident has expired before they enter information into the system, regardless of whether or not the resident is Medicare or Medicaid, so there is no disruption in the resident's Medicare coverage.On [DATE] at 3:00 PM, V8 (Registered Nurse-RN) said she was the nurse on duty that discharged R2 home with his wife. V8 said there is a place in PCC to enter whether the resident was discharged home, to a hospital, deceased , etc. V8 said she usually does not enter information to take a resident out of the system in case someone still needs to document on them. V8 said R2 was very much alive. V8 said, It is important to make sure you enter information into the system correctly for the billing, financial aspect, as well as for the resident, so it does not delay their medical care.On [DATE] at 3:12 PM, V1 (Administrator) identified V14 (second shift nurse) entered it incorrectly in the system. V1 said he thinks V14 went to edit R2 in the system and mistakenly checked deceased instead of discharged to home. On [DATE] at 7:41 AM, V14 said she may have been the one that took R2 out of the system, she does not recall. V14 said no one has said anything about there being an error yet to her. She said she would talk to V1 and see what might have happened. She said it is important to make sure you document correctly whether a resident is discharged to home or discharged due to being deceased . V14 said R2 went home with his wife (V9).On [DATE] at 8:56 AM, V16 (Social Services Director) said she was not the one that took R2 out of the system. I do not do that. If I print out a form, my name would be at the top as the user. I did not print out any forms for (R2) or (V9), or for anyone related to this issue. (R2) was at the facility for short-term therapy. He discharged to home with his wife. When (R2) and (V9) mentioned that he was ready to go home, we started putting things in place like home health services. We did not try to prolong the discharge. We just had to get everything set up to ensure a safe discharge for (R2).On [DATE] at 10:18 AM, this surveyor called V21's (R2's neurosurgeon's) office and asked V21 to return the call to discuss what the follow up appointments for R2 were for and how the delay could affect R2. At 11:30 AM, V19 (V21's nurse) returned call. V19 said she would let V21 know the reason for the call and ask him to return this surveyor's call. No return call was received prior to exiting the facility on [DATE].On [DATE] at 1:56 PM, V12 (facility's Medical Director) was informed about the discharge to home for R2 being incorrectly documented as deceased . V12 said, Oh no. V12 was informed the error caused R2 to lose his Medicare coverage. V12 said, You mean he had to go for months without insurance? V12 said it is important for the nursing staff to make sure they enter information into the system carefully, so they do not kick a resident off their Medicare, or other insurance. V12 said this is the first time he was hearing of this. The facility's policy and procedure titled Transfer and Discharge (including AMA), with a review date of 11/2024, did not include how to remove a resident from the facility electronic system when a resident is discharged .

Based on observation, interview, and record review, the facility failed to perform a pressure risk screen for a resident (R6) at risk for developing pressure ulcers, failed to ensure pressure-reducing interventions were implemented correctly for one resident (R6), and failed to perform weekly facility wound assessments for one resident (R5). These failures affected two of three residents (R5, R6) reviewed for pressure ulcers in the sample size of 6.Findings include:1. R6's face sheet documented an admission date of 11/07/2024, with a past medical history not limited to: hemiplegia and hemiparesis, aphasia, hypertension, type 2 diabetes mellitus and chronic kidney disease. Brief Interview for Mental Status (BIMS), dated 05/23/2025, indicated R6 has moderate cognitive impairment, with a score of 11/15.R6's care plan, with review start date of 05/27/2025, documented R6 is an extensive assist too dependent with activities of daily living (ADL's); has had pressure ulcer development related to disease process and impaired mobility; and has a wound to sacrum, and right/left buttock. Care plan interventions for R6 included but not limited to the following: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning and follow facility policies/protocols for the prevention/treatment of skin breakdown.Weekly pressure ulcer and unstageable pressure ulcer report, dated 07/07/2025, documented R6 acquired at facility on 05/29/2025, an unstageable pressure ulcer to the left buttock, with current measurement of 6.8x4.8x2.8 (length x width x depth) in centimeters, and an unstageable pressure ulcer to the right buttock with current measurement of 3.8x1.8x0.6 in centimeters; and acquired at facility on 07/07/2025, a stage two pressure ulcer to sacral region, with no measurements documented.R6's last documented weight on 07/14/2025 at 11:42 AM indicated weight of 148.6 Lbs.Review of R6's clinical assessment log on 07/16/2025 at 11:30 AM showed no pressure ulcer risk assessment (Braden) on file. On 07/15/2025 at 10:24 AM, 07/16/2025 at 10:57 PM, and 07/17/2025 at 10:35 AM and 12:15 PM, R6 was observed lying in bed on his back and wearing an incontinent brief. Low air loss mattress was in place and set to 350 pounds. R6 was also observed to be lying on top of two incontinent pads and the air mattress was covered with a cotton bottom sheet. R6 was alert to self and not interviewable.R6's active physician orders as of 07/16/2025 included to cleanse left and right buttock wounds with a topical antiseptic (dakins), apply calcium alginate and medical honey then cover with borderer gauze and to cleanse sacral wound with a topical antiseptic (dakins), apply medical honey then cover with borderer gauze daily and as needed. admitted to hospice on 07/12/2025.On 07/17/2025, facility presented a pressure ulcer risk assessment for R6, dated 07/16/2025 at 12:08 PM.2. R5's face sheet documented admission date of 07/15/2024, with a past medical history not limited to: paraplegia, traumatic brain injury, and neuromuscular dysfunction of the bladder. Brief Interview for Mental Status (BIMS), dated 05/01/2025, indicated R5 had no cognitive impairment.R5's pressure ulcer risk assessment (Braden), dated 04/10/2025, indicated resident is at moderate risk for developing a pressure ulcer. Weekly pressure ulcer and unstageable pressure ulcer report, dated 07/07/2025, documented R5 acquired at facility on 12/21/2025, and a pressure ulcer to the sacral region with current measurement of 3.5x3.0x0.1 in centimeters and an unstageable pressure ulcer to the right buttock with current measurement of 3.8x1.8x0.6; and acquired at facility on 07/07/2025, a stage two pressure ulcer to sacral region, with no measurements documented.On 07/15/2025 at 10:12 AM, R5 was observed in room seated in a wheelchair watching television. R5 said he goes out on Mondays to a wound clinic every two weeks and receives daily wound care at the facility between visits to wound clinic. R5 then added the wound nurse has never measured or assessed his wounds until last week. R5 said he was shocked because his wounds have never been assessed at the facility, only done at the wound clinic. Review of R5's care plan on 07/15/2025 showed no documentation related to wounds or wound care. Facility presented undated care plan on 07/16/2025 for R5 that documented resident has actual impairment to skin integrity with current wounds to sacral, lateral right and left ankles. Interventions included but not limited to weekly treatment documentation to include measurement of each skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R5's active physician orders as of 07/16/2025 included to cleanse sacrum with normal saline/wound cleanser then apply (aquacel silver) dressing and cover with bordered gauze nightly and cleanse left lateral ankle with normal saline/wound cleanser then apply (aquacel silver) dressing and cover with absorbent bordered gauze dressing nightly every Monday, Thursday, and Saturday.On 07/11/2025 at 1:54 PM, V3 (Wound Nurse) said if a resident goes out for wound care, he does not perform a wound assessment and goes by the measurements and assessments done by the wound clinic. V3 added R5 goes to an offsite clinic for wound care. At 2:48 PM, V3 said there was not a wound nurse when he first took the position as wound nurse, and did not really receive any training on how to do the job; V3 is still learning things.On 07/15/2025 at 09:50 AM, V3 (Wound Nurse) said he has not received any extensive training in wound care and is not wound care certified. V3 added he received about four hours of training when he took the job that was mostly on paper and on a laptop. V3 also said the regional consultant provided some guidance. V3 stated V3 was nurse for 20 yrs, other than that, he said he has not had any specific wound training or certification.On 07/16/2025 at 2:02 PM, V12 (Medical Director) said, Staff nurses should assess a resident's wound weekly, do dressing changes and follow physician's orders and monitor wounds for improvement. If a resident goes out to the wound care clinic, facility nurses should do their own wound assessment with every dressing change, document their findings and inform the physician of any significant changes. On 07/16/2025 at 3:02 PM, V3 (Wound Nurse) said wound care/dressing changes were all changed on day shift so that he can supervise the wounds and wound care.On 07/17/2025 at 09:38 AM, V2 (Director of Nursing) said pressure ulcer risk assessments should be done upon admission, readmission, quarterly, annually, and with a significant change in condition.On 07/17/2025, facility presented pressure ulcer risk assessment log, dated 07/16/2025, that documented both R5 and R6 were at high risk for developing a pressure injury.On 07/17/2025 at 11:20 AM, V3 (Wound Nurse) said the protocol for a low air loss mattress is that nothing should be between the mattress and the resident, such as layers of pads and/lines because that defeats the purpose of the mattress. V3 added only a turning sheet should be placed. V3 then said the mattress is set to the resident's weight and to their preference level. V3 then said R5 is able to reposition himself in bed, and R6 is on a turning schedule and should be turned every two hours.On 07/17/2025 at 1:02 PM, V1 (Administrator) indicated he was informed by supplier that the low air loss mattress setting is auto adjusted based on the resident's weight.On 07/17/2025 at 2:55 PM, V2 (Director of Nursing) indicated R6 cannot communicate his preference for his low air loss mattress settings.Skin Assessment policy, last revised 03/2025, reads: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.Pressure Injury Prevention Guidelines, last revised 03/2025, reads: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment.prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses).interventions will be documented in the care plan and communicated to all relevant staff.the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound.Repositioning: reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition.routine positioning schedule: every two hours, using both side-lying and back positions.avoid positioning resident on bony prominences/turning surfaces with existing pressure injurie.Wound Treatment Management policy, last revised 03/2025, reads: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.the effectiveness of treatment will be monitored through ongoing assessment of the wound.

Based on record review and interview the facility failed to perform CPR (Cardio-Pulmonary Resuscitation) correctly as per standards of practice, failed to call a code blue within the facility, and failed to call EMS system (911) for an unresponsive resident identified as a full code on the physician's orders in accordance with the Facility policy. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE], at 5:25 AM, when R55, who had full code orders, expired in the facility after being found unresponsive and staff did not perform CPR as per the Standards of Practice and did not follow their policy for Medical Emergencies. V1 (Administrator) and V24 (Regional Director of Operations) were informed of the Immediate Jeopardy on [DATE], at 4:17 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but the facility remains out of compliance at a severity level two because additional time is needed to evaluate the implementation and effectiveness of the training. This applies to 31 of 53 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R55, R158, R257 and R307) reviewed for code status and request CPR to be performed. The Findings include: The admission record showed R55 was admitted to the facility on [DATE], with diagnoses of fracture of the right femur subsequent encounter for closed fracture with routine healing, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea and cerebral infarction due to embolism of the cerebral artery. R55's progress note dated [DATE], at 3:00 PM showed R55 was admitted for further rehabilitation, was a full code status and transferred from another SNF (Skilled Nursing Facility), R55's hospital referral notes to prior facility dated [DATE], showed R55 had a fall on [DATE], and had surgery for femur fracture on [DATE]. R55 was hospitalized from [DATE], until [DATE]. R55 transferred to this facility on [DATE]. The transfer orders showed under advanced directives that R55 was a full code. R55's vital signs at the time of admission showed blood pressure ,d+[DATE], Pulse 62 beats per minute, Temperature 98.0 F, Respirations 18 breaths per minute and oxygen saturation was 97% on room air. The next documentation after R55's initial admission note was [DATE], at 08:04 AM written by V11 (RN) that showed R55 was found unresponsive, no pulse and cool to touch at 5:25 AM and pronounced dead by 2 nurses. During interview of V11 (RN), on [DATE], at 2:10 PM, V11 stated she had seen R55 sleeping on his side with regular respirations during her first round at around 11:00 PM. V11 stated the next time she did rounds was between 2:30 AM and 3:00 AM, she observed R55 and appeared to be sleeping, but was making coughing type noises while breathing. V11 stated she did not assess R55 at that time. V11 stated the next time she saw R55 when she went to his room to administer medications at around 5:20 AM and attempted to wake R55 up but R55 did not respond. V11 stated she then turned on the light, did not find a pulse, found R55 was lying in brown, yellow stained sheets, did a sternal rub and left the room to call for help. V11 stated it appeared R55 had defecated, and stool was on the bed and on the floor. V11 stated she used the nurses desk phone to call the other nurses' station to get the other nurse, (V10) to help and told V13 (CNA) to go to R55's room. V11 stated she did not overhead page a code blue because she had never been taught how to overhead page. V11 then stated she called V14 (former DON) from her cell phone and went back to R55's room. V11 stated while on the cell phone with V14, V11 stated she started to do chest compressions for less than a minute, when V14, who was not in the facility, instructed her to stop compressions and not to call 911. V11 stated she did not bring the crash (emergency) cart to R55's room. V11 stated she was unsure what to do in the situation and was looking for guidance. V11 stated in hindsight she would have called 911 and started CPR as soon as she found R55 unresponsive. V11 stated she was unaware of R55's code status until she was contacting the funeral home. V11 stated as of now she does not know how to use the facility's intercom system to announce a Code Blue. V14 was no longer employed by the facility and not available for interview. On [DATE], at 3:47 PM, V10 (LPN) stated she worked the overnight shift with V11 on [DATE]. V10 stated she was in a resident's room when she heard the desk phone ring at the nurses' station, she was unsure of the time but said it was at the end of the shift. She stated she made the resident safe and went to answer the desk phone. V10 stated V11 was calling her to come to R55's room. V10 stated by the time she got to R55's room, V11 was talking on the cell phone to V14, so she left and did not provide any assistance and did not assess R55. V10 stated when she saw V11 talking on the cell phone she left the room and went back to her assignment. V10 stated she did not call a code blue; she did not bring the crash cart and she did not call 911. When asked about who could pronounce a resident dead in the facility, V10 stated she was not sure if the facility had a policy, but only an RN can pronounce a resident dead in the facility. On [DATE], at 3:15 PM, V13 (CNA) was working on the unit with V10. V13 stated near the end of the shift, V11 asked him to help clean R55 because the family was coming. V13 stated when he walked into R55's room he did a sternal rub, but R55 did not respond. V13 stated he thought R55 might be dead, but he also thought only a doctor could pronounce someone dead. V13 stated there was no crash cart at the room, he was not aware of a code blue and the paramedics were not in the facility. On [DATE], at 5:40 PM, V12 (Medical Director) stated if a resident is found unresponsive, without a pulse and is a full code, the paramedics should be called. V12 stated CPR should be initiated unless rigor mortis is present. V12 stated the presence of feces on or around the resident is not an indication that CPR should not be performed. R55's progress notes on [DATE], did not indicate an assessment for signs of clinical death or the presence of rigor mortis was done and was not documented. On [DATE], at 3:05 PM, V1 (Administrator) stated there was no investigation regarding the death of R55. V1 stated he was not the Administrator at that time, both the Administrator and Director of Nursing at the time of R55's death were no longer employed by the facility. On [DATE], at 10:30 AM, V24 (Regional Director of Operations) stated the facility does not have a policy regarding nurses determining death and pronouncing time of death of a resident. V24 stated he would have to ask the Regional Clinical Consultant what the policy should be. On [DATE], at 1:00 PM, the facility provided a list of residents in the facility with their code status and there were 30 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R158, R257, and R307) identified as full code status in the facility. The Facility's policy titled Medical Emergency Response dated reviewed [DATE], showed Policy Explanation and Compliance Guidelines .1. The employee who first witnesses or is first on the sight of a medical emergency, will initiate immediate action, including CPR as appropriate . 3. A Nurse will .b. Stay with the resident . c. Designate a staff member to announce a Code Blue, notify the physician and call 911 .4. A Code Blue will be announced over the intercom system. 5. All available staff will respond to the emergency accordingly .6. The staff on the unit will take the emergency cart to the code .7. This will continue until emergency personnel arrive and resident is transported to the emergency room via EMS (Emergency Medical Services) .8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. In accordance with the resident's advance directives. The facility submitted an abatement plan to remove the immediacy on [DATE], at 6:08 PM. The Survey Team reviewed the abatement plan and was unable to accept the plan and returned the abatement plan to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 12:34 PM. The Survey Team reviewed the plan and was unable to accept the abatement plan and it was returned to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 5:34 PM. The Survey Team reviewed the abatement plan and was unable to accept the third revision. The abatement plan was returned to the facility for fourth revision. The Facility submitted the revised abatement plan on [DATE], at 6:15 PM. The Survey Team accepted the abatement plan on [DATE], at 6:20 PM. The Immediate Jeopardy that began on [DATE], was removed on [DATE], when the facility took the following actions to remove the immediacy: -Administrator/ designee will provide training for all staff, initiated on [DATE], on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The Training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift. -Administrator/designee will provide training for all staff, initiated on [DATE], on Resident Rights regarding Treatment and Advance Directives. -Provide Mock Code evaluation drills, initiated on [DATE], in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained. -The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills initiated on [DATE]. The training will continue until all staff have been trained. -The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, initiated [DATE], and the process is ongoing. - Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, initiated [DATE], and ongoing. -The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met on [DATE], at 5:00 PM to review the F678 IJ (Immediate Jeopardy). -The Facility created a Quality Assurance audit tool to be implemented on [DATE], used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses for three months. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings. -The Facility created a QA audit tool to be used by Social Service/designee daily to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily for one month, then monthly for 3 months and then quarterly for a year. The audit tool to be implemented on [DATE].

Based on observation, interview and record review the facility failed to ensure that an RN (Registered Nurse) was assigned to serve as a full time DON (Director of Nursing) to coordinate nursing care and supervision, to provide quality care to residents. This applies to all the 52 residents that reside at the facility. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) 671 (Long Term Care facility application for Medicare and Medicaid) dated April 15, 2025 showed the total resident at the facility was 52. On April 15, 2025 at 1:17 PM, V2 (Corporate Nurse) stated that the facility's designated DON had resigned, and she (V2) comes to the facility on ce a week, since the DON left. On April 17, 2025 at 2:15 PM, V1 (Administrator) stated that he received a text message from V14 (RN/former DON) on April 4, 2025 stating that she was not coming in the facility that day and that she (V14) will be sending an official letter of resignation by the end of the day. V14 stated that on April 7, 2025 he received a call from V14, informing him that she will be resigning effective May 2, 2025 and will be sending her resignation letter. According to V1, V14 never came to report to the facility from April 4 to the current (April 17, 2025) to perform her duties. V1 stated that the facility has not heard from V14 and have not received any letter of resignation from her (V14). V1 believes that V14 will not be coming back to work at the facility, so he went ahead and hired a new DON. V1 acknowledged that the facility does not have a full time DON from April 4 until the newly hired DON starts on April 22, 2025. During the entire survey from April 15 through April 18, 2025, the facility did not have a designated RN to serve as the DON (Director of Nursing). During this survey deficient practice were identified on the following areas: ADL (activities of daily living) care, urinary catheter care, IV (intravenous) care, oxygen therapy and care, labeling of medications, controlled medication inventory and storage, addressing pharmacy recommendations, infection control surveillance, advance directive, and development of care plan.

Based on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to all 52 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents. Facility provided information that there were no residents on NPO (nothing by mouth) status. On April 15, 2025 at 09:20 AM, the initial tour of facility kitchen was done in presence of V4 (Dietary Manager). The hand sink area had unknown grime and had 2 scrub pads inside the sink that appeared to be used to prewash dishes at the dish machine. When questioned why the hand sink area was soiled, V4 stated that they do not have enough space in the kitchen to manage all tasks. The reach in, two door steel refrigerator in the kitchen had marked grime and unknown smears on the handle and the surface of the refrigerator. V5 (Cook) and V4 were seen opening and closing the refrigerator during meal prep and or service. There was a large pan inside the top shelf of the refrigerator which was half full of stagnant water. V4 stated that there was a leak in the refrigerator and the pan was placed to catch the drips of water. V4 added that it was the same problem that was identified in the last year annual survey and it was never fixed. A drawer at the prep station near the stove that stored utensils used for cooking, had grime and dust. The surface areas on shelves beneath the center workstation that stored multiple inverted pans also had food debris, dust and unknown grime. The ice scoop used to scoop ice from the ice machine was placed on workstation that had dust and unknown debris. V4 stated Does it (ice scoop) have to be covered. I don't remember. During the tour V4 was also notified of the above unsanitary surfaces. On April 15, 2025 at 11:40 AM, V6 LPN (Licensed Practical Nurse) was seen coming into the kitchen and taking the scoop from the workstation and get ice from the ice machine V6 did not wash her hands or wear gloves. V6 stated that she is getting the ice to add it into the water pitcher on her medication cart as some residents like cold water. On April 15, 2025 at 11:43 AM, prior to start of meal service, V5 (Cook) was requested to take the food temperatures. The pureed spaghetti and pureed garlic bread both showed 120 degrees Fahrenheit respectively. V4 had to be prompted to reheat the items prior to serving the same. On April 17, 2025 at 2:44 PM, V17 (Dietitian) stated that the food prep and refrigerator door surface area should be clean for sanitary purposes. V17 stated that staff coming from outside the kitchen should wash their hands prior to getting ice from the ice machine and that the ice scoop should be in a scoop holder. V17 stated that hot foods at the steam table should be at minimum 135 degrees Fahrenheit. Facility policy and procedure taken from 'Guideline & Procedure Manual 2020' included as follows: Storing Utensils, Tableware, and Equipment- Guideline: Employees will store utensils, tableware and equipment according to the following guideline Procedure: 2. Food contact surfaces of fixed equipment should be protected from contamination by splash, dust or other means. 3. Clean and sanitize drawers and shelves before clean items are stored. Ice Handling and Cleaning: Guideline: Ice will be stored and served to residents in a sanitary manner. Procedure: 1. Ice will be handled, transported and stored to protect against contamination. 3. Ice buckets, other designated containers, and scoops will be kept clean and sanitized. Scoops will be stored in a protected manner . Monitoring Food Temperatures for meal Service: Guideline: Food temperatures will be monitored to prevent foodborne illness and to ensure foods are served at palatable temperatures. Procedure: 3d. If the serving holding temperature of hot food item is not at 135 degrees Fahrenheit or higher, when checked prior to meals service, the item will be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds.

Based on observation, interview and record review, the facility failed to provide hand hygiene during medication administration, failed to use PPE (Personal Protective Equipment) while providing direct care for a resident on EBP (Enhanced Barrier Precautions) and failed to do complete infection control surveillance monitoring for the facility. This applies to all 52 residents who reside in the facility. The Findings include: Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents. 1 On April 17, 2025, at 2:50 PM, V1(Administrator) stated V3 (MDS Nurse) was in the role of IP (Infection Preventionist) but was not trained. V3 was not in the facility and unavailable for interview. V1 provided the infection prevention surveillance documentation for January, February and March 2025, and V1 stated there was no infection surveillance the month of April 2025, and no residents who required TBP (Transmission Based Precautions). V1 provided the Infection Log the facility utilizes for tracking infection. The Infection Log included a column for documentation for the following: Unit, Date, Resident, Room #, Site, Organism, Lab/Culture, Antibiotic, Isolation/Precautions, Symptoms present on admission, and Acquired in Facility (HAI). The total resident days per month and the infection incidence rate for the month were at the top of the form to complete the documentation. The Infection Log dated January 2025, showed missing data and no infection Incidence rate. There were 12 residents listed on the infection log. The log showed 9/12 residents missing the Site of the infection, 6/12 residents missing the Organism, 12/12 did not specify if any Lab/Culture results were completed, 10/12 did not identify if symptoms were present, if isolation precautions were needed, or if the infection was acquired in the facility or was community acquired. The Infection Log dated February 2025, showed missing data and no infection incidence rate. There were 7 residents listed on the infection log. The log showed: 7 of 7 residents listed, had no data entered for Site, Isolation/Precautions, Symptoms, Labs/Cultures or if Acquired in the facility. The Infection Log dated March 2025, showed incomplete data and no infection incidence rate. There were 12 residents listed on the infection log. The log showed: 7 of 12 residents did not have the Site recorded or if Facility Acquired, 8 of 12 residents did not specify if Labs/Culture was done or if Symptoms were present, and 9 of 12 had no data for Isolation /Precautions. The Facility's policy titled Infection Surveillance dated August 2024, showed Policy: A system of infection surveillance serves as the core activity of the facility's infection prevention and control program .5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit depending on the measure observed. A combination of process and outcome measures will be utilized .6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected .i. the infection site, pathogen (if available), signs and symptoms, and resident location including summary and analysis of the number of residents (and staff) who developed infections .9. All resident and infections will be tracked. 29562 2. Face sheet shows that R44 has multiple medical diagnoses including paraplegia, urinary tract infection, neuromuscular dysfunction of bladder. Care plan report shows that R44 has indwelling urinary catheter, intravenous catheter, and R44 was placed on Enhance Barrier Precaution (EBP). On April 15, 2025, at 10:27 AM, V15 and V23 (Both Certified Nursing Assistant/CNA) provided morning care to R44. V15 and V23 donned gloves while providing care to R44. They provided peri-care, emptied catheter bag, applied petroleum jelly to R44's legs and thighs, and transferred R44 via mechanical lift from bed to wheelchair. Though they changed gloves and sanitized hands in between tasks, they did not wear an isolation gown throughout the care. Enhance Barrier Precautions (EBP) shows Providers and Staff must also wear gloves and a gown for the following High-Contact Resident Care Activities such transferring, changing briefs or assisting with toileting, device care or use central line, urinary catheter, feeding tube, and tracheostomy. 3. On April 15, 2025, at 4:07 PM, V7 (Nurse) administer medications to R49, then she donned a pair of gloves to checked R49's blood glucose. After getting the glucose level and while wearing same gloves, she went back to the medication cart and documented R49's glucose in the computer. V7 continued to open the medication drawer to get the BP (blood pressure) apparatus. V7 removed her gloves and checked R49's BP. V7 returned to the cart and opened the drawer to get cell phone to call the NP (Nurse Practitioner). V7 did all these different tasks from the dirty to clean and did not perform hand hygiene during R49's medication administration and assessments. 4. On April 15, 2025, at 4:26 PM, V21 (Nurse/RN) prepared and attempted to administer medications to R36. When R36 refused the medications, V21 started to prepare the medication of R43. At 4:33 PM, V21 adjusted the Oxygen tube of R43 with her bare hands, then she donned gloves and check the blood glucose level. V21 removed her gloves and without hand hygiene, left R43's bedroom to administer medication to another resident (R5) who was asking her for a pain reliever. After V21 gave the pain reliever to R5, V21 returned to R43's bedroom to continue to give the nebulizing treatment. V21 did all the different tasks and assisted different residents without performing hand hygiene in between tasks and residents. On April 17, 2025, at 3:09 PM, V2 (Corporate Nurse) stated the nurses must perform hygiene before and after resident care, in between tasks and in between residents, regardless of wearing gloves. Gloves are not a substitute for hand hygiene for infection control. Whenever the staff is providing hands on care to resident who is identified under enhance barrier precaution, the nurse must wear complete personal protective equipment such as gown and gloves as part of infection prevention. Facility's Hand Hygiene Policy and Procedure dated October 2023, shows: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility. Policy Explanation and Compliance Guidelines shows: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interview and record review the facility had incomplete documentation on the Antibiotic Surveillance log and failed to evaluate the presence of infection utilizing the standardized criteria to define infections, in accordance with facility policy. This applies to all 52 residents who reside in the facility. The Findings include: On April 17, 2025, at 2:50 PM V1 (Administrator) stated he was unsure if the facility utilizes McGeer criteria or any criteria for evaluating the use of antibiotics. V1 provided Antibiotic Surveillance Log for the months of January, February and March 2025. V1 stated there was no Antibiotic Surveillance Log for the month of April 2025. V1 stated V3 (MDS Nurse) was assigned the role of IP (Infection Preventionist) but was not trained and was not available for interview. Upon request for the documents related to the facility Antibiotic Stewardship program the facility provided the policy and 3 months of Antibiotic Surveillance Logs. The Antibiotic Surveillance Log had 8 columns for data to be entered. The columns were titled: Date, Resident, Room #, Antibiotic order, Diagnosis, Ordering Practitioner, Documentation Supports Necessity, and ordered upon admission. The Antibiotic Surveillance Log dated January 2025, showed 11 residents listed on the log. The log was incomplete. The log showed 4 of 11 residents did not have diagnosis for use of antibiotic, and 10 of 11 residents had no data in the columns for ordering Practitioner, Documentation supports necessity, and ordered upon admission. The Antibiotic Surveillance Log dated February 2025, showed 6 residents listed on the log. The log was incomplete. The log showed 1 of 6 residents did not have a diagnosis for antibiotic use, and 6 of 6 residents had no documentation for the columns for ordering Practitioner, Documentation Supports Necessity and Ordered upon admission. The Antibiotic Surveillance Log dated March 2025 showed 8 residents listed on the log. The log was incomplete. The log showed 3 of 8 residents did not have a diagnosis listed for use of antibiotic, and 8 of 8 residents did not have documentation for the column Documentation Supports Necessity. The Facility did not provide completed assessment forms to define infections (i.e. McGeers criteria, Loeb's Minimum criteria or NHSN surveillance definitions), antibiotic stewardship meeting minutes or records related to education of physicians, staff, residents and families as outlined in the facility policy. The facility's policy titled Antibiotic Stewardship Program dated January 2025, showed Policy: It is the policy of the facility to implement an Antibiotic Stewardship program as part of the facility's overall infection control program .4. The program includes antibiotic use protocols and a system to monitor antibiotic use .a. Antibiotic use protocols: iii. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections .iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics .9. Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents and family.

Based on interview and record review the facility failed to ensure that the facility's IP (Infection Preventionist) had completed specialized training in infection prevention and control. This applies to all 52 residents who reside in the facility. The findings include: On April 17, 2025, at 2:50 PM, V1 (Administrator) stated the facility's trained IP was the former Director of Nursing, who last worked in the facility on April 4, 2025. V1 stated V3 (MDS Nurse) was assigned the duties of the IP. V1 became Administrator on February 24, 2025, and stated V3 was already assigned the IP position. V1 stated currently there is no staff onsite who completed specialized training in Infection Control. V3 had not received any specialized training in infection control. V3 was not available to be interviewed during this investigation. The infection control surveillance tracking that V1 provided for January, February and March 2025, was incomplete. There was no infection control surveillance tracking for the month of April 2025. The in-service training provided by the facility on infection control topics, since the last annual survey was reviewed. The most recent infection control in-service provided for facility staff was provided by V14 (former DON) on December 30, 2024. There was no infection control in service training provided in 2025. The facility's policy titled Infection Surveillance dated August 2024, showed Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective action made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .6. The facility will collect data to properly identify possible communicable disease or infections among residents and staff before they spread by identifying: a. Data to be collected: i. The infection site, pathogen, signs and symptoms .including summary and analysis .ii. Observations of staff including the identification of ineffective practices .ii. The identification of .infection trends .8. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends.

Based on observation, interview and record review the facility failed to ensure residents have a comprehensive care plan, that identifies their individual needs and includes all aspects of their care including assistance needed with ADLs (Activities of Daily Living), urinary catheter care, oxygen administration, and wound care. This applies to 4 of 4 residents (R19, R51, R53 and R158) reviewed for care plans in the sample of 20. The findings include: 1. R19's admission record showed R19 was admitted to the facility on [DATE], with multiple diagnoses including diabetes type 2, essential hypertension, non-displaced fracture of head of right radius, major depressive disorder, obstructive sleep apnea, atherosclerotic heart disease. R19's MDS (Minimum Data Set) dated March 17, 2025, showed R19 had a stage 3 pressure ulcer, the presence of a pressure reducing device for bed, pressure reducing device for chair, and was receiving care and application of ointments for the pressure ulcer. R19's order summary dated April 11, 2025, showed an order for barrier cream to be applied to the coccyx every shift and as needed. On April 16, 2025, at 11:10 AM, R19's wound care was observed and R19's coccyx area remained red, V10 (LPN) stated this site was a pressure ulcer that was healing. R19's care plan initiated on November 19, 2024, did not identify a plan of care for a pressure ulcer, or a plan for prevention of pressure ulcers. 43389 2. R53's electronic medical record showed R53 is a [AGE] year old admitted to the facility on [DATE] with diagnoses that includes acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Type 2 Diabetes Mellitus. On April 15, 2025 at 10:55 AM, R53 was receiving 3 liters of oxygen via nasal cannula. R53 has a physician order dated January 23, 2025 that showed R53 should have continuous oxygen at 2-3 liters via nasal cannula or mask. As of April 18, 2025 at 9:08 AM, R53 did not have a care plan for his continuous oxygen, respiratory failure with hypoxia, nor his chronic obstructive pulmonary disease. 29562 3. R51's electronic medical records (EMR) shows that R51 is [AGE] years-old who has medical diagnoses including urinary tract infection, site not specified, and essential hypertension. Minimum Data Set (MDS) dated [DATE], shows that R51's Brief Interview for Mental Status (BIMS) is 10 (moderately impaired cognition) and requires assistance for grooming and hygiene. Though R51's BIMS was 10, R51 was unable to respond well to instructions this was confirmed by V15 (Certified Nursing Assistant/CNA) who stated that R51 is confused. R51 was observed on April 15 and 16, 2025, displaying nails with black and brown substances underneath her fingernails. R51's nail beds had brownish discoloration. R51 also has curly facial hair on her chin. R51 was verbal and able to respond to yes or no questions. However, she was unable to coherently answer questions that needed explanation. On April 16, 2025, at 1:39 PM, V15 and V22 (CNA) rendered peri-care and catheter care to R51. R51's urinary catheter was not secured or anchored. R51 also remained with brownish discoloration on her nail beds, and with black/brown substances underneath the nails. R51 remained with curly facial hair on her chin. R51 was cooperative during provision of peri-care. V15 and V22, did not attempt to secure the urinary catheter, and did not offer to provide nail care and shaving to R51. R51's care plan report was reviewed. There were no specific care plans addressing R51's ADL (activities of daily living) care pertaining to grooming and hygiene, and the care for indwelling urinary catheter. 4. The electronic medical record (EMR) shows that R158 was admitted on [DATE]. R158's past medical history include hypertension, diabetes, and osteomyelitis of the right foot. The nurse practitioner notes dated April 10, 2025, shows that R158 had a surgery on March 26, 2025, with a partial ray amputation of the right foot. R51's treatment from the hospital was completed and he was sent to the facility for wound care and antibiotic therapy. R158's nutrition/dietary notes dated April 11, 2025, shows R158 was admitted to the facility following hospitalization for infected right foot diabetic ulcer, then diagnosed with osteomyelitis. On April 15, 2025, at 11:14 AM, R158 was resting in bed, he was alert and oriented and could communicate well during interview. R158's right foot was covered with a wound dressing. R158 stated that he was diabetic, and he had a recent amputation of his right big toe about a month ago. R158 also stated that he has history of amputation of his two other right toes. From 4/15/25 through 4/17/25, R158 has been observed ambulating the hallway and going outside for smoking. R158's care plan report was reviewed. There were no specific care plans addressing R158's diabetes and diabetic wound. On April 17, 2025, at 3:01 PM, V2 (Consultant Nurse) stated that part of the grooming/hygiene is to offer shaving and nail care and if resident refuses the staff must report and document refusal and update care plan. In addition, V2 stated that comprehensive care plan should be develop and implemented within 7 days upon completion of MDS. Facility's Policy for Comprehensive Care Plans dated January 2025 shows: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standard of quality. Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines shows: 2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. All Care Assessment Areas (CAA) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will be address in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. d. The resident's goals for admission, desired outcomes, and preferences for future discharge.

Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that narcotic medication was stored in a sealed packaging. This applies to 4 of 4 residents (R2, R28, R37, R47) reviewed for controlled medications in the sample of 20. The findings include: On April 15, 2025, at 5:45 PM, the controlled medication was counted with V7 (Nurse/LPN), and the following were observed: 1. R37's blister pack of Tramadol HCl 50 mg (milligrams) number 8 and number 16 tablets, the seal of the packagings were broken. 2. R47's blister pack of Oxycodone 50 mg with 19 tablets remaining that were intact and sealed. R47's controlled drug receipt/record/disposition form for the Oxycodone showed that there should be 20 remaining in the blister pack. V7 stated that she gave the Oxycodone tablet to R47 earlier and has not signed it out yet. 3. R28's blister pack of Alprazolam 0.25 mg with 3 tablets left that were intact and sealed. R28's controlled drug receipt/record/disposition form for the Alprazolam showed that there should be 4 tablets remaining in the blister pack. V7 stated that she gave the Alprazolam tablet to R28 earlier and has not signed it out yet. 4. R2's blister pack of Phenobarbital 64.8 mg with 12 tablets left that were intact and sealed. R2's controlled drug receipt/record/disposition form for the Phenobarbital showed that there should be 13 tablets remaining in the blister pack. V7 stated that she gave the Phenobarbital tablet to R2 earlier and has not signed it out yet. On April 17, 2025, at 2:52 PM, V2 (Corporate Nurse) stated the nurse must document in the MAR (Medication Administration Record) and sign out the controlled medication from the controlled drug receipt/record/disposition form as soon as the medication was given to the resident. This was according to the facility's policy and for accuracy of record. If the seal is broken from the blister pack of the controlled medication, the medication should be disposed with a secondary nurse as a witness, to prevent drug discrepancy or unlawful drug diversion. Facility's Policy and Procedure for Controlled Substance Administration and Accountability dated May 2024, shows: Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. Policy Explanation and Compliance Guidelines: g. In all cases, the dose noted on the usage form or entered to the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.

Based on observation, interview, and record review, the facility failed to label medication for the date it was opened to determine expiration date. This applies to 4 of 5 residents (R2, R8, R37, R49) reviewed for labeling and storage in the sample of 20. The findings Include: On April 15, 2025, at 5:29 PM, the unit 2 medication cart was inspected with V7 (Nurse), and the following were observed: 1. R2's Incruse Ellipta was opened and not dated. The manufacturer's recommendation shows to safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler. 2. R37's Insulin Lispro was opened and not dated. The pharmacy list for expiration date shows that this medication expires 28 days after first use or removal from refrigerator. 3. R49's Insulin Lantus was opened and not dated. The pharmacy list for expiration date shows that this medication expires 28 days after first use or removal from refrigerator 4. R8's Fluticasone Furoate/Vilanterol Ellipta Inhalation Powder was opened and not dated. The manufacturer's recommendation shows to safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler. On April 17, 2025, at 2:56 PM, V2 (Corporate Nurse) stated that the medications mentioned above should be dated upon opening to determine the expiration dates.

Based on interview and record review, the facility failed to ensure that residents signed POLST (Practitioner Order for Life-Sustaining Treatment) form and the physician's order are consistent, to reflect the resident's treatment wishes in an event of a medical emergency. This applies to 3 of 3 residents (R15, R32, and R51) reviewed for advanced directives in the sample of 20. The findings include: 1. R15 had multiple diagnoses including flaccid hemiplegia affecting left nondominant side, kidney transplant status and ESRD (end stage renal disease), based on the face sheet. R15's quarterly MDS (minimum data set) dated [DATE] showed that the resident was cognitively intact. R15's EMR (electronic medical records) scanned POLST dated [DATE], signed by R15 showed that the resident selected, Do Not Attempt Resuscitation/DNR (Do Not Resuscitate). R15's active order summary report showed an order dated [DATE] to, Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation). R15's active care plan initiated on [DATE] showed that the resident has a full code status and to attempt resuscitation/CPR. The same care plan showed multiple interventions including, Code status will be reviewed at least quarterly and with changes in his condition, execute any of wishes for code changes and implement any changes desired, and If code status changes the clinical record will be updated to reflect the changes. On [DATE] at 3:33 PM, V7 (LPN (Licensed Practical Nurse) stated that if a resident has no pulse and no breathing, she will first check the EMR dashboard section to see the code status and then look at the code status order. V7 stated that whatever was documented on the dashboard should match the actual order and whatever the code instructions written on the dashboard and the physician's order should be followed. During this interview, V7 checked R1's EMR dashboard and the active order then stated that both sources showed that the resident is a full code and CPR should be performed. V7 was asked if she would also check if the resident had a signed POLST in EMR and she (V7) stated yes, if it is in the electronic records. V7 then looked at the EMR for R15's signed POLST. V7 stated that the signed POLST for R15 showed that the resident is DNR. V7 commented, Okay, this is confusing. V7 acknowledged that based on the EMR dashboard and active order, and the resident's signed POLST, there is a conflicting information about R15's code status. On [DATE] at 3:40 PM, V2 (Corporate Nurse) stated that the resident's signed POLST should be reflected on the physician's order. V2 was shown R1's physician order to attempt resuscitation and R1's signed POLST indicating DNR. According to V2, the two information were conflicting and needs to be looked at immediately in case of an emergency. The facility's policy for resident's rights regarding treatment and advance directives, last reviewed by the facility on [DATE] showed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The same policy under explanation and compliance guidelines showed in-part, 3. Upon admission should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. 29562 2. Face sheet shows that R51 is [AGE] years-old who has medical diagnoses including urinary tract infection (UTI), site not specified, and hypertension (HTN). R51 was admitted to the facility on [DATE]. R51's Physician Order Summary (POS) advance directives dated February 24, 2025, shows that R51's is a full code (meaning Attempt Cardiopulmonary Resuscitation/CPR). R51's signed POLST (Practitioner Order for Life-Sustaining Treatment For) dated [DATE], showed that R51 selected, Do Not Attempt Resuscitation/DNR. On [DATE], at 3:06 PM, V2 (Corporate Nurse) stated that all orders and care plans for advance directives should follow code status or POLST. R51's care plan for advance directives shows R51 has chosen DNR (Do Not Resuscitate). This care plan was created on [DATE], after surveyor's inquiry. 36567 3. R32's EMR (electronic medical records) included diagnoses of face hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, unspecified convulsions, end stage heart failure, personal history of other diseases of the respiratory system. R32 EMR dashboard showed special instructions Full Code and POLST form uploaded in EMR showed No CPR (Do Not Attempt Resuscitation (DNAR). There was no order for advance directive on POS (Physician Order Sheet). On [DATE] at 12:33 PM, R32's nurse (V6, LPN, Licensed Practical Nurse) when asked how she determines the code status of a resident in the event of an emergency, V6 stated Usually the dashboard (of computer) will tell you if it's a DNR or full code. R32 then looked up R32's EMR and stated that he is a full code and that she will attempt full CPR (Cardio Pulmonary Resuscitation) in the advent of an emergency for R32. V6 added that sometimes the code status is also uploaded under miscellaneous section. V6 then made several attempts to look up the miscellaneous section but was unable to do so. V6 stated that she is fairly new at the facility and don't know the system (EMR) here. V10 (LPN) who was in the vicinity stated that the code status is also listed on the crash cart. On reviewing the crash cart listing for full code status R32's name was not found. V6 then remarked that she goes by the dashboard for code status of the patient as the list on the crash cart is not always updated. On [DATE] at 12:47 PM, as V6 and V7 were not able to access the miscellaneous section of the EMR with multiple tries, V2 (Corporate Nurse) was requested for R32's POLST form. V2 then confirmed that special instructions on R32's dashboard showed Full Code and POLST form uploaded in EMR showed No CPR (Do Not Attempt Resuscitation (DNAR). V2 stated that the facility process is that the social service reviews the resident's clinical records on admission and obtains the advance directive and collaborates with the nursing IDT (interdisciplinary team) to put the orders in the resident's EMR. On [DATE] at 12:55 PM, V9 (Social Service Director) stated that when she obtains a POLST form she uploads it in the system and then puts a progress note and updates the care plan to reflect what is on the POLST. V9 added that she does not enter the orders for the advance directive as its only the nurses that enters orders on POS.

Based on observation, interview and record review, the facility failed to ensure grooming for residents who require assistance for ADLs (Activities of Daily Living). This applies to 3 out of 3 residents (R13, R21, and R51) reviewed for ADL care in the sample of 20. The findings include: 1. On April 15, 2025, at 1:05 PM, R51 was in the dining room, sitting in her wheelchair. R51's fingernails had black and brown substances underneath nails and nail beds had brownish discoloration. R51 also has curly facial hair on her chin. R51 was able to respond to yes or no question, however, she was unable to coherently answer questions that needs explanation. V15 (CNA, Certified Nursing Assistant) stated that R51 is confused. On April 16, 2025, at 1:39 PM, V15 and V22 (CNA) rendered peri-care and catheter care to R51. R51's nails remained with brownish discoloration on the nail bed, and with black/brown substances underneath nails, and with curly facial hair on her chin. R51 was pleasant and cooperative during provision of peri-care. V15 and V22 did not offer to provide nail care and shaving to R51 after they completed providing the peri-care. Minimum Data Set (MDS) dated [DATE], shows that R51 requires assistance for personal hygiene. On April 17, 2025, at 3:01 PM, V2 (Cooperate Nurse) stated part of the grooming/hygiene is to offer shaving and nail care and if resident refuses the staff must report and document refusal and update care plan. There was no evidence in the progress notes from April 1, 2025, to present, that R51 was refusing care, and there was no care plan showing that R51 was non-compliant with ADL care. 16746 2. R13 had multiple diagnoses including contracture on the left and right hand, based on the face sheet. R13's quarterly MDS (minimum data set) dated March 13, 2025 showed that the resident was moderately impaired with cognition. The same MDS showed that R13 had functional limitation in ROM (range of motion) to both upper extremities and required assistance from the staff with regards to personal hygiene. On April 15, 2025 at 10:57 AM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. R13 stated that he needs help from the staff with shaving. On April 16, 2025 at 1:30 PM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. In the presence of V2 (Corporate Nurse), R13 stated that he needs help with shaving and wants the staff to shave him. R13's active care plan initiated on November 12, 2024 showed that the resident has an ADL (activities of daily living) self-care performance deficit related to limited range of motion/contractures in both hands. 3. R21 had multiple diagnoses including lack of coordination, legal blindness and unspecified intellectual disabilities, based on the face sheet. R21's quarterly MDS dated [DATE] showed that the resident was cognitively intact and required total assistance from the staff with personal hygiene. On April 15, 2025 at 11:02 AM, R21 was in bed, alert and oriented. R21 had accumulation of long facial hair. R21 stated that he needs staff assistance with shaving and that he wanted to be shaven. On April 16, 2025 at 1:31 PM, R21 was in bed, alert and oriented. R21 had accumulation of long facial hair. In the presence of V2 (Corporate Nurse), R21 asked to be assisted with shaving. R21's active care plan initiated on January 21, 2016 showed that the resident has an ADL self-care performance deficit. The same care plan showed multiple interventions including, The resident is dependent of 1 staff for personal hygiene. On April 16, 2025 at 1:35 PM, V2 stated that it is part of the nursing care and service, and the staff are expected to assist residents needing assistance with ADL including removal/shaving of facial hair to ensure and maintain resident's hygiene and grooming.

Based on record review and interview the facility failed to further assess a resident for changes in breathing and notify resident's physician. This applies to 1 of 3 residents (R55) discharged records reviewed in the sample of 20. The findings include: The admission record showed R55 was admitted to the facility on [DATE], with diagnoses of fracture of the right femur subsequent encounter for closed fracture with routine healing, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea and cerebral infarction due to embolism of the cerebral artery. On April 16, 2025, at 2:10 PM, V11 (RN) stated during the overnight shift of January 30-31, 2025, V11 was R55's nurse. V11 stated during the first rounds between 10:30 PM and 11:00 PM, V11 observed R55 sleeping on his side with regular respirations. V11 stated the next time she did rounds was between 2:30 AM and 3:00 AM, she observed R55 appeared to be sleeping, but was making coughing type noises while breathing. V11 stated she did not further assess R55 at that time. There is no documentation in R55's progress note of January 31, 2025, of V11's observations regarding R55's change in breathing. On April 16, 2025, at 5:40 PM, V12 (Medical Director) stated if a nurse observes a change in a resident's breathing, a further assessment should be done, especially a resident new to the facility. V12 stated an assessment should be documented in the medical record and report new findings to the physician. The facility's policy titled Notification of Changes, dated September 2024, showed Compliance guidelines: the facility must .consult with the resident's physician when there is a change requiring such notification .Circumstances that require notification include: .3. Circumstances that require a need to alter treatment. This may include: a. new treatment .

Based on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter was secured. This applies to 1 out of 2 residents (R51) reviewed for catheter care in the sample of 20. The findings include: Face sheet shows that R51 is [AGE] years-old who has medical diagnoses including urinary tract infection (UTI). R51 was admitted to the facility on [DATE]. Minimum Data Set, dated dated dated [DATE], shows R51 requires assistance with toileting and hygiene. On April 15, 2025, at 1:05 PM, R51 was in the dining room sitting in her wheelchair in the dining room. R51 was actively moving in her wheelchair and had an indwelling urinary catheter bag handing under her wheelchair seat. R51 was able to respond to yes or no question, however, she was unable to coherently answer questions that needs explanation. V15 (CNA) stated that R51 was confused. On April 16, 2025, at 1:39 PM, V15 and V22 (Both Certified Nursing Assistants/CNA) rendered peri-care and catheter care to R51. The catheter tube was not secured to R51 and was hanging loosely. V15 and V22 did not attempt to secure or apply security device for R51's urinary catheter. On April 16, 2025, 1:51 PM, V8 (Nurse/RN) stated that indwelling urinary catheter must be always secured to the resident to prevent pulling of the catheter and prevent dislodging, and potential infection. On April 17, 2025, at 3:07 PM, V2 (Corporate Nurse) stated the urinary catheter should be secured or anchored to the resident to prevent any trauma and to ensure placement of indwelling urinary catheter.

Based on observation, interview and record review, the facility failed to provide double portions of protein to a resident with weight loss. This applies to 1 out of 3 residents (R41) reviewed for nutrition in the sample of 20. The findings include: R41's EMR (electronic medical records) included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, end stage heart failure, gastro-esophageal reflux disease without esophagitis, chronic kidney disease, stage 3 unspecified. R41's quarterly MDS (minimum data set) dated January 20, 2025 showed that R41 was cognitively intact. R41's diet order on POS (Physician Order Sheet) showed General diet, Mechanical Soft texture, Regular/Thin consistency, Double proteins at each meal for Nutritional health (revised March 20, 2025), Offer Super Cereal with breakfast (revised March 27, 2025). R41's weight history recorded in lbs (pounds) in EMR included as follows: 148.4 lbs (March 1, 2025) 153.2 lbs (February 1, 2025) 158.4 lbs (January 1, 2025) 169.2 lbs (December 1, 2024) 163.0 lbs (November 1, 2024) 161.4 lbs (October 1, 2024) 161.4 lbs (September 1, 2024) Dietitian Weight Change Note dated March 14, 2025 included the following in summary with pertinent information: R41 with continued gradual weight loss after initial significant weight loss. Weight loss of 12.3% times 3 months, 20.8 lbs. Diet: General diet, Mechanical Soft texture, Regular/Thin consistency. R41 on Hospice care- comfort measure in place. Current body weight 148.4 lbs, Ht: 67 inches, Body Mass Index 23.2. Intake: overall good at 75-100% meals. Recommend to offer super cereal in the morning. Dietitian to follow up as needed. On April 15, 2025 at 10:18 AM, R41 stated I lost about 4 lbs as I got Prostate cancer. They haven't given me supplements. I would like some. On April 16, 2025 at 11:40 PM, R41 stated that he only receives one portion at meals. R41 stated When ever I ask for more portions they say that I can't have it. R41 patted his frame and stated I could really use it. R41 stated that he receives grits at breakfast. On April 16, 2025 at 12:12 PM, during lunch meal service at tray line, R41 received ground bratwurst served with a #10 scoop in a bun with cooked peppers and onions and a side order of tater tots, ice cream for dessert. R41's diet card only showed Dental soft, mechanical soft, super grits (for breakfast). The diet spread sheet (Week 4, Wednesday) for lunch included (one) portion size for ground bratwurst as #10 scoop with bun. Portion control chart showed that #10 =3 ounces. On April 16, 2025 at 12:14 PM, when V4 (Dietary Manager) was asked why R41 only received one portion of bratwurst when his diet order showed double protein, V4 stated that R41's diet card only shows one portion. V4 later added that he was not notified that R41 should have double protein portions. On April 17, 225 at 2:44 PM, V17 (Dietitian) stated that when she wrote (above referred) progress note, she only added supercereal. On checking the order on POS, V17 stated that the recommendation for double portions came from nursing and should have been implemented if its a diet order. V17 stated that after the order for double protein was added on the POS she is not aware of what happened after that. V17 stated that R 41 could use the extra calories with double protein as he has weight loss and more so if resident is asking for it. On April 18, 2025 at 12:57 PM, V24 (Regional Director of Operations) stated that facility does not have a policy and procedure on how a diet order change notification to dietary is made. R41's care plan revised September 23, 2024 included that R41 has nutritional potential nutritional problem related to cancer of prostate with metastasis to bone. Interventions included to provide and serve diet as ordered, provide and serve supplements as ordered.

Based on observation, interview, and record review, the facility failed to monitor and ensure a resident on a gastrostomy tube feeding was receiving the total amount ordered. This failure resulted in a 10.44 percent weight loss in three months. This applies to 1 of 2 residents (R36) reviewed for gastrostomy tube feedings. The findings include: According to the Electronic Health Record (EHR) R36 had diagnoses including Parkinson's Disease, protein calorie malnutrition, hypertension, gastroesophageal reflux disease, and acute embolism and thrombosis of left lower extremity. The Minimum Data Set (MDS) dated [DATE] showed R36 was totally dependent on one staff for feeding, and was receiving gastrostomy tube feedings. R36 was 69 inches tall and weighed 143 pounds on admission. The MDS showed R36's cognition was severely impaired. A Care Plan showed R36 had unplanned weight loss with interventions to contact the physician and dietitian immediately if weight decline persists. The Physician Order Sheet (POS) showed an order dated 03/14/2023 for Osmolite 1.5 calorie at 80 milliliters per hour (ml/hr) to start at 3:00 PM and end at 9:00 AM. The EHR showed the following weights: on 01/26/2023, 142.7 pounds; on 02/23/2023, 142.8 pounds; on 02/13/2023, 142 pounds; on 03/01/2023, 129 pounds; on 03/08/2023, 128.6 pounds; on 03/15/2023, 129 pounds; on 03/22/2023, 131 pounds; on 03/29/2023, 130 pounds; on 04/05/2023, 130 pounds; on 04/12/2023, 132 pounds; on 04/19/2023, 130 pounds; on 04/26/2023, 127.8 pounds; and on 04/27/2023, 127.6 pounds. On 01/26/2023, the resident weighed 142.7 pounds and on 04/26/2023, the resident weighed 127.8 pounds which is a 10.44 % loss. On 04/25/2023 at 11:35 AM, R36 was lying in bed and did not have any bottles of Osmolite hanging at the bedside. V17 (R36's family member) said R36 receives a feeding through his gastrostomy tube from 3:00 PM until 9:00 AM. V17 said the nursing staff usually starts the feeding later than 3:00 PM sometimes 5:00 PM and V17 does not know what time they discontinue it at. V17 said the dietitian started the continuous feedings to make sure R36 was receiving the correct amount consistently to keep his weight stable. On 04/26/2023 at 8:50 AM, R36 way lying in bed and did not have the Osmolite feeding infusing. V10 (Certified Nursing Assistant/CNA) and V15 (CNA) said they had provided incontinence care for R36 at 8:00 AM and the feeding was not infusing and was no longer even connected. V10 and V15 weighed R36 using the total body mechanical lift and R36's weight was 127.8 pounds. On 04/26/2023 at 9:05 AM, V6 (RN) said she had discontinued R36's feeding around 8:45 AM because the bottle was empty. She did not start another Osmolite feeding bottle. On 04/26/2023 at 3:19 PM, V17 said R36's feeding was started at 3:30 PM on 04/25/2023, a half hour later than scheduled. On 04/27/2023 at 10:24 AM, V19 (Registered Dietitian) said she only visits the facility once a month and that if the resident receiving gastrostomy tube feedings is losing weight, they should notify her and the doctor. V19 said the facility did not notify me regarding R36's weight loss yesterday. R36 should be receiving a total of 1440 ml of Osmolite 1.5 calorie. V19 said weight loss could happen if he was not receiving the full amount of 1440 ml. V19 said if a feeding was started late, it was more important to ensure the total amount of 1440 ml was received, instead of ending it at a certain time. On 04/27/2023 at 10:38 AM, V22 (Medical Doctor/MD) said he would not expect any weight loss in residents receiving tube feedings. V22 was not notified of R36 having a weight loss. On 04/27/2023 at 2:20 PM, V26 (nurse) said she works the night shift from 10:00 PM until 6:00 AM and said the same container, which had been started on the evening shift, will usually last for the entire shift and would not be empty at 6:00 AM. V26 said she did not start a new feeding bottle for R36 on 04/26/2023. On 04/27/2023 at 4:29 PM, V2 (Director of Nursing/DON) said either she or the nurse should notify the dietitian and the physician when a resident has weight loss. According to V2, the physician and dietitian have not been notified with R36's weight loss as of now. V2 said the Osmolite containers are 1000 ml containers. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2023 do not show any documented total feeding amounts infused. The facility's Care and Treatment of Feeding Tubes policy dated 12/2022 included the staff should be ensuring the administration of enteral nutrition is consistent with and follows the practitioner's orders. Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders. 48308

Based on interview and record review the facility failed to ensure 2 staff were present and a gait belt was used to safely transfer a resident. This failure resulted in R32 sustaining a left leg laceration requiring emergency medical care, sutures and staples. This applies to 1 of 12 residents (R32) reviewed for safety/supervision in the sample of 12. The findings include: R32's face sheet shows she has diagnoses including: Alzheimer's disease, history of falls, generalized anxiety disorder, muscle weakness and unspecified abnormalities of gait and mobility. R32's 11/16/2021 facility assessment shows she has a memory problem, is cognitively impaired, she has behaviors which include hitting staff, and she requires extensive assistance of 2 staff for transfers. R32's active care plan shows she has a self- care deficit and requires staff assistance for her Activities of Daily Living (ADL's). The same care plan shows she is at risk for falls and requires 2 staff assistance for transfers, and a sit to stand lift may be needed based on her behaviors. A facility injury report completed on 12/12/2021 by V5 (Registered Nurse/RN), shows on 12/12/2021 at 6:30 PM, R32 was being assisted to bed by a Certified Nursing Assistant/ CNA (V3). V3 came and reported to V5 that she found blood on R32's bed sheets so she thinks R32 must have scraped her leg on the wheelchair during the transfer. The same report shows when V5 assessed R32's leg, she had a laceration to her right lateral leg which measured 3 centimeters (cm.) X 2 cm. X 2 cm. deep. Nursing progress notes show on 12/12/2021 at 7:15 PM, R32 was sent to a local emergency room for treatment of the laceration. The same notes also show R32 returned to the facility on [DATE] at 11:25 PM and had 4 staples and 3 sutures in her right posterior leg. R32's facility Wound Evaluation Management and Summary Reports show the injury R32's sustained during the transfer required ongoing treatment with an ointment and dressing changes and did not fully heal until 3/22/2022. On 3/29/2022 at 12:41 PM, V3 was contacted by phone and said on 12/12/2021, she had transferred R32 from her wheelchair to her bed by herself with no gait belt, and she did not use a sit to stand lift. V3 said R32 was becoming combative so all she was thinking about was getting her in bed. She said once she got R32 in bed she saw blood on the sheets, so she went and got a nurse. V3 said she thinks R32's leg was cut on the wheelchair leg rest during the transfer. V3 said 2 staff and a gait belt were required to safely transfer R32. V3 said when R32 becomes combative a sit to stand lift was often used to transfer her. V3 said she thinks the injury could have been prevented if she had gotten another CNA to help her transfer R32 and if she had used the sit to stand lift. On 3/29/2022 at 1:05 PM, V4 (Certified Nursing Assistant/ CNA) said R32 requires 2 staff and the sit to stand lift to safely transfer her and has for a long time, probably almost a year. She also said gait belts are required to be used always for all transfers. V4 additionally said if R32 was becoming combative she would have gotten another person to help transfer her as well as used the sit to stand lift. On 3/29/2022 at 1:19 PM, V2 (Director of Nursing) said staff should always use a gait belt to transfer a resident. V2 said R32 can be both a 2-person pivot transfer and a sit to stand transfer. V2 verified the injury R32's sustained during the transfer was not fully healed until 3/22/2022. The facility's undated Gait Belt policy shows, .All residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers unless contraindicated. The staff person will utilize safe transfer technique, moving with the resident, with the knees bent and a strong grasp of the transfer belt .

Based on observation, interview, and record review, the facility failed to provide adequate staff assistance and supervision to a dependent resident with dressing, bed mobility, and transfer as per resident assessment. This resulted in R1 sustaining a left arm fracture. This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in a sample of 3. Findings include: On 11/9/21 at 10:35 AM, R1 was observed with a left elbow sling and stated, I had a left , upper arm fracture when V3 (Certified Nurse Assistant, CNA) and V4 (CNA) transferred me back to bed when I was about to fall on 10/28/21. On 11/9/21 at 12:45 PM, V3 (CNA) stated, It was around 6:30 AM on 10/28/21 when I was trying to get R1 up in the morning. I gave a bed bath, and I sat her up at the bedside to dress. V3 stated that when R1 started to slide down the edge of the bed. V3 thought R1 slid down because of the special air loss mattress. V3 stated that she stopped R1 from falling by cradling and hugging R1. V3 called for help because she was trying to prevent R1 from falling and was continuing to hold R1 upright, using V3's arms wrapped around R1,in the hugging motion. V4 (CNA) entered the room and V4 used V4's gait belt to put R1 back to bed. R1 never reached the floor. V3 stated that R1 was saying you hurt me you hurt me. V3 apologized to R1, saying that V3 was sorry and admitted to R1 that V3 aggravated R1's arm. V3 did not want R1 to fall. V3 stated that R1 had no bruising to the left arm at that time. On 11/12/21 at 1:15 PM, V3 added, On 10/28/21, before I let R1 sit down at the bedside, I didn't put the mattress on static mode. The company sets up the air loss mattress, and we don't manipulate that. On 11/9/21 at 1:00 PM, V4 (certified nursing assistant - CNA) stated during interview that about 7:00AM on 10/28/21 she heard V3 calling me for help. V4 went to R1's room and V3 was holding R1 at the bedside to prevent R1 from falling. V4 stated that V4 placed a gait belt on R1, and along with V3, transferred R1 back to bed. The whole time V3 was holding R1 in a hug type movement to keep her from falling to the floor. After R1 was placed in bed, V3 and V4 finished dressing R1 on the bed, and V4 stated she left the room. Record review on the incident note dated 10/30/21 document that the facility noticed a dark reddish purplish discoloration with R1's left upper arm. The X-ray report dated 10/30/21 reported a displaced humeral neck fracture with the left arm. Record review on MDS (minimum data set) dated 9/16/21 indicates that R1 requires two-person extensive assistance with bed mobility, dressing, and transfer. On 11/9/21 at 1:00 PM, V4 stated, I was not with R1 until V3 called me for help, and I didn't help R1 to get up to wheelchair after dressing. On 11/12/21 at 1:15 PM, V4 confirmed that she was not in R1's room when V3 was providing bed bath/dressing and during transfer R1 from bed to wheelchair. Record review on R1's care plan document that R1 has poor coordination related to a history of stroke (left [CONDITION(S)]) and left radius fracture requires her two staff members to assist with transfers. On 11/10/21 at 10:20 AM, V3 stated, R1 is a two-person assist, and my other CNA (V4) was assisting another resident (R3). If the other CNA (V4) was with me from the beginning, maybe the incident could have been avoided on 10/28/21. On 11/10/21 at 10:35 AM, V6 (R1's attending physician) stated, R1 had the previous injury from a fall that happened on 7/16/21, and she was recovering. R1's left arm is congenitally deformed and can cause some imbalance in her body structure along with her [CONDITION(S)]. If the facility assessed her for two-person assistance, then there should be two-person to offer her care. Record review on Functional Impairment - Clinical Protocol revised on September 2012 document: The staff will identify individuals with a significant decline in function, including activities of daily living (ADL).

A. Based on interview and record review, the facility failed to follow their policy for abuse investigating and reporting by not immediately suspending employees accused of sexual abuse pending an outcome of the investigation to protect the residents. The facility also failed to follow their policy to immediately report an allegation of sexual abuse to the facility's abuse coordinator and the facility failed to notify law enforcement regarding an allegation of sexual abuse. This failure resulted in Immediate Jeopardy. The immediate jeopardy was noted to begin on July 7, 2020 when R1 reported an allegation of sexual abuse to V10 (Laundry Staff). This failure applies to all 38 residents residing in the facility. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 28, 2020 at 2:27 PM. V1 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on October 29, 2020 at 9:45 PM, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and procedures and Quality Assurance monitoring. The findings include: The Facility Data Sheet dated October 20, 2020 shows the facility census as 38 residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2018. R1 was transferred to the local hospital on October 16, 2020 and has not returned to the facility. R1 had multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated September 16, 2020 shows R1 had moderate cognitive impairment, required supervision with setup help only for eating, and extensive to total assistance with all other ADLs (Activities of Daily Living). R1 was always incontinent of bowel and bladder. On October 22, 2020 at 2:17 PM, V10 (Laundry Staff) stated, On July 7, 2020 at around 11:30 AM (R1) told me that (V8) (CNA-Certified Nursing Assistant) and (V5) (CNA) had been raping her. After the resident told me, I finished passing out folded clothes to the other residents, for about 30 minutes to an hour. Then I went and told the Director of Nursing. V10 confirmed she (V10) did not immediately report R1's allegation of sexual abuse. The facility's initial and final State Report of Patient Incident, dated July 7, 2020 shows, (R1) stated that 5 different males raped her, and that people were wanting to kill her. The incident report shows R1 specifically named V5 (CNA), V8 (CNA), V9 (CNA), V11 (CNA), and V12 (CNA) as having raped her. Facility documentation shows the initial and final abuse investigation was initiated and completed on July 7, 2020 and was sent to IDPH (Illinois Department of Public Health) on July 7, 2020 at 8:42 PM by V2 (DON). The facility did not have documentation to show the local police department was notified of R1's allegation of sexual abuse. On October 22, 2020 at 10:06 AM, V1 (Administrator) said, I did not suspend any of the staff that (R1) named in her sexual abuse allegation. I did not call the police department. If I really believed it had happened I would have. On October 27, 2020 at 3:27 PM, V1 (Administrator) said, If she wasn't confused, and stuck to the same story, we would have called the police. All I can say is that I know our residents. I can say that I know her well enough to say that she was fabricating her story. If it happened to a different resident, I would have to look at the whole picture before I decided to suspend someone or call the police. You have to look at the whole thing. (R1) is an alert and oriented person unless she has a UTI (Urinary Tract Infection). We treated her for a UTI, though we don't have anything to prove she had a UTI. The CNAs weren't suspended because (R1) has only female CNAs assigned to her. But yes, the people she named were present in the building. How can I suspend someone when they don't even take care of her? The facility did not have documentation to show that R1 had a urinary tract infection. The facility's CNA schedule dated June 28 through July 11, 2020 shows V8 and V11 (CNAs) were scheduled to work on July 7 and 8, 2020 from 2:00 PM to 10:00 PM. The same schedule shows V12 (CNA) was scheduled to work on July 7 and 8, 2020 from 6:00 AM to 2:00 PM. V8's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V8 worked July 7, 2020 from 12:44 PM to 10:01 PM, and July 8, 2020 from 1:50PM to 10:05 PM. V11's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V11 worked July 7, 2020 from 1:58 PM to 10:01 PM, and July 8, 2020 from 1:52 PM to 10:01 PM. V12's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V12 worked July 7, 2020 from 5:57 AM to 2:01 PM, and July 8, 2020 from 6:01 AM to 2:01 PM. On October 27, 2020 at 10:32 AM, V8 (CNA) said, I work the second shift, 2:00 PM to 10:00 PM. We get assigned to a group of residents, but we do go throughout the building and help each other out. I was not suspended or sent home on July 7 or 8. When (V2) (DON) told me about this situation, I guessed she had done the investigation already and I was in the clear. On October 27, 2020 at 10:25 AM, V11 said, I work evening shift 2:00 PM to 10:00 PM. We have groups and we circulate, and we go from one end of the building to the other. In our group we do a lot of teamwork and we do go from group to group, all over the building and help out with other residents. I was assigned to the same unit (R1) resided on during the time of July 7 and 8. I did not have to go into the room that night. I was not suspended or sent home or anything on July 7 or 8, 2020. On October 27, 2020 at 10:40 AM, V12 (CNA) said, I work the first shift, 6:00 AM to 2:00 PM. We do go all over the building and help each other, we don't have to stick to just our group. I was here at the facility on July 7, 2020, but I didn't take care of (R1). I would trade her off to one of the female CNAs. I was not suspended at any time due to her allegation of sexual abuse. On October 28, 2020 at 10:41 AM, V13 (Nurse) said, I was the nurse caring for (R1) on July 7, 2020 from 6:00 AM to 2:30 PM. Neither (V1) (Administrator) or (V2) (DON) ever told me about (R1's) abuse allegation during my shift. I never examined the resident on July 7, 2020, nor did I notify her physician or family member since I was not aware. On October 28, 2020 at 9:33 AM, V14 (Medical Director) said he was told about R1's allegation of sexual abuse by V1 (Administrator). V14 stated, It was mentioned in a meeting, but this patient is not my patient. After it happened we talked about it in August. I didn't have any conversations per se it was just mentioned that this was going on. It is absolutely my expectation that the facility staff follow the policy for abuse. Otherwise, what's the point of having policies? I would expect them to suspend the staff pending the outcome of the investigation. If this had been my patient, I would have said send her to the emergency room . The facility's policy entitled Abuse Investigation and Reporting, revised July 2017 shows, Policy Interpretation and Implementation, Role of the Administrator: 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. Reporting: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: e. Law enforcement officials 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately. Through observation, record review, and interviews conducted on November 2, 2020, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: · The Regional Director of Clinical Services will ensure any staff member that is named in an abuse allegation, no matter the circumstances, will be immediately suspended until the completion of the investigation. · The facility interviewed all residents on October 28, 2020, beginning at 4:00 PM, to see if any staff member had been inappropriate with them or had they witnessed any staff member being inappropriate with other residents. None of the residents reported that a staff member had been inappropriate with them or another resident. If the resident was unable to answer or comprehend the question, that was documented. · The QAPI committee reviewed the facility's policy on Abuse and Neglect to determine if any revisions needed to be made. It was determined that no revisions needed to be made. · The facility initiated inservice training for all staff in the building on 10/28/2020, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the facility Administrator, and/or the facility Director of Nursing. All training will be completed on 10/29/2020. This training includes: 1) F 607 and findings. 2) Abuse and Neglect Policy a. What are the eight types of abuse? b. Who do you report abuse or neglect to? c. Who is the abuse coordinator? d. Abuse or Neglect should be immediately reported to the abuse coordinator, do not wait to report. e. All allegations of abuse should be reported to law enforcement f. All residents will be examined by a physician following an allegation of sexual or physical abuse of any type. g. All staff members that are named in the abuse complaint will be immediately suspended until the outcome of the investigation. h. A thorough investigation will be conducted after an allegation of Abuse or Neglect. Steps in this investigation will include: a) Prior to the investigation being initiated, any staff member named in the allegation will be suspended. b) The physician, Medical Director, and family will be notified c) Law enforcement will be notified of abuse. d) Medical care will be provided as indicated, if sexual abuse is alleged, the resident will be sent to the hospital for examination. e) Review the completed documentation forms f) Review the resident's medical record to determine events leading up to the incident g) Interview the person(s) reporting the incident h) Interview any witnesses to the incident i) Interview the resident (as medically appropriate) j) Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition. The investigation will continue regardless of the resident's cognitive status. k) Interview all staff members (on all shifts) during the period of the alleged incident l) Interview the resident's roommate, family members, and visitors m) Interview other residents to whom the accused employee provides care or services n) Review all events leading up to the alleged incident o) IDPH will be notified p) If investigation has been concluded and new information becomes available, an addendum will be sent to IDPH and other concerned parties. · In addition to the inservice training above, each staff member was provided with a pocket guide which outlines the eight types of abuse and the number for the abuse coordinator. · The facility will conduct pre-employment screening of employees and pre-admission screening of residents. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · All newly hired staff will be inserviced prior to working the floor on the facility abuse and neglect policy. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · All staff members will be inserviced on the abuse and neglect policy weekly for a period of 1 month, then monthly for 3 months, then quarterly for 1 year. This will end on March 1, 2022. Staff will be inserviced in person by the facility Administrator or DON, if a staff member is unable to attend the inservice due to vacation or illness, they will be inserviced prior to working the floor on their next shift. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · The Regional Director of Clinical Services will review all abuse and neglect investigations monthly to ensure that the facility abuse policy was followed, this will be completed until November 1, 2021. · All abuse and neglect allegations/investigations will be reviewed by the facility's Quality Assurance Performance Improvement committee until November 1, 2021. Any issues identified will be immediately corrected and additional training will be provided as indicated. · A facility created quality assurance tool will be implemented and used by the Administrator, or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year, this will be completed until March 1, 2022. This tool will monitor that the facility is following the abuse policy. The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings. Any issues identified will be immediately addressed. B. Based on interview and record review the facility failed to follow their abuse policy for pre-employment screening. This has the potential to affect all 38 residents residing in the facility. The findings include: The Facility Data Sheet dated October 20, 2020 shows the facility census as 38 residents. During this sexual abuse investigation, V1 (Administrator) provided the employee files of the last ten employees hired for review of pre-employment screening. Of the ten files reviewed, concerns were identified with the employee files of V17 (MDS-Minimum Data Set Coordinator), V18 (Dietary Aide), V19 (Dietary Aide), and V20 (Maintenance Director). Each employees' date of hire was obtained from the Staff Detail Report, dated October 20, 2020, provided by V1 (Administrator), and the employee's personnel file. The following concerns were identified: V17 (MDS Coordinator), Start date: August 24, 2020. State Police background was checked on October 27, 2020, and Healthcare Worker Registry was checked on September 8, 2020. V18 (Dietary Aide), Start date: September 3, 2020. State police background was checked on October 27, 2020, and Healthcare Worker Registry was checked September 14, 2020. V19 (Dietary Aide), Start date: October 5, 2020. State police background check was completed on October 27, 2020. V20 (Maintenance Director), Start date: September 29, 2020. Sex offender website was checked on October 27, 2020. On October 28, 2020 at 9:33 AM, V14 (Medical Director) said he expects the facility to follow their abuse policy. On November 4, 2020 at 12:20 PM, V1 said, We haven't been doing background checks on new employees before they start working at the facility. We've been doing them the day they start. They come into the building, we have a meeting with them. Then we do the background checks. The facility's Abuse Prevention Program policy, revised in December 2016 shows: As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].

Based on interview and record review, the facility failed to protect the residents by immediately suspending employees accused of sexual abuse, pending the outcome of an investigation. The facility also failed to thoroughly investigate an allegation of sexual abuse. This failure resulted in Immediate Jeopardy. The immediate jeopardy was noted to begin on July 7, 2020 when R1 reported an allegation of sexual abuse to V10 (Laundry Staff). This failure applies to all 38 residents residing in the facility. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 28, 2020 at 2:27 PM. V1 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on October 29, 2020 at 9:45 PM, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and procedures and Quality Assurance monitoring. The findings include: The Facility Data Sheet dated October 20, 2020 shows the facility census as 38 residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2018. R1 was transferred to the local hospital on October 16, 2020 and has not returned to the facility. R1 had multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated September 16, 2020 shows R1 had moderate cognitive impairment, required supervision with setup help only for eating, and extensive to total assistance with all other ADLs (Activities of Daily Living). R1 was always incontinent of bowel and bladder. On October 22, 2020 at 2:17 PM, V10 (Laundry Staff) said, On July 7, 2020 at around 11:30 AM (R1) told me that (V8) (CNA-Certified Nursing Assistant) and (V5) (CNA) had been raping her. After the resident told me, I finished passing out folded clothes to the other residents, for about 30 minutes to an hour. Then I went and told the Director of Nursing. The facility's initial and final State Report of Patient Incident dated July 7, 2020 shows, (R1) stated that 5 different males raped her, and that people were wanting to kill her. The incident report shows R1 specifically named V5 (CNA), V8 (CNA), V9 (CNA), V11 (CNA), and V12 (CNA) as having raped her. Facility documentation shows the initial and final abuse investigation was started and completed on July 7, 2020 and was sent to IDPH (Illinois Department of Public Health) on July 7, 2020 at 8:42 PM by V2 (DON) as an unsubstantiated allegation caused by a UTI (Urinary Tract Infection). The facility did not have documentation to show the local police department was notified of R1's allegation of sexual abuse. On October 22, 2020 at 10:06 AM, V1 (Administrator) said, I did not suspend any of the staff that (R1) named in her sexual abuse allegation. I did not call the police department. If I really believed it had happened I would have. On October 27, 2020 at 3:27 PM, V1 (Administrator) said, If she wasn't confused, and stuck to the same story, we would have called the police. All I can say is that I know our residents. I can say that I know her well enough to say that she was fabricating her story. If it happened to a different resident, I would have to look at the whole picture before I decided to suspend someone or call the police. You have to look at the whole thing. (R1) is an alert and oriented person unless she has a UTI. We treated her for a UTI, though we don't have anything to prove she had a UTI. The CNAs weren't suspended because (R1) has only female CNAs assigned to her. But yes, the people she named were present in the building. How can I suspend someone when they don't even take care of her? The facility's CNA schedule dated June 28 through July 11, 2020 shows V8 and V11 (CNAs) were scheduled to work on July 7 and 8, 2020 from 2:00 PM to 10:00 PM. The same schedule shows V12 (CNA) was scheduled to work on July 7 and 8, 2020 from 6:00 AM to 2:00 PM. V8's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V8 worked July 7, 2020 from 12:44 PM to 10:01 PM, and July 8, 2020 from 1:50PM to 10:05 PM. V11's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V11 worked July 7, 2020 from 1:58 PM to 10:01 PM, and July 8, 2020 from 1:52 PM to 10:01 PM. V12's Time Card Report for the period June 28, 2020 to July 11, 2020 shows V12 worked July 7, 2020 from 5:57 AM to 2:01 PM, and July 8, 2020 from 6:01 AM to 2:01 PM. On October 27, 2020 at 10:32 AM, V8 (CNA) said, I work the second shift, 2:00 PM to 10:00 PM. We get assigned to a group of residents, but we do go throughout the building and help each other out. I was not suspended or sent home on July 7 or 8. When (V2) (DON) told me about this situation, I guessed she had done the investigation already and I was in the clear. On October 27, 2020 at 10:25 AM, V11 said, I work evening shift 2:00 PM to 10:00 PM. We have groups and we circulate, and we go from one end of the building to the other. In our group we do a lot of teamwork and we do go from group to group, all over the building and help out with other residents. I was assigned to the same unit (R1) resided on during the time of July 7 and 8. I did not have to go into the room that night. I was not suspended or sent home or anything on July 7 or 8, 2020. On October 27, 2020 at 10:40 AM, V12 (CNA) said, I work the first shift, 6:00 AM to 2:00 PM. We do go all over the building and help each other, we don't have to stick to just our group. I was here at the facility on July 7, 2020, but I didn't take care of (R1). I would trade her off to one of the female CNAs. I was not suspended at any time due to her allegation of sexual abuse. The facility's documentation shows the facility concluded R1 had a history of [REDACTED]. The facility treated R1 for a UTI with an antibiotic, though no urine specimen was sent to confirm the [DIAGNOSES REDACTED]. A review of the facility's sexual abuse investigation for R1, completed by the facility on July 7, 2020 shows the facility obtained 20 written statements from facility staff, dated and signed by each staff member. Sixteen of the 20 facility staff members' written statements were dated July 8, 2020, the day after the investigation had been completed and reported to IDPH as unsubstantiated due to a UTI. V5 (CNA) was named by R1 as one of the perpetrators of sexual abuse. V5 was on vacation on July 7, 2020. V5's time card shows V5 returned to work on July 10, 2020 and worked from 3:39 PM to 10:02 PM. On October 27, 2020 at 10:48 AM, V5 said, I work second shift, from 2:00 PM to 10:00 PM. I was aware that (R1) made an allegation that she was sexually assaulted by some of the CNAs here. No one ever specifically spoke to me about it, nor was I ever suspended. I was never interviewed by anyone regarding the resident's allegation I sexually assaulted her. The facility does not have any documentation to show R1 was seen by a physician, or sent to the local hospital, or provided with a head-to-toe assessment by any medical professional including physician or nursing staff, following her allegation of sexual abuse as shown on the facility's policy. On October 20, 2020 at approximately 10:00 AM, V1 (Administrator) said, I am an old ER nurse. I sent two nurses down there to assess (R1) right away with a flashlight. One of the nurses was (V13). They did not see any genital redness, bruising, discharge or odor. The facility does not have any documentation by the nursing staff to show an assessment was done of R1's genitalia. On October 28, 2020 at 10:41 AM, V13 (Nurse) said, I was the nurse caring for (R1) on July 7, 2020 from 6:00 AM to 2:30 PM. Neither (V1) (Administrator) or (V2) (DON) ever told me about (R1's) abuse allegation during my shift. I never examined the resident on July 7, 2020, nor did I notify her physician or family member since I was not aware. I did return to the facility two days later, on July 9, 2020 and I had (R1) for a patient. (V1) (Administrator) asked me to examine (R1) with a flashlight. She's very small so it didn't take long. She's very contracted and it's hard to look at the perineal area. We changed her brief real quick, and that's how we saw her perineal area. I graduated from nursing school in July 2019. I have never been trained to do a sexual assault exam. We did not document our examination of the resident I just told (V1) I didn't see anything. The facility does not have documentation to show R1 was examined on July 7, 2020. On October 27, 2020 at 2:44 PM, V16 (NP-Nurse Practitioner) said, I was filled in by the facility on July 7, 2020. I remember they called, and they updated me, and I wanted (R1) sent to the emergency room . The vaginal assessment from the nurse was fine is what the facility told me. I texted (V2) (DON) and she said everything was unfounded. According to the (V2), the resident's story was changing. I was told by the facility that the family did not want (R1) sent to the emergency room , but I myself never spoke to the family to confirm that. On October 28, 2020 at 11:05 AM, V21 (R1's POA-Power of Attorney) said, In July, (V1) (Administrator) told me that my sister said she was raped. She did not say to me that she wanted to call the police and send her to the emergency room . (V1) told me that her nurses checked her in her private area and she said there was no sign anything happened. I thought it was the nursing home's responsibility to call the police and send her to the hospital. I never said don't send her to the hospital. I never said don't call the police. On October 27, 2020 at 1:13 PM, V15 (R1's Attending Physician) said, I was informed that (R1's) allegation was an unfounded allegation. They said there was no evidence of a sexual assault. I was not aware they did not do a physical examination of (R1). At that time, during COVID-19, physicians and nurse practitioners were not going into facilities to see patients. All of our encounters were via telephone or virtual. My nurse practitioner said she was going to treat (R1) for a UTI. (R1) should have been seen by a physician if she made an allegation of sexual assault. We did not give any other orders because the nursing home said there was no evidence for this. The facility said there were no male CNAs working there that night. We were told there were none. If she did name the CNAs, and that was not reported to us, then that was a problem. If someone gives you a name then you should go to the full length of an investigation, that would include sending the patient to the emergency room to do a rape exam. That is not how it was reported to me. It was reported to us that it was a made-up allegation. If it was presented to you incorrectly then you come up with the wrong conclusion. On October 28, 2020 at 9:33 AM, V14 (Medical Director) said he was told about R1's allegation of sexual abuse by V1 (Administrator). It was mentioned in a meeting, but this patient is not my patient. After it happened we talked about it in August. I didn't have any conversations per se it was just mentioned that this was going on. It is absolutely my expectation that the facility staff follow the policy for abuse. Otherwise, what's the point of having policies? I would expect them to suspend the staff pending the outcome of the investigation. But as far as plain black and white, you have to follow the policy. I do not think a nurse armed with a flashlight has adequate training to do a sexual assault examination unless they have specific training for it. If this had been my patient, I would have said send her to the emergency room . The facility's policy entitled Abuse Investigation and Reporting, revised July 2017 shows, Policy Interpretation and Implementation, Role of the Administrator: 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. Reporting: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: e. Law enforcement officials . 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately. The facility's policy entitled Abuse and Neglect - Clinical Protocol, revised July 2017 shows, 3. Sexual abuse is defined at 483.5 as non-consensual sexual contact of any type with a resident. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment (bleeding, bruising, deformity, swelling etc.); b. Pain assessment; c. Current behavior; d. Patient's age and sex; e. All current medications, especially anticoagulants, NSAIDs, [MEDICATION NAME]; f. Other platelet inhibitors; g. Vital signs; h. Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); i. History of any tendency towards bruising; j. All active diagnoses; and k. Any recent labs. Through observation, interviews, and record review conducted on November 2, 2020, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: · The Regional Director of Clinical Services will ensure any staff member that is named in an abuse allegation, no matter the circumstances, will be immediately suspended until the completion of the investigation. · The facility interviewed all residents on October 28, 2020, beginning at 4:00 PM, to see if any staff member had been inappropriate with them or had they witnessed any staff member being inappropriate with other residents. None of the residents reported that a staff member had been inappropriate with them or another resident. If the resident was unable to answer or comprehend the question, that was documented. · The QAPI committee reviewed the facility's policy on Abuse and Neglect to determine if any revisions needed to be made. It was determined that no revisions needed to be made. · The facility initiated inservice training for all staff in the building on 10/28/2020, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the facility Administrator, and/or the facility Director of Nursing. All training will be completed on 10/29/2020. This training includes: 1) F610 and findings. 2) Abuse and Neglect Policy a. What are the eight types of abuse? b. Who do you report abuse or neglect to? c. Who is the abuse coordinator? d. Abuse or Neglect should be immediately reported to the abuse coordinator, do not wait to report. e. All allegations of abuse should be reported to law enforcement f. All residents will be examined by a physician following an allegation of sexual or physical abuse of any type. g. All staff members that are named in the abuse complaint will be immediately suspended until the outcome of the investigation. h. A thorough investigation will be conducted after an allegation of Abuse or Neglect. Steps in this investigation will include: a) Prior to the investigation being initiated, any staff member named in the allegation will be suspended. b) The physician, Medical Director, and family will be notified c) Law enforcement will be notified of abuse. d) Medical care will be provided as indicated, if sexual abuse is alleged, the resident will be sent to the hospital for examination. e) Review the completed documentation forms f) Review the resident's medical record to determine events leading up to the incident g) Interview the person(s) reporting the incident h) Interview any witnesses to the incident i) Interview the resident (as medically appropriate) j) Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition. The investigation will continue regardless of the resident's cognitive status. k) Interview all staff members (on all shifts) during the period of the alleged incident l) Interview the resident's roommate, family members, and visitors m) Interview other residents to whom the accused employee provides care or services n) Review all events leading up to the alleged incident o) IDPH will be notified p) If investigation has been concluded and new information becomes available, an addendum will be sent to IDPH and other concerned parties. · In addition to the inservice training above, each staff member was provided with a pocket guide which outlines the eight types of abuse and the number for the abuse coordinator. · The facility will conduct pre-employment screening of employees and pre-admission screening of residents. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · All newly hired staff will be inserviced prior to working the floor on the facility abuse and neglect policy. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · All staff members will be inserviced on the abuse and neglect policy weekly for a period of 1 month, then monthly for 3 months, then quarterly for 1 year. This will end on March 1, 2022. Staff will be inserviced in person by the facility Administrator or DON, if a staff member is unable to attend the inservice due to vacation or illness, they will be inserviced prior to working the floor on their next shift. This will be monitored to ensure completion by the Regional Director of Clinical Services, or designee, monthly for 3 months, then quarterly for 1 year, this will be completed November 1, 2021. · The Regional Director of Clinical Services will review all abuse and neglect investigations monthly to ensure that the facility abuse policy was followed, this will be completed until November 1, 2021. · All abuse and neglect allegations/investigations will be reviewed by the facility's Quality Assurance Performance Improvement committee until November 1, 2021. Any issues identified will be immediately corrected and additional training will be provided as indicated. · A facility created quality assurance tool will be implemented and used by the Administrator, or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year, this will be completed until March 1, 2022. This tool will monitor that the facility is following the abuse policy. The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings. Any issues identified will be immediately addressed.

Based on interview and record review, the facility failed to ensure adequate interventions and monitoring were in place to prevent the development of maggots in a resident's gangrenous toe wound. This failure resulted in maggot infestation in R2's wound, resulting in R2's hospitalization . This applies to 1 of 4 residents (R2) reviewed for wounds in the sample of 7. The findings include: On (MONTH) 7, 2019 at 3:00 PM, V6 (LPN-Licensed Practical Nurse) documented in the EMR (Electronic Medical Record), Situation: Elevated temp 100.0 oral. Maggots to left foot toe. On (MONTH) 7, 2019 at 4:54 PM, V10 (MD-Medical Doctor) documented in local hospital records, Medical Condition: [AGE] year-old male with a history of [MEDICAL CONDITION], diabetes, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). He was sent over from nursing home for evaluation of wound on his left great toe that had maggots crawling around it when nursing home staff came to evaluate him today. Patient denies any fevers, denies any significant pain. On exam, the left great toe has a darkened appearance with wounds medial and laterally, that are infested with maggots, wound has a foul-smelling odor. The EMR shows R2 was admitted to the facility in (MONTH) 2019 with multiple [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) dated (MONTH) 10, 2019 shows R2 is cognitively intact, requires limited assistance with bathing, and supervision for all other ADLs (Activities of Daily Living). R2 is always continent of bowel and bladder R2's Order Review Report dated (MONTH) 17, 2019 shows the following order dated (MONTH) 2, 2019: Left great toe: cleanse with wound cleanser, pat dry, paint w/[MEDICATION NAME], leave OTA (Open To Air), keep clean and dry every day and night shift for redness/irritation. On (MONTH) 16, 2019 at 9:15 AM, V13 (Wound Doctor) said, I last saw (R2) on (MONTH) 2, 2019 and said he needed to see a podiatrist right away. I was basically treating him palliatively because in the end the toe needed to be amputated. A resident living in a nursing home should not get maggots in a wound. On (MONTH) 16, 2019 at 9:25 AM, R2 was lying in bed in his room. R2's left foot was wrapped in an elastic bandage. R2 said, I just returned to the facility last night. I was in the hospital having my foot amputated. I did not know I had maggots in my foot before I went to the hospital. I did not go outside the building a lot, especially in the days leading up to going to the hospital. I pretty much stayed in my room. On (MONTH) 16, 2019 at 12:34 PM, V3 (Licensed Practical Nurse, LPN) said, Sunday, (MONTH) 7, when I cleaned (R2's) toe with [MEDICATION NAME], the tissue on the foot separated and a maggot fell out. I was in shock. (V6) (LPN) came in and moved the tissue on the foot and looked and saw more maggots inside. It was right at 2:00 PM on Sunday. It was between the two toes, where the area separated. I don't think the resident even realized what was going on. There was one maggot on the bedding after I covered the foot. He's been leaving the foot open to air, sometimes he's does wear a non-skid sock at times. On (MONTH) 16, 2019 at 2:05 PM, V14 (MD) said, At the time I saw the resident, I did not see maggots in the wound because they had been cleaned out. He had the right leg amputation, above the knee, several months ago, and he already had signs of left foot problems and the need for surgery. When you develop gangrene, which is dead tissue, it acts like a breeding ground for organisms to get in and take advantage of the situation, especially if you don't protect the wound. Any time you have dead tissue, and sorry to say this, but if you leave the meat out on the counter and there is something around like flies, you can end up with maggots in it. On (MONTH) 16, 2019 at 2:45 PM, V6 (LPN) said, On Sunday, (MONTH) 7, (V3) (LPN) was doing the treatment to the resident. She told me she found a maggot and we were able to look at the wound together. I was able to see underneath the skin towards the big toe and the [MEDICATION NAME] had hardened the skin and you could lift up the side and I could see more maggots. I think they were eating that tissue from underneath. We were shocked. There was an odor to the wound and in the room. We couldn't see the opening on the top part of the toe, but upon closer inspection, we could see an opening on the bottom side of the toe. I don't usually do his wound care on my shift, so I had not assessed the wound before. During observations on (MONTH) 15, 2019 from 1:45 PM to 4:15 PM, (MONTH) 16, 2019 from 9:00 AM to 3:00 PM, and (MONTH) 17, 2019 from 9:00 AM to 4:00 PM, multiple house flies were observed flying in the facility. On (MONTH) 16, 2019 at 10:55 AM, V15 (Maintenance Director) said he had not been notified by any facility staff that a resident was found with maggots in his wound. On (MONTH) 16, 2019 at 10:59 AM, V16 (Pest Control Manager) said, We supply twice a month service to the facility. When we show up at the facility we touch base with (V15), and he lets us know if there are any problems. We were in the facility on (MONTH) 26, 2019 and on (MONTH) 12, 2019. The maggot issue wasn't reported to us. A house/bottle fly is the type of fly that would land on a wound and lay eggs and that's how a wound would get maggots in it. The fly would not be able to lay eggs through a sock or if the wound was covered. Flies are attracted to wounds and they hone in on odors and will go right to the wound. Based on the service reports, we did not get a recall to go to the facility due to the finding of maggots. The facility's Wound Care policy, revised in (MONTH) 2010, shows: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. The facility did not have documentation by the nursing staff to show assessment data of R2's toe wound, including wound bed color, size or drainage when providing wound care twice daily.

Based on observation, record review and interview the facility failed to: - have an effective system to conduct pressure ulcer assessment; - develop and implement individualized interventions including use of pressure relieving mattress to prevent and / or to promote healing of pressure sores in the facility. As a result: R1 acquired in the facility on 9/20/12 (a) left heel 1.5 cm x 1.6 cm 100% necrotic deep tissue injury (DTI); (b) right heel 2.5 cm x 3.0 cm 100% necrotic DTI. R1 also acquired a pressure ulcer in the facility on 9/21/12 to her sacrum. The facility did not document details to show size and stage of the sore. R2 acquired a stage III pressure sore to his sacrum on 10/12/12. As of 11/16/12 the sore noted to have deteriorated. This is for two of three residents (R1 and R2) who have facility acquired pressure sore in the sample. Findings include: R1 had no pressure sore upon her admission to the facility (11/5/11) as evidenced by her Minimum Data Set (MDS) from 11/18/11 through 8/18/12. R1's 9/20/12 1:55 am Nurses Notes indicated R1 acquired in the facility: (1) 3.5 cm x 1.5 cm pressure sore to lateral aspect of right heel; (2) 1.5 cm x 3.0 cm pressure sore to lateral aspect of left heel. Facility 9/21/12 weekly wound care report indicated R1's both heel sores had 100% necrosis. On 9/25/12 11:51 am R1's Nurses Notes indicated she acquired a pressure sore to her sacrum. No details of the pressure sore were documented, however a treatment order was noted in the nurses notes to indicate the pressure sore to be treated with 'no sting barrier wipe, [MEDICATION NAME] bordered foam dressing, change every two to three days'. On 9/26/12 at 12:40 am R1's nurses notes indicated she was admitted to the local hospital for evaluation and treatment of [REDACTED]. On 9/26/12 at the hospital the wounds were described as bilateral heels decubitus ulcers which are blistered and are not open wounds, deep tissue injury (DTI). R1 also has sacral decubitus, two of them, which are about stage II. There was no documentation to show if the facility conducted a pressure sore assessment to indicate why R1 acquired the pressure sores in the facility. On 11/15/12 E1 at 4:30 pm the facility has a consultant who visits the facility once a week. E1 also stated the consultant does the weekly wound management. A review of consultant's weekly wound management reports for R1 indicated only date, location, size and status of the wounds, but has no explanation to show why R1 acquired pressure sore. The facility presented a form 'Risk Determination Instrument.' The form noted dates were 5/4, 5/18, 6/18, and 9/21/12. This form had check marks for low, moderate and high risk. The form noted Braden Scale score being '12' which included incontinence, immobility and [MEDICAL CONDITION] as risk factors and checked R1 to be at high risk for acquiring pressure sores. There was no further evaluation of these risk factors to show if the pressure sore were preventable or not; and to develop and implement individualized interventions. R1's 11/9/11, 2/9/12 and 9/21/12 skin breakdown plan of care interventions are individualized or specific to address the risk factors. The interventions added after R1 acquired pressure sore to her bilateral heel were vague, for example 'wound care nurse saw, ordered treatment, wound nurse to follow along with physician and facility nurse.' The care plan had no interventions to address the use of specific pressure relieving devices and heel positioning as a measure to prevent and or to promote healing of the pressure sore. On 11/16/12 at 3:30 pm via phone interview, the facility wound care consultant (Z2) stated she visits facility once a week or whenever she gets referral from the facility after a resident acquires a pressure sore. Z2 said until then she has no way of knowing which residents is at risk for acquiring pressure ulcers. Z2 stated R1's bilateral heel sores were of DTI nature, she was not aware of R1's sacral ulcer, because the sacral ulcer was not there when she saw R1 on 9/21/12. Z2 also stated it would have been 9/28/12 to evaluate R1's sacral ulcer. Z2 indicated R1 got DTI sores to bilateral heels due to her heels being in prolonged dependent position on her legs. On 11/15/12 at 3:00 pm R1's physician (Z3) stated he does not treat pressure sores, however based on Z2's recommendations the pressure sore treatments are ordered. Z3 stated any one should not acquire pressure sore given adequate staff availability; and in case of R1's pressure sores, she was not eating well, repeated infections, incontinence, immobility, positioning, transferring to prevent friction and shearing may be some of the issues. Z3 stated he was aware of R1's bilateral heel sores, but not aware of her sacral sore. II. On 11/15/12 at 1:38 pm R2 was in his bed, his both feet were curled in blanket, his knees were contracted and his heel were pressing against his mattress. R2 was alert when called his name, responded to questions with short response, but was appropriate. On 11/16/12 at 12:30 pm was in his in supine position, again his both feet were pressing against the mattress. There was a sign posted at the head of his bed to indicate 'TED HOSE on at all times to his both legs,' but he had no TED hose on to his legs.' E2 the Director of Nurses confirmed this observation. E2 stated she will check with the Certified Nurse Aide (CNA). Both days R2 had regular mattress on his bed similar to the one other residents have. There were no positioning devices such as pillow or heel boots to float his heels. The facility 9/21/12 weekly wound surveillance report noted R2 acquired a stage III pressure sore on 10/12/12 measuring 1.0 cm x 0.1 cm. This pressure sore as of 11/16/12 weekly wound management tool noted deteriorated, size noted noted to be 1.5 cm x 0.6 cm x 0.6 cm with exudate and serosangious drainage. R2's 10/11/12 Braden Scale scored '19' which indicates he is less than mild risk for acquiring pressure ulcer. There was no assessment to show why R2 acquired a stage III pressure sore to his sacrum. R2's pressure sore care plan dated 4/15, 4/20, 6/18, 9/21 and 10/5/12 interventions included (a) special ordered mattress with air on bed when resident in bed, (b) apply heel protectors to relieve pressure on heels, place pillows under calf to raise the heel off the bed, (c) use positional devices (pillows, foam wedges) to keep bone prominence from direct contact with one another. The facility did not implement these interventions 11/15/12 and 11/16/12. On 11/16/12 at 12:45 pm E1 stated R2 used to have special ordered mattress with air on bed, and mattress changed to a regular one when his pressure sore got better. Now that R2's sore is deteriorating, E1 stated she will order a special mattress. The facility policy and procedure titled 'pressure ulcers / skin breakdown - clinical protocol' is specific as to how the staff should conduct assessment, develop and implement interventions for the prevention and treatment of [REDACTED].

Based on record review and interview the facility failed to have a protocol for insertion and care for the management of peripherally inserted central catheter (PICC) and maintain PICC line free from infection. As a result R1 acquired a gram-positive cocci infection to the PICC line site. This is for one of one residents (R1) in the sample of three residents who had PICC line. Findings include: On 9/15/12 R1 had a physician order [REDACTED]. On 9/16/12 pharmacy clinical infusion progress note indicated a PICC was inserted to R1's left upper arm for the administration of medication via IVPB. The progress notes did not indicate the size of the catheter, length of the catheter, or the circumference of the arm at PICC line site. The PICC line insertion infusion progress note at the time of the PICC line insertion was signed, but there is no name or the title of the person who inserted the PICC line. E1 the Administrator stated it was a Nurse from the pharmacy consultant. There was no plan of care on record for the management of R1's PICC line, and maintain the line and site patent and keep the site free from infection. On 11/16/12 at 12:45 E1 stated that the facility has no policy or procedure for the management of the PICC line and they just follow physician orders. R1's 9/16/12 treatment record indicated 'PICC line dressing to left arm, change every 72 hours' and signed off as done on 9/19 and 9/23/12. There is no documentation to indicate if the site was patent and describe the site (swelling, redness, pain and infiltration). On 9/26/12 the facility sent R1 to the local hospital for the evaluation and treatment of [REDACTED]. The hospital 9/26/12 medical necessity determination noted R1 had to be hospitalized 'due to the need to treat acute [MEDICAL CONDITION], as evidenced by abrupt change in mental status in the setting of high infectious risk due to an indwelling PICC line and [MEDICAL CONDITION].' The hospital report also noted R1 to have a UTI, as well as her left arm PICC line blood culture was positive for gram-positive cocci bacteria. The emergency room notes indicated 'no known IV PICC line date,' at R1's left arm PICC line site. R1's physician (Z3) on 11/15/12 at 3:00 pm stated he was aware of her UTI and that is why he ordered IVPB medicine via PICC line, Z3 stated he was not aware of R1's PICC line being infected. Z3 also stated the UTI and PICC line infection can cause [MEDICAL CONDITION] and mental status can also change.