Every finding on record at Loft Rehab of East Peoria, The

Based on observation, interview, and record review, the facility failed to ensure that two staff were present during a mechanical lift transfer for one of four residents (R4) reviewed for transfers in a sample of four. Findings include: The facility's Comprehensive Care Plans policy, reviewed 1/20/2026, documents that 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 standards of quality. R4's current care plan documents that R4 requires staff assistance for completion of activities of daily living and mobility tasks related to: immobility, cognitive deficits, deconditioning, poor cardiorespiratory endurance, incontinence, fall risk. This form documents that R4's chair to bed/bed to chair requires 2 staff using a mechanical lift for all transfers. On 8/4/26 at 9:20am, V5, Certified Nursing Assistant, had R4 hooked up to the mechanical lift machine and in mid-transfer. V4 continued to transfer R4 from his wheelchair to his bed. V4 stated that she transferred R4 by herself because he was yelling to use the bathroom. V5 stated that transfers done with the mechanical lift require two staff members. On 8/4/26 at 11:50am, V6, Assistant Director of Nursing/Infection Preventionist, stated that V5 should not have transferred R4 by herself; all mechanical lifts require two staff members.

Based on observation, interview, and record review, the facility failed to ensure two large trash dumpsters are secured from flying birds/insects and other small animals/rodents, in that the lids of the trash dumpsters were not closed. This failure has the potential to effect all 117 residents residing in the facility. FINDINGS INCLUDE: Facility Policy, entitled Standards and Guidelines: Garbage Dispose and Refuse, revised 3/4/2021, document: 4. will ensure the garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 10/22/2024, document 117 residents reside in the facility. On 10/22/2024, at 9:00 a.m., during the initial kitchen tour, with V17/Dietary Manager, the two trash dumpsters, located outside, had lids which were open and both dumpsters had facility trash in them. On 10/22/2024, at 9:00 a.m., V17 confirmed the trash dumpster lids should have been closed.

Based on observation, interview, and record review, the facility failed to revise a Minimum Data Set (MDS) to include legally blind for vision for one (R106) of 24 residents reviewed for accurate MDS assessments in a sample of 36. Findings include: R106's medical record documents R106 has Legal Blindness, as defined in the USA (United States of America). R106's Quarterly MDS, dated [DATE], documents under vision Adequate. R106's current care plan documents (R106) has impaired visual function related to blindness of both eyes and she is at risk for new/ worsening complication. On 10/22/24 at 9:36AM, R106 in her room lying across her bed, alert and oriented, and legally blind notes posted in her room. R106 stated she is blind, and cannot see shadows. On 10/24/24 at 12:07PM, R106 stated she has been blind all her life. On 10/24/24 at 12:01PM, V18 Care plan/MDS nurse verified R106 was legally blind.

Based on observation, interview, and record review, the facility failed to revise a care plan to include a specific dialysis access site, and which arm to use for blood pressure monitoring for two (R36 and R103) of 24 residents reviewed for care plan revision in a sample of 36. Findings include: Facility Care plan revisions, revised 1/25/23, documents The care plan will be reviewed and revised as necessary. The designated staff member will communicate care plan interventions to all staff involved in the resident's care. 1. R36's Physician orders for October 2024 documents (Dialysis) Shunt is in left arm. On 10/24/24 at 1:48 PM, R36 was in her room in bed on her left side, and stated her dialysis shunt was in her left arm. R36's current care plan has no documentation where R36's dialysis shunt is located, and which arm to use for blood pressure monitoring. 2. R103's Physician orders for October 2024 documents Dialysis site observation in right chest port. R103's current care plan has no documentation where R103's dialysis shunt is located, and which arm to use for blood pressure monitoring. On 10/24/24 at 11:59 AM, V18 care plan nurse verified R36 and R103's care plans did not identify where their dialysis shunts were located, and which arm to use for blood pressure monitoring.

Based on observation, interview and record review, the facility failed to follow physician orders for one (R18) of three residents reviewed for antibiotic orders in a sample of 36. Findings include: Facility's Physician/Practitioner Orders Policy Dated 12/13/22 documents: 2. For physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. R18's 10/4/24 Physician Order documents: Doxycycline Hyclate (Vibramycin) (Antibiotic) 100 mg/milligrams tablet. Take one Tablet (100mg/milligrams total) by mouth two times daily for ten days x seven days due to UTI/Urinary Tract Infection. R18's Medication Administration Record/MAR dated 10/2024 does not document R18 was administered Doxycycline Antibiotic until 10/7/24. R18's Progress Note dated 10/4/24 documents: Resident returns to facility via facility van. New orders obtained per (Local Facility) health family medicine-(City). Order states take one tab (100mg total) Doxycycline Hyclate by mouth two times daily for 'ten days x seven days' due to UTI/Urinary Tract Infection. On 10/25/24 at 7:55am, V13 Power of Attorney/POA to R18 stated: (V10 Primary Care Physician to R18) prescribed antibiotics for (R18). I talked to the Director of Nursing/DON (V2) about the antibiotic and why it was not started on 10/4 and she said the facility did not follow through on that one. On 10/23/24 at 9:55am V7 Licensed Practical Nurse/LPN stated that she did not start R18 on the prescribed antibiotic after receiving the order from R18's Primary Care Physician on 10/4/24, and stated that the antibiotic was not administered until 10/7/24.

Based on observation, interview and record review the facility failed to don proper personal protective equipment during gastronomy tube medication administration for one of one residents (R50) reviewed for Enhanced Barrier Precautions in a sample of 36. Findings include: The facility's Enhanced Barrier Precautions policy, dated 1/1/24, documents Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order foe enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (Multidrug-Resistant Organisms). High-contact resident care activities include: Device care or use; central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. The facility's Care and Treatment of Feeding Tubes policy, dated 12/19/22, documents It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Direction for staff on how to provide the following care will be provided: Use of infection control precautions ad related techniques to minimize the risk of contamination. R50's admission record documents that R50 admitted to facility on 7/6/21 with diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. R50's current physician's orders documents isolation: maintain enhanced barrier precautions per Centers for Disease Control (CDC) guidelines every shift for prophylaxis related to gastronomy tube (G-Tube/GT). R50's Minimum Data Set assessment (MDS) dated [DATE], documents that R50 has a feeding tube. On 10/23/24 at 11:00 AM V5 (Licensed Practical Nurse/LPN) performed hand hygiene, donned gloves, and proceeded to administer medications via gastronomy tube (G-Tube/GT). On 10/23/24 at 11:30 AM V5 (LPN) verified that R50 is on enhanced barrier precautions due to her G-Tube. V5 also verified she should have worn a gown with the gloves while administering G-Tube medications but realized she forgot to after administration of the G-Tube medications.

Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency for one resident (R1) of three residents reviewed for falls. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated/revised 12/5/22 documents: 6.) Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: c.) Physical injury of a resident, of unknown source. Physician Order Summary Report dated 4/2024 indicates R1 was [AGE] years old with diagnoses that include Long Term/Current Use of Anticoagulants, Personal History of Venous Thrombosis and Embolism, Unspecified Rotator Cuff Tear or Rupture of Left/Right Shoulder, Pain in Left Shoulder. Had been receiving Coumadin (anticoagulant) 2mg (milligrams) MAR (Medication Administration Record) indicates R1 received Coumadin (anticoagulant) 2mg (milligrams) in the evening for Afib (Atrial Fibrillation). Incident Report dated 4/19/24 at 5:25pm indicates R1 was sent to the Emergency Department due to swollen left breast. Report indicates left breast area was hard, no redness or warmth.; no discoloration noted. R1 had been complaining of left arm pain. Report/Resident Description indicates I haven't fallen or had any issues. It just started hurting more after my shower. Report indicates R1 had been on long-term anticoagulant therapy. Incident Report Notes dated 4/22/24 indicates only incident for R1 was a fall that occurred on 4/10/24. Note indicates an X-ray and doppler of R1's ankle was performed after R1's fall with negative results for both tests. Incident Report note dated 4/22/24 indicates Nurse notified physician of increased edema and family's request to have R1 sent to hospital for evaluation. Progress Notes dated 4/19/24 at 6:50pm indicates R1 was transported to the hospital at that time. Progress Note dated 4/20/24 at 4:25am indicates R1 was admitted to the hospital with diagnosis of chest wall hematoma. Hospital ED (Emergency Department) Report dated 4/19/24 indicates R1 presented to the ED for evaluation of left chest wall/breast region. Report indicates Apparently, this morning (R1) showered and was unsteady on her feet, went to grab onto the CNA (Certified Nurse Assistant) and (R1's) chest wall came into contact with the nurses shoulder. Report indicates as the day went on, (R1) developed increasing pain and swelling to the chest wall. Report indicates As a side note, (R1) has been reporting pain in her left foot and ankle region. Family relates that X-rays were done at the nursing home, but results were unknown. ED Report Physical Exam indicates Findings: Bruising (there are multiple areas of bruising noted to the upper arms, left chest wall, and left foot present. Swelling and tenderness of left foot. ED Report CT (Computed Tomography) Chest with Contrast dated 4/19/24 at 10:07pm Indication: [AGE] year-old with given clinical history of Chest trauma, blunt trauma. ED CT findings indicate Chest all soft tissues: there is a large left-sided chest wall hematoma measuring up to 8.2cm (centimeter) x 11.6cm in greatest axial dimension. ED CT Impression: A critical finding has been communicated to physician. ED left ankle and left foot X-ray results indicate a fracture at the base of R1's 5th metatarsal. ED Report dated 4/19/24 at 10:53pm indicates (R1's) CT returned and there is a large hematoma to the left chest wall. There were foci of contrast noted in the posterior aspect of the hematoma worrisome for active hemorrhage. Report indicates (R1), and family are amenable to proceeding with FFP (Fresh Frozen Plasma) as well as Vitamin K ordered. ED Report dated 4/19/24 at 11:09pm indicates (R1) would receive conservative management and would receive 3 units of FFP and management with ice. Hospitalist Admission Report dated 4/19/24 at 7:12pm indicates: Patient Active Hospital Problem List: 1. Left chest wall hematoma secondary to injury at nursing home where a worker's shoulder hit the left chest wall on transfer. 2. Right foot metatarsal fracture: unclear etiology however (r1) has bruised foot. 3. Acute blood loss/chronic anemia. Report indicates On assessment (R1) is unable to tell me how she hurt herself. She does not remember falling, she does not know how she hurt her foot. She is able to tell me that her chest significantly hurts over the area of the hematoma. On 4/26/24 at 11:10am V1, Abuse Coordinator stated that both V2, DON (Director of Nursing) and herself reviewed R1's hospital records on Monday 4/22/24 and after speaking with V11, Family and V12, Family - who stated they believed R1's chest wall hematoma was due to her long-term anticoagulant use - made the decision not to report the incident to the State Agency.

Based on interview and record review, the facility failed to verify code status, failed to follow up on advanced directives, and failed to have the current paperwork on advanced directives for one (R1) of three residents reviewed for advanced directives in a sample of seven. Findings include: R1's medical record documents R1 is a full code as of [DATE]. R1's medical record, dated [DATE] by V18 APRN/Advanced Practice Registered Nurse, documents Recommend hospice and DNR/Do Not Resuscitate. R1's Medical Record documents R1 was admitted to hospice on [DATE] due to her diagnosis of End Stage Multiple Sclerosis and was not cognitively intact. R1's nurses note, dated [DATE] by V6 LPN/Licensed Practical Nurse, documents Packet filled out and forwarded to state guardian for (R1). Guardian called and noted sections left blank. Forwarded packet to hospice to be filled out by MD/Medical Doctor and forwarded back to the facility to be forwarded to (R1's) state guardian. Packet is consent to change from full code to DNR status. (R1) remains full code at this time. R1's medical record has no documentation of the information sent to R1's OSG/Office of State Guardian. R1's nurses notes, dated [DATE] at 4:00am by V13 RN/Registered Nurse, documents This nurse called to bedside by CNA/Certified Nurse Aid at 1:25am; resident without pulse, respiration and cool to touch; second RN called to pronounce at 1:30am; hospice notified at 1:40am; coroner called at 1:42am; funeral home notified at 2:05am; and body released to funeral home at 3:40am. R1's medical record has no documentation CPR/Cardiopulmonary Resuscitation was performed on R1. On [DATE] at 10:56am, V15 RN Administrator of Hospice stated I thought (R1's) DNR form filled out and filed with (R1's) OSG made her a DNR but she was a full code because it was not signed by the judge. We were working on a document with the guardian, but the guardian was not able to take it to court prior to the resident's death. My hospice nurse got the call (R1) had passed, my hospice nurse called me for clarification on her code status, and she was a full code. I looked thru (R1's) form, she was a full code, and I told the nursing home to do CPR. The nursing home did not have the paperwork for the OSG, we had at our office which is why the hospice nurse did not know her code status and had to call me. When the hospice nurse got to the facility she was told they had (R1) listed as a full code, (R1's) guardian would not make her a DNR without a Judge's order so the hospice nurse called me for clarification. R1's OSG DNR paperwork, filled out on [DATE] by the physician, and provided to this state department by V15 RN Administrator of Hospice has no documentation of R1's OSG consent for DNR or withdrawal of treatment. On [DATE] at 12:25pm, V13 RN stated (R1) was hospice but was a full code. She was not changed to a DNR by the judge. I missed it and did not do CPR. We have a yellow notebook at the nurse's station that has the code status forms in case the power goes out. (R1's) code status was in the computer under her name and in the computer in the miscellaneous part of (our charting system). I called the hospice nurse when (R1) passed. (R1's) DNR paperwork was filled out for the OSG but not signed by the Judge. Hospice called her supervisor for clarification since she had the paperwork with her, we did not have it here. On [DATE] at 12:40pm, V2 DON/Director of Nursing stated (V13 RN) did not perform CPR on (R1) and was disciplined with a final written reprimand. (V13) had never been disciplined before. (V13) assumed (R1) was a DNR because she was hospice and did not follow the full code orders. We sent the paperwork to the OSG on [DATE]th, 2023, but (R1) died before it could go before the judge and get the DNR. Usually, it takes less than one week for the judges signature and the code status is done. We did not have time to follow up on her form with the holidays. (R1) was a full code when you pulled the electronic face sheet on (R1). (R1) could not talk for herself at the time of her death which is why she had an OSG. V13's employee file, dated [DATE], documents Disciplinary Action Form 3rd/final written reprimand- did not follow nursing guidelines, failed to verify a resident code status, and no prior discussion or warnings. Employee educated and stated she missed verifying (R1's) code status. Facility Residents' Rights Regarding Treatment and Advanced Directives, revised [DATE], documents 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 advanced directive. The advance directive will be added to Physician Orders. The copy of the form will be scanned into the resident record.

Based on interview and record review, the facility failed to obtain an order for catheter care upon admission for one (R3) of two residents reviewed for indwelling urinary catheters in a sample of seven. Findings include: R3's medical record documents R3 was admitted to the facility on [DATE] with a diagnosis of traumatic L4 compression fracture and urinary retention. R3's medical record documents R3 was at the facility for pain management, indwelling urinary catheter care, and weakness. R3's medical record has no documentation R3 received catheter care from 12/23/23 through 12/28/23. R3's Physician's orders, dated 12/28/23, documents R3's catheter care was to be conducted every day shift, to start on 12/29/23, and discontinued on 1/10/24. R3's Treatment Administration Record/TAR, dated December 2023, documents catheter care was started on 12/29/23. On 1/31/24 at 3:00 PM, V2 DON/Director of Nursing stated R3's physician order for catheter care was not obtained until 12/28/23 due to R3 being admitted on a weekend and the holiday followed. V2 verbally agreed catheter cares were not documented as completed until 12/29/23 and did not know why the admitting nurse did not put in orders upon R1's admission for catheter care. Facility Catheter Care policy, dated 1/24/23, documents The facility will ensure that residents with indwelling catheters receive appropriate catheter care per standard of care.

Based on interview, observation and record review, the facility failed to ensure a resident's call light was within reach for one of 24 residents (R2) reviewed for call lights in the sample of 49. Findings include: The facility's Call Lights: Accessibility and Timely Response Policy (dated 08/01/19) documents the following: With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. R2's current care plan documents the following: (R2) has impaired vision in left eye related to ophthalmologic complications resulting from Diabetes Mellitus and Blindness right eye, and is at risk for new or worsening complications, including decrease in visual acuity. On 01/08/23 at 03:55 PM, R2 was sitting in her wheelchair near her bed with her eyes closed. R2 was dressed, groomed and had a full mechanical lift sling in place underneath her. R2 had a heel protector in place on her right lower extremity. R2's call light was out of her reach sitting inside of a plastic basin on a bedside table approximately five feet away from R2. When R2 was asked about the location of her call light, she stated, I don't know where it is. I'm blind. They didn't give it to me. They take it away at night because they say I use it too much. On 01/08/23 at 04:05 PM, V20 (Licensed Practical Nurse) confirmed that R2's call light was out of R2's reach and stated, She should have it within her reach.

Based on observation, interview and record review, the facility failed to provide privacy during incontinence care for one of four residents (R110) reviewed for personal care, in a sample of 49. Findings Include: The facility policy, Promoting/Maintaining Resident Dignity, dated (revised 12/5/22) directs staff, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. On 1/8/24 at 10:48 A.M., V5/Certified Nursing Assistant (CNA) was providing incontinence care for R110, who resides in a bed closest to the 200 hall, in the facility. R110 was lying on the top of the bed fully unclothed, while V5/CNA applied an incontinence brief. The privacy curtains for R110's bed were open. R110's roommate was present, watching television, in direct view of R110. The room curtains, that open to the front visitor, staff and vendor parking lot, were open. V5/CNA continued to apply the incontinence brief and then a gown to R110, in full view of R110's roommate, and visitors and staff in the parking lot. When V5/CNA completed dressing R110, V5/CNA left the room. At that time, V5/CNA verified the privacy curtain for R110, and the room curtains were left open during incontinence care and dressing of R110.

Based on observation, interview and record review the facility failed to implement a restorative program and provide range of motion for two residents (R24, R64) of five residents reviewed for limitations in range of motion in a sample of 49. Findings include: The facility's Activities of Daily Living policy revised 12/5/22, documents that the facility will provide a maintenance and restorative program if indicated to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 1. On 1/8/24 at 10:30 am R64 was lying in bed. R64's right hand appeared contracted, and her right arm was edematous (swollen). R64's right arm was resting on the bed. On 1/8/24 at 10:30 am R64 was up in the chair, with her right arm lying in her lap and no splint on. R64's current Physician Order Sheet documents R64's right arm is to be elevated at all times. R64's Occupational Therapy evaluation and plan of treatment, dated 10/4/23, documents the R64 will consistently have right upper extremity splint donned for four to six hours per day. This form documents that R64 is currently not wearing the right upper extremity splint due to lack of follow through from the Certified Nursing Assistants. R64 will increase her right upper extremity shoulder and wrist extension passive range of motion for flexion. R64's current care plan documents that R64 has a self-care/mobility deficit and requires staff assist for completion of all activities of daily living. This form documents that R64 is to participate in passive range of motion exercises for preservation of range of motion to bilateral knees and elbows as tolerated. R64's care plan documents to provide restorative programs/interventions as ordered/indicated. 2. On 1/8/24 at 11:00 am, R24 stated that he does not get assistance with range of motion or exercises. R24's Minimum Data Set, dated dated [DATE], documents an impairment of both sides of upper and lower extremities. This form also documents that R24 has not received any therapies or range of motion services. R24's current care plan documents that R24 has an activity of daily living self-care deficit. This form documents that R24 is dependent for activities of daily living. On 1/9/24 at 12:00 pm, V2, Director of Nursing, stated that the facility does not have a restorative program at this time. V2 stated that the Certified Nursing Assistance are supposed to do range of motion during any cares. On 1/11/23 at 11:30 am, V2 stated that no documentation of range of motion or restorative notes could be found in R24 or R64's medical record. On 1/11/24 at 12:00 pm, V5, Minimum Data Set Coordinator, stated that the facility does not have restorative programs at this time. V5 also stated that the Certified Nursing Assistance are not allowed to perform passive range of motion on residents with contractures, because of possible injury.

Based on record review and interview the facility failed to offer bedtime snacks to two of 24 residents (R61 and R274) reviewed for bedtime snacks in the sample of 49. Findings include: The Nourishment Night-Time Snacks policy dated 12-5-22 documents, Nourishments will be provided to the clients at approximately bedtime. Food and nutrition services will deliver the bedtime nourishment (snack) as planned on the cycle menu to the nursing units after the evening meal. Clients will receive an appropriate bedtime snack according to their diet order. Nursing will distribute the bedtime nourishments. 1. R61's Order Summary Sheet dated 1-22-24 documents R61 has the diagnoses of Mild Protein-Calorie Malnutrition, Dysphagia, Hemiplegia, and Hemiparesis. R61's Medical Record does not include any documentation of R61 being offered bedtime snacks. On 01-08-24 at 01:37 PM V19 (R61's Family Member) stated, (R61) does not get offered bedtime snacks, cannot get up to get them on his own and cannot ask for them. 2. R274's Order Summary Report dated 1-11-24 documents R274 has diagnoses of Severe Protein-Calorie Malnutrition and Type II Diabetes Mellitus. R274's Medical Record does not include any documentation of R274 being offered bedtime snacks. On 01-08-24 at 11:04 AM R274 stated, I am diabetic and would like a bedtime snack. They do not offer bedtime snacks to me. On 1-11-24 at 9:30 AM V2 (Director of Nursing) stated, All residents should be offered a bedtime snack. There is no documentation in (R61 and R274's) records indicating they were offered bedtime snacks. On 1-11-23 at 9:45 AM V6 (Dietary Manager) stated, I do not know if all of the residents are being offered a bedtime snack. I do not believe residents being offered bedtime snacks is documented anywhere in their medical records.

Based on interview and record review the facility failed to ensure quarterly MDS (Minimum Data Set) assessments were completed and submitted within the required time frame for six of 50 residents (R34, R94, R63, R62, R26, R11) reviewed for timing of MDS assessments in a sample of 50. Findings include: A Resident Assessments Instrument under Quarterly assessment dated ,d+[DATE] states, The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date), or Assessment Reference Date plus 14 days. The facility MDS Analysis dated 11/21/22, documents Due to increased census on both MED A stays and public aid, there has been an increase in MDS's needing to be completed and some of them have fallen behind in submission timeliness. There is a back log of MDS's that still need to be caught up. Social Services is new to the roll, as well as activities and dietary manager, therefore there has been a lot of the completion done solely by MDS, therefore making some assessments late. 1. R34's Quarterly MDS assessment section A2300 documents R34's assessment reference date for that MDS was 10/14/22. This same MDS section Z0500 documents R34's MDS was not completed until 12/15/22. 2. R94's Quarterly MDS assessment section A2300 documents R94's assessment reference date for that MDS was 10/10/22. This same MDS section Z0500 documents R94's MDS was not completed until 12/19/22. 3. R63's Quarterly MDS assessment section A2300 documents R63's assessment reference date for that MDS was 11/08/22. This same MDS section Z0500 documents R63's MDS was not completed until 12/21/22. 4. R62's Quarterly MDS assessment section A2300 documents R62's assessment reference date for that MDS was 11/04/22. This same MDS section Z0500 documents R62's MDS was not completed until 12/21/22. 5. R26's Quarterly MDS assessment section A2300 documents R26's assessment reference date for that MDS was 11/08/22. This same MDS section Z0500 documents R26's MDS was not completed until 12/21/22. On 12/21/22 at 1:17p.m. V3 (MDS Coordinator) verified the MDS section A2300 ARD dates and the MDS section Z0500 completion dates for R34, R94, R63, R62, R26's Minimum Data Set assessments. V3 verified none of these assessments were completed within the required 14 days following the ARD dates. 32875 6. R11's Admission MDS (Minimum Data Set) assessment was dated 8/16/22. R11's Quarterly was due 11/16/22. There were sections completed on the Quarterly by V3 (MDS Coordinator) dated 11/23/22, V10 (Social Services) dated 11/29/22, and was signed as completed by V18 (Assessment Coordinator) on 12/20/22. On 12/20/22 at 1:30 PM, V3 (MDS Coordinator) verified that R11's assessment was late being done. V3 was asked why the assessment was late and V3 stated No specific reason. On 12/21/22 at 10:55 AM, V1 (Administrator) stated that the reason some residents' MDS's were not completed on time was because the facility's resident census was high and there was only one MDS Coordinator until September 2022.

Based on interview and record review the facility failed to ensure the Admission MDS (Minimum Data Set) Assessment was completed and submitted in the correct timeframe for two of 50 residents (R66 and R305) reviewed for timely MDS assessment in a sample of 50. Findings include: The facility MDS Analysis dated 11/21/22, documents Due to increased census on both MED A stays and public aid, there has been an increase in MDS's needing to be completed and some of them have fallen behind in submission timeliness. There is a back log of MDS's that still need to be caught up. Social Services is new to the roll, as well as activities and dietary manager, therefore there has been a lot of the completion done solely by MDS, therefore making some assessments late. 1. The Resident Assessment Instrument (RAI) policy dated October 2019, documents Assessment Reference Date (ARD) (Item A2300) No Later Than the 14th calendar day of the resident's admission (admitted + 13 calendar days). R305's MDS Summary dated 12/21/22 at 10:30 AM, documents R305 was admitted on [DATE]. The ARD Target date was 12/12/22. The Submission Information documents the MDS is in Progress. On 12/20/22 at 1:30 PM, V3 (MDS Coordinator) verified that R305's assessment was completed late. V3 was asked why the assessment was late and V3 stated No specific reason. 30312 2. A Resident Assessment Instrument policy dated 12/2002 states, The Annual assessment must be completed no later than 14 days after the ARD (Assessment Reference Date). R66's Annual MDS assessment section A2300 documents R66's assessment reference date (ARD) for that MDS was 10/18/22. This same MDS section Z0500 documents R66's MDS was not completed until 12/19/22. On 12/21/22 at 1:17p.m. V3 (MDS Coordinator) verified R66's annual MDS assessment completion date of 12/19/22 was not within the required time frame of no later that 14 days from R66's ARD date of 10/18/22. On 12/21/22 at 10:55 AM, V1 (Administrator) stated that the reason some residents' MDS's were not completed on time was because the facility's resident census was high and there was only one MDS Coordinator until September 2022.

Based on observation, interview, and record review the facility failed to implement services to maintain and/or improve range of motion limitations for three of seven residents (R7, R80, R88) reviewed for limited range of motion in the sample of 50. Findings include: The facility's Rehabilitation Contracture Management policy dated 3-1-21 documents, It will be the standard that the facility must ensure that a resident with a limited range of motion receives appropriate treatment to increase range of motion and/or prevent further decrease in range of motion. A resident with limited mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Guidelines: 1. Recognition of a limited range of motion or changes in mobility must be reported to rehabilitation services. The specific joint that has limitation should be indicated. 1. R7's MDS (Minimum Data Set) assessment dated [DATE] documents R7 is cognitively intact and has functional limitations in range of motion to both sides of the lower extremities. This same MDS documents R7 does not receive restorative nursing programs such as passive or active range of motion, or splint assistance. R7's Electronic Tasks Nursing Restorative documents, Active ROM (Range of Motion) - Position upright, provide visual demonstration of flexion/ extension exercise then cue (R7) to complete five sets of 10 flexion & extension of both knees & elbows BID (twice daily) to maintain joint mobility. On 12/19/22 at 10:16 AM R7 was sitting up in a high back wheelchair. R7 was unable to lift her arms above chest level and both of R7's pinky fingers were contracted. R7 was unable to open either of her pinky fingers. R7 stated, I have not had any (range of motion) exercises or therapy done with me since April if this year. I would love for staff to do range of motion exercises with me. 2. R80's MDS assessment dated [DATE] documents R80 is cognitively intact and has functional limitations in range of motion to both sides of his upper and lower extremities. This same MDS documents R80 does not receive restorative nursing programs such as passive or active range of motion, or splint assistance. R80's Current Care Plan documents R80 has diagnoses of Parkinson's Disease, Morbid Obesity, Abnormalities of Gait and Mobility, Pain in right and left shoulders, and Disc Degeneration of the Lumbar Region. R80's current Electronic Tasks document, Nursing Rehabilitation Active Range of Motion: (R80) will perform with verbal cues and encouragement to complete three sets of 15 to bilateral upper extremities elbow flexion and extension and bilateral lower extremities knee flexion and extension. On 12/19/22 at 10:25 AM R80 was sitting in a wheelchair in his room. R80 was unable to lift his arms up above chest level. R80 stated, I cannot raise my arms up very far. I have not had therapy or range of motion exercises since September (2022). I would love for staff to do range of motion with me. The staff do not help me do range of motion. 34118 3. On 12/21/22 at 10:15 AM, R88 was sitting in her room in a wheelchair with V19/R88's daughter. V19 stated (R88) needs assistance of staff for all ADL's (Activities of Daily Living) and has limitations in ROM to both her legs. R88's MDS assessment dated [DATE] documents R88 has a BIMS (Brief Interview of Mental Status) of 03, (cognitively impaired), has limitations in range of motion to her lower extremities, and does not receive range of motion services to address R88's limitations. R88's electronic medical records do not include any programs or documentation of R88 receiving ROM to R88's lower extremities or at all. On 12/21/22 at 10:15 AM, V19/R88's daughter stated, I am here with (R88) everyday all day. (R88) does have limitations to both her legs. I have never seen any staff do any kind of ROM with (R88).

Based on observation and interview the facility failed to ensure urinary catheter tubing was kept off the floor for one of one resident (R75) reviewed for urinary catheter in the sample of 50. Findings include: On 12/19/22 at 11:40 AM R75 was sitting in his wheelchair with this catheter bag attached under the wheelchair seat. R75's catheter tubing was laying on the floor. V4 COTA (Certified Occupational Therapy Assistant) entered R75's room and transported R75 in his wheelchair from his room to the therapy room. During transport R75's catheter tubing was dragging on the floor. On 12/19/22 at 12:15 PM V4 transported R75 in his wheelchair from the therapy room to the dining room. During transport, R75's catheter tubing was dragging on the floor. On 12/19/22 from 12:15 PM through 12:50 PM R75 was sitting in his wheelchair in the dining room. R75's catheter tubing was laying on the floor during this time. On 12/21/22 at 9:20 AM V1 (Administrator) stated, All catheter tubing should be off of the floor at all times.

Based on observation, interview, and record review the facility failed to offer hydration during lunch for two of two residents (R75, R76) reviewed for hydration in the sample of 50. Findings include: The facility's Hydration policy dated 3-5-21 documents, Standard: Residents' hydration needs are met throughout the day from various sources. A major portion of the total fluids consumed is provided at mealtimes, either in a dining room setting or on trays served in the rooms or common areas, as preferred. 1. R75's current Care Plan documents, (R75) has potential fluid imbalance related to diuretic use. (R75) will have adequate fluid volume balance, good skin turgor, pink and moist mucous membranes, and sufficient fluid intake through next review. Encourage fluid intake. On 12/19/22 at 12:15 PM V8 (Licenses Practical Nurse/LPN) served R75 his meal tray. R75 was not served any fluids at this time. While eating, R75 was not offered any fluids. At 12:40 PM R75 finished eating and was still not offered any fluids. On 12-19-22 at 12:45 PM R75 stated, I would have liked to have had something to drink while I was eating. A lot of times when I come to the dining room late, I do not get offered a drink. On 12-19-22 at 12:50 PM V8 stated, I do not know why (R75) was not given anything to drink. 32875 2. On 12/20/22 at 12:10 PM, R76 was given his lunch, but was not given a drink. At 12:16 PM, V12 (Activity Assistant) asked R76 if he would like a cup of coffee or cranberry juice. R76 shook his head yes. V12 went back to the drink cart but did not return with a drink for R76. On 12/20/22 at 12:35 PM, V12 was asked if there was a reason R76 did not get a drink with his meal. V12 stated (R76) was given coffee during activities. V12 then went to R76 and gave him a cup of coffee. R76 immediately started drinking the coffee. On 12/20/22 at 12:45 PM, R76 was asked if he likes to have his drink at the start of his meal and he shook his head yes. R76's current Care Plan documents, (R76) has potential for fluid imbalance r/t (related to) Cognitive deficit, Poor intake and terminal prognosis. On 12/21/22 at 9:20 AM, V1 (Administrator) was asked if she thought the residents should have a drink when they got their meals. V1 stated Yes, that's why we have the drink cart that can be taken around the dining room. That way the residents can be given their drink when they get to the table.

Based on interview and record review, the facility failed to provide three meals a day on dialysis treatment days for one of one resident (R98) reviewed for dialysis in the sample of 50. Findings include: The facility's Hemodialysis Policy revised 3/27/21, documents, It will be the standard of this facility to provide the necessary care and services to those residents receiving hemodialysis while a resident is at the facility. If the resident requires a meal to be sent with them to the dialysis center, one shall be provided by the facility. R98's current electronic Hemodialysis plan of care documents, Dialysis three times a week, Tuesday, Thursday, and Saturday at 10:45 AM. Resident goes out to Dialysis. Check with nurse for the schedule and assist the resident to be ready to go on time. A bag lunch may be needed, help to be sure the resident has it with them. On 12/21/22 at 10:50 AM, R98 stated, I receive dialysis on Tuesday, Thursday, and Saturday. We leave the facility between 9:30-9:45 a.m. My dialysis starts at 10:45, and I normally get back to the facility at about 2:20-3:30 PM. The facility doesn't send lunch/food with me. I would like to have a sandwich, or something sent with me so I can eat something on my way or on my way back to the facility. On 12/21/22 at 11:45 AM, V20/Dietary Manager stated, We get a list of Dialysis residents. All morning residents get their breakfast early before they leave. We do not send a lunch or snacks with any residents that have later Dialysis, I don't even have anyone listed that leaves later. On 12/22/22 at 11:30 AM, V1 (Administrator) stated, We've never sent any food with the residents to dialysis since the dialysis center doesn't allow food to be ate there, but we will start sending snacks/sandwiches on the transportation van.

Based on observation, interview, and record review, the facility failed to document target behaviors to warrant the use of an antipsychotic and perform a GDR (Gradual Dose Reduction) for one of five residents (R8) reviewed for antipsychotics in the sample of 50. Findings include: The facility's Psychotropic Medications policy, dated 3/27/21, documents, Residents will only receive psychotropic medications (anti-psychotic, anti-anxiety, antidepressant, hypnotic or other drugs that result in similar effects, not including opioids) when necessary to treat specific conditions for which they are indicated and effective. Nursing staff will document in the medical record an individual's target symptoms. On 12/19/22 at 10:52 AM, R8 was alert lying in bed watching tv and looking at Christmas cards. R8 was short with answering questions but otherwise pleasant. R8's Physician's orders, dated 12/21/22, document that R8 has an order to receive Zyprexa (antipsychotic) 5 mg (milligrams) by mouth daily for agitation and crying related to Schizoaffective disorder and Bipolar disorder. R8's Pharmacy Recommendation, dated 4/4/22, documents that R8's Physician declined the pharmacy's recommendation to decrease R8's Zyprexa with the rational of: R8 continues to have signs/symptoms of agitation and anxiety. Continued use is in accordance with current standards of practice and a reduction would likely impair resident's function or exacerbate the psychiatric disorder and therefore is clinically contraindicated. R8's Psychoactive Medication Informed Consent, date 4/12/22, documents that R8 is receiving Zyprexa 5 mg daily for the diagnoses of Bipolar and Schizophrenia Affective Disorder. The consent also documents that the target behaviors for the use of R8's Zyprexa is agitation and crying. R8's Care plan, dated 9/15/22, documents, R8 continues to exhibit inappropriate and maladaptive behavior at times. Symptoms include engaging in deceitful practices such as confabulation-making up stories, lying, dishonesty for perceived personal gain, sabotaging personal relationship with roommate to elude having one. History of using others personal items without permission, attention seeking, gossiping. R8's Care plan also documents, R8 uses psychotropic medications antipsychotic, anti-depressant related to Bipolar Disorder, Depression for agitation and crying. R8's Pharmacy Recommendation, dated 9/16/22, documents a recommendation to decrease R8's Zyprexa. The recommendation has no follow up physician signature declining or accepting the pharmacist's recommendation. R8's Social Services Progress Note, dated 9/30/2022 at 11:33 a.m, documents, The Social Services Director met with R8 to complete the Quarterly Note and to review the advanced directives in place. Resident was alert and oriented and able to make needs known. Resident was cooperative, pleasant, and communicative. Resident has not experienced any significant changes to her mood and/or behaviors this quarter, which is noted by current PHQ-9 score of 02. The previously recorded score was also 02. R8's MDS (Minimum Data Set) assessment, dated 10/5/22, documents that R8 does not have any behaviors including indicators of psychosis and that R8 received seven days of an antipsychotic medication with no GDR being attempted. R8's Nurse Practitioner progress note, dated 12/5/22, documents, Review of symptoms: Psychiatric/Behavioral: negative for agitation, behavioral problems, and sleep disturbance. R8 is not nervous/anxious. Physical exam: Psychiatric: Mood and affect: Mood normal. R8's Clinical Physician orders, dated 12/20/22, document that R8 has been receiving Zyprexa 5 mg by mouth daily since 4/12/21. R8's MARs (Medication Administration Record), dated 10/22, 11/22, and 12/1-12/20/22, document that R8 had no behavioral episodes during the time span of 10/1-12/20/22. On 12/21/22 at 01:33 PM, V13 (Licensed Practical Nurse) stated, (R52) is Bipolar and gets very anxious and worried and then she will mellow out. She will cycle with those behaviors. She is very OCD (Obsessive Compulsive). She never wants anyone touching any of her belongings. She is very manipulative and convincing. I don't think any of her behaviors put her or others at risk for injury. She is very set in her ways. During the interview, R8 self-propelled herself to the nurses' station, and had a conversation with V13. R8 was pleasant and smiling not displaying any behaviors. On 12/21/22 at 1:36 p.m., V6 CNA (Certified Nursing Assistant) stated, (R8's) only true behaviors I'm aware of are attention seeking. If she notices staff taking care of another resident and she thinks she needs the attention she will turn her call light on to get a staff member in her room. I don't feel like she puts herself or others at risk for harm. She just wants attention. On 12/21/22 at 1:40 p.m., V15 CNA stated, The only think I can think of that (R8) does is wanting staff attention all the time. Nothing that she would hurt herself. On 12/21/22 at 02:56 PM, V1 (Administrator) confirmed that (R8's) Zyprexa has not been decreased since it was started.

Based on observation, interview and record review, the facility failed to follow a resident's plan of care for a mechanical transfer; and failed to ensure the staff followed safety precautions and implemented supervision for the prevention of wheelchair tipping backward after mechanical lift transfer to prevent a fall for one (R1) of three residents reviewed for falls. These failures resulted in R1 being hospitalized with left sided bruised ribs and subdural hemorrhage. Findings include: Facility's Standards of Clinical Care-Fall Prevention Policy (Revised 3/27/21) documents: It is the standard of this facility to complete an initial assessment, ongoing monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. Facility's ADL (Activities of Daily Living) Mechanical Lifts Policy (Revised 3/27/21) documents: It is the standard of this facility to provide a safe environment for our residents and staff. The Nursing and Therapy departments will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/repositioning residents will receive instruction on the safe operation of the mechanical lifts. Facility's Initial and Final Reports to (State Department of Public Health) for R1 document: On 10/8/21 at approximately 8:15am during transfer from resident bed to wheelchair, resident wheelchair tipped back, causing resident to fall to the floor and sustain laceration to the back of her head. R1's Order Summary Report documents: Full mechanical lift with two staff for all transfers every shift related to [CONDITION(S)] (most common type of short-limbed [CONDITION(S)]--Internet definition). R1's Minimum Data Set (MDS) documents R1 has a BIMS (Brief Interview of Mental Status) of 15 on a scale of 00 - 15. Section G Functional Status, documents R1 as needing extensive assistance of two person physical assist for transfers. R1's Care Plan documents: Transfer: the resident is not able to help with a transfer at all and will need the assistance of (two) staff and a (mechanical lift) to move from bed to chair and back. Nurse's Notes (Dated 10/8/21) document: (R1) was treated at a local hospital for left sided bruised ribs and laceration of scalp, and returned to the facility on [DATE]. R1's CT Scan result (Dated 10/9/21) documents: Impression: Small focal area of hemorrhage along the posterior falx likely subdural with no evidence of midline shift or mass effect. R1's Chest X-ray (Date 10/9/21) documents: Impression: No acute displaced rib fracture is identified. On 10/13/21 at 2:00pm, R1 stated that one CNA (Certified Nursing Assistant) (unable to state the name of the CNA) was getting R1 up from bed on 10/8/21 using a mechanical lift; and all of a sudden, R1 fell while R1 was in the wheelchair. Stated R1 was in (local hospital) for a few days; ribs bruised on left; no fractures; right side of head was hurt. R1 stated there was only one (CNA) using the lift with her (R1) and there were supposed to be two. Stated she (R1) slid to the floor and hit her (R1) head; she (R1) did not black out, that she cried out and screamed. Stated that staff at both the facility and hospital said there should have been two people during the transfer on her (R1). R1 stated that she (R1) had one bad arm and it is her (R1) right arm and she does not use it. On 10/14/21 at 9:10am, V9 Staffing Coordinator/Central Supply stated that she (V9) does the scheduling for the CNAs including Agency CNAs. Stated that the CNA who was transferring R1 on 10/8/21 was (V12), an Agency staff. Stated that V12 has worked at the facility for a few months as needed and was very familiar with R1 and was by herself when she transferred R1 with the (mechanical lift); stated that R1 has been a mechanical lift since admit to the facility; that R1's right upper extremity does not work, nor does her lower extremities, and takes two person assist for transfers. Stated that V1 Administrator sent V12 out of the facility immediately and V12 cannot return to the facility. On 10/14/21 at 9:50am, V11 Certified Nursing Assistant (CNA) stated that V11 was working on R1's hall and getting residents up on 10/8/21. Stated that when she needed assist, if people need help with mechanical lift resident, always ask someone, can you come and assist me; stated that she did not know V12 (Certified Nursing Assistant/CNA) was getting R1 up by herself. Stated that V12 had worked with R1, knew who R1 was and knew that R1 was a mechanical lift with two people. Stated that two people are to transfer residents needing mechanical lifts; might not know if resident will let go in using an (assisted lift). On 10/14/21 at 10:10am, V1 Administrator stated that V12 had been assigned to R1 on 10/8/21; was providing cares and getting R1 up for the morning; that R1 is top heavy due to her (R1) [CONDITION(S)], needing the proper placement in the wheelchair, and the wheelchair tipped backwards; the chair was locked. Stated that she took V12 off the floor and DNR'd (Do Not Return) V12 that day. On 10/14/21 at 10:30am, V2 Assistant Director of Nursing (ADON) confirmed that with residents who are transferred with a mechanical lift, two people assist and two people should have been with R1 when the mechanical lift was used; policy is for transferred people like R1 to have two person assist with transfers. Policy for mechanical lift, follow manufacturer's policy/procedure and facility would have two people with lifts. V2 stated that staff are trained at the facility to use two people assist. V2 stated that V12 told her the reason V12 did not have assist was because it was morning time and she thought everyone else was busy; V12 apologized and said she knew she was wrong and was supposed to have another person assist her with R1. On 10/14/21 at 10:55am, V12 Certified Nursing Assistant (CNA Agency) stated that she already know how to do transfers with mechanical lifts; supposed to have assistant when using a mechanical lift. Stated that staff were assisting her in the beginning of cares with R1, that the staff left out before R1 was placed in the wheelchair. V12 stated she positioned herself to the side of R1's wheelchair and tried to tip the chair just right to get R1 into the wheelchair while lowering R1 into the wheelchair; stated R1 was not positioned right and the chair fell . V12 stated that she was trying to do too many things at once with the remote etc. and with trying to get R1 into the wheelchair; and then the wheelchair tipped all the way backwards and tipped over.

Based on interview and record review, the facility failed to implement infection control procedures to prevent the potential spread of a highly contagious disease to residents and staff. Direct care staff, while working with signs and symptoms of COVID-19 (sore throat, cough, and body aches) unnecessarily exposed residents to an infectious disease. This failure affects 28 of 36 residents (R1, R14, R15, R16, R19 though R42) reviewed for infection control on the sample list of 42. These failures resulted in an immediate jeopardy, while the immediate jeopardy was removed on 11/25/20. The facility remains out of compliance at a severity level 2 while the facility is in the process of implementing re-education components and training related to infection control and prevention of COVID-19 exposure. Findings include: The facility's COVID-19 Testing and Response Plan dated 6/11/20 documents, B. Staff Symptom Screening and Testing: Consistent with the facility's infection control policies, and IDPH guidance, all HCP (Health Care Personal) (including non-staff visiting HCP, vendors, volunteers, and visitors) are screened for temperature and symptoms of [DIAGNOSES REDACTED]-CoV-2 in accordance with IDPH guidance prior to shift and at midshift. HCP who have fever of symptoms receive [DIAGNOSES REDACTED]-CoV-2 testing as described in Section III and are excluded from work pending the results of the test. HCPs who test positive for [DIAGNOSES REDACTED]-CoV-2 are excluded from work until they met return to work criteria as defined in the current IDPH guidance. The facility's COVID-19 tracking sheet documents on 11/9/20, V25 Certified Nurse's Assistant tested positive for COVID-19. This tracking sheet documents V25's symptoms as sore throat, cough, and body aches. On 11/23/20 at 2:51 PM, V25 (Certified Nurse's Assistant) CNA stated, I started feeling bad on 11/7/20 which was my day off. I went back to work Monday morning (11/9/20) at 6:00 AM and they tested me around 7:30 AM or 8:00 AM. I told my nurse (V30, Registered Nurse) all morning that I didn't feel good and some of the CNAs I worked with (V28, CNA) that day. I should have called in. I worked on the 100 hall for two hours before I was sent home. On 11/24/20 at 11:22 AM, V25 stated, When we get to work there is a paper (screening form) we have to fill out. I went onto the floor and we started getting people up for breakfast, we usually have two CNAs on the floor. We work together to get all the resident's up. I was up and down the whole hallway. We fill out our paper (screening form) ourselves, there is no one there screening us. I think I put down I was having symptoms, but I don't remember. I just don't remember a lot about that day because I was so sick. I don't even remember driving there that day. V25's Coronavirus staff checklist signed by V25 dated 11/9/20 does not document V25 had a cough, sore throat, or body aches. This checklist documents V25's temperature as 98.3 and pulse ox as 99 percent. This checklist documents no for the question, Have you experienced shortness of breath, sore throat, fever, cough, or a combination of two: diarrhea/ chills/ repeated shaking with chills/ muscle pain/headache/ acute loss of taste or smell? On 11/24/20 at 8:48 AM, V3 ADON (Assistant Director of Nursing)/Infection Preventionist stated V25 and V28 were working the 100 wing hallway together on 11/9/20. V3 stated when she arrived at work, V28 came to her and reported V25 was working while sick. V3 stated V3 went and got V25 and performed a rapid COVID-19 test on V25. V3 stated V25 tested positive for COVID-19. V3 stated it is the expectation of the staff to call off and let them know they are having symptoms. V3 stated if a staff member is having symptoms, they can rapid test them. V3 stated no staff should work with symptoms. V25's daily punch sheet dated 11/9/20 documents V25 clocked into work at 5:53 AM and clocked out of work at 8:47 AM. The facility's census sheet dated 11/9/20 documents R1, R14, R15, R16, R19 though R42 were residing on the 100 hall on 11/9/20. The facility's COVID-19 tracking sheet documents on 11/10/20, R19, R27, R28, R34, R35, R36, R38, R40, and R41 were tested for COVID-19. This sheet documents on 11/15/20 results of the 11/10/20 testing documented R19, R27, R28, R34, R35, R36, R38, R40, and R41 were positive for COVID-19. The facility's COVID-19 tracking sheet documents V28, CNA tested positive for COVID-19 on 11/16/20. The facility's COVID-19 tracking sheet documents on 11/20/20, R1, R14, R15, R30, R31, and R37 tested positive for COVID-19. On 11/24/20 at 2:55 PM, V29, County Health Department Director of Clinical Services, stated V25 would have exposed the 100 wing residents and V28 to COVID-19 and may have contributed to the residents and V28 testing positive. The Immediate Jeopardy situation was identified on 11/25/20. The Immediate Jeopardy was determined to have begun on 11/9/20 when V25 CNA came into work at 5:53 AM sick with symptoms (sore throat, cough, and body aches) of a highly contagious disease (COVID-19) and provided direct resident care to residents on the 100 wing, potentially exposing those residents (R1, R14, R15, R16, R19 though R42) and a co-worker (V28 CNA) to COVID-19. V1 Administrator was notified of the Immediate Jeopardy on 11/25/20 at 8:50 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy. 1. A screening audit was completed of staff working in the facility on 11/25/20 to ensure that staff with signs and symptoms of COVID-19 were not working in the facility. 2. Staff responsible for oversight of staff screenings were identified and those identified were educated regarding review of screening tool and nurse review. 3. Alternative staff responsible for oversight were identified and educated on staff screenings. 4. Nurses identified for follow up on the screening tool were educated on the process of follow up of the screening tool. 5. All staff were educated on accurate completion of the screening tool, process for review of any concerns on the screening tool, reporting of symptoms immediately upon occurrence to supervisor or Administrator, and severity of failure to accurately and immediately report any symptoms. 6. The facility DNS/designated staff has reviewed COVID-19 screening tools of staff upon entry and ensured they are completed with signatures and has followed upped with any concerns. 7. The facility has randomly screened staff throughout shifts for for symptoms of COVID-19. 8. The facility has monitored testing outcomes for trends or concerns for identification for areas of performance improvement. 9. The facility has had two Quality Assurance meetings with the Interdisciplinary Team to review systems related to infection control, staff entrance screening tool and process, and reviewed findings of the state agency.

Based on record review, observation and interview, the facility failed to ensure the safety of a resident (R3) by not utilizing the wheelchair safety belt during transport, not ensuring the safety equipment on facility van functioned properly and the facility failed to prevent a residents(R1) fall due to improper clothing wear. This failure affects two of three residents (R3, R1) reviewed for falls on the sample list of 42. This facility failure resulted in R3 falling forward out of the wheelchair landing face first on the van floor. R3 required emergency services and sustained a concussion, forehead contusion, and neck strain. Findings include: 1. R3's Undated Medical [DIAGNOSES REDACTED]. R3's Minimum Data Set (MDS) documents a Brief Interview for Mental Status score of 15 out of possible 15 (cognitively intact). R3's emergency room Report dated 11/3/20 documents reason for R3 visit was patient was not secured in wheelchair in wheelchair van, and when the van slammed on the brakes, patient fell forward out of wheelchair. This same report documents injuries caused by fall of neck strain, forehead contusion and concussion without loss of consciousness. On 11/19/20 at 11:10 AM, R3's seatbelt on the motorized wheelchair was missing the buckle on the wheelchair's left side. The safety belt strap was intact on both sides of wheelchair. On 11/19/20 at 10:10 AM, R3 stated R3's motorized wheelchair safety belt was not buckled while riding in facility van en route to a physician's appointment. R3 stated the facility van over the lap seat belt was in place. R3 stated driver had to 'slam' on the brakes to avoid hitting another vehicle and this forced R3 to be thrown out of R3's wheelchair, landing on chest and abdomen, on van floor. R3 stated R3 was sent to emergency room after falling in facility van. R3 stated R3 did not slide under the seatbelt, but was thrown out of wheelchair because the facility van seatbelt broke and R3 was not wearing the motorized wheelchair safety belt. R3 stated the facility staff are aware of the broken seatbelt on R3's motorized wheelchair. On 11/19/20 at 11:30 AM, V6, Transportation Aide, stated V6 remembers driving R3 to the physician's appointment on 11/3/20. V6 stated V6 buckled R3's wheelchair down to the van floor with safety straps. V6 stated R3 did not have the wheelchair seatbelt buckled because it was broken. V6 stated V6 did use the van lap seatbelt to buckle R3 in. V6 stated en route to the physician's appointment, another car pulled out in front of the facility van, causing V6 to slam on the brakes in order to avoid an accident. V6 stated R3 was thrown out of the wheelchair and landed on V6's chest/abdomen area because the facility's van safety lap belt broke. V6 stated when the emergency personnel arrived, R3 was transported to the emergency room . V6 also stated that the firemen on the scene told V6 that cause of R3's fall was that the facility's van seatbelt malfunctioned. On 11/21/20 at 2:00 PM, V19, Certified Nurse's Aide stated V19 assisted R3 to transfer from the bed to the motorized wheelchair on 11/3/20 prior to going to the physician's appointment. V19 stated R3 is alert and oriented. V19 stated R3 uses a mechanical lift for transfers. V19 stated V19 does not remember if R3's seat belt was fastened or not on 11/3/20 and that, if (R3) said it was not fastened, then it was not fastened. (R3) would tell the truth and (R3) would know. The facility policy titled Standards and Guidelines: SG Transportation revised 11/21/2017 documents the following: Guidelines: Facility fleet vans may be utilized to transport residents for care and service needs such as [MEDICAL TREATMENT], physician appointments, hospital transport, etc. Vehicles will adhere to State and Federal guidelines for safe operation of the vehicle. 2. R1's Nurse's note dated 10/14/2020 at 6:45 AM documents, (R1) noted lying on (R1's) back in front of (R1's) toilet with CNA (V29, Certified Nursing Assistant) holding (R1's) head in her hands No shoes or socks on (R1's) feet, gait belt in place. R1's fall report dated 10/14/20 at 6:45 AM, documents that, (R1) was being assisted to the bathroom when (R1's) foot slipped on (R1's) pant leg and (R1) was lowered to the floor. (R1) was barefoot at the time of the fall. On 11/23/20 at 2:43 PM, V29, CNA stated V29 and V30,CNA were transferring R1 to the bathroom. V29 stated when R1 was inside of the bathroom, R1 went to stand up from the wheelchair and grabbed the bathroom bar to stand up. V29 stated V30 was holding the wheelchair and V29 was holding R1. V29 stated once R1 was fully standing, we (V29 and V30) went to move the wheelchair, R1 began sliding and we had to lower R1 to the floor. V29 stated R1 didn't have socks or shoes on. V29 stated R1 doesn't like to wear shoes but will wear nonskid socks. V29 stated R1 didn't have any on that day. On 11/23/20 at 2:51 PM, V30 CNA stated, we (V30 and V29 CNA) got (R1) in the bathroom. I was behind the wheelchair and (V29) was by the (R1). (R1's) pant leg had slid underneath (R1's) foot. Now I make sure we roll (R1's) pants up. (R1) didn't have shoes or socks on either.

Based on interview and record review, the facility failed to ensure that treatments and assessments were completed for necrotic wounds for one resident (R2) of five residents reviewed for wounds in a sample of 12. This failure resulted in R2 being hospitalized for [REDACTED]. Findings include: The facility's Wound Care policy, revised 11-1-2018, documents Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of [REDACTED]. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 3. Nurses are to be notified to inspect skin if newly developed skin changes are identified. 6. Wound care procedures and treatments should be performed according to physician orders. 10. Document in the clinical record when treatments are performed. 11 Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. R2's clinical record documents R2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's unsigned assessment dated [DATE], documents that R2's body has sores noted to right hand, three fingers, scab noted to left hand ring finger, and questionable marking of left thumb with no explanation written as to type. R2's Skilled Nursing Admission History & Physical, dated 2-24-2020 and signed by V19 (R2's Medical Doctor/MD/nursing home physician), documents (R2) is hoping to salvage some of (R2's) fingers that has necrosis present. (R2) is questioning the treatment. The Physical Exam documents Left hand: left 4th digit with necrosis, digit 2, 3 partially amputated. The Assessment/Plan documents to admit to the facility and includes 3) wound care physician to see him for further management and care of his fingers and 11) weekly f/u (follow up) while SNF (Skilled Nursing Facility) status. R2's Physician order [REDACTED]. R2's Treatment Administration Record/TAR, dated 2-20-2020, documents R2's [MEDICATION NAME] treatment was not completed in February 2020 on the 20th, 21st, 22nd, 27th, 28th, or 29th. There is no documentation in R2's clinical record that indicates [MEDICATION NAME] was being applied to R2's necrotic fingers in March or April 2020. R2's February, March and April 2020 Physician order [REDACTED]. On 8-28-2020, at 11:36am, V4 Wound Nurse states that V3 received a referral on 1-30-2020 to see R2 by a facility facsimile. V4 also stated that V3's Wound Specialist visits should have continued without needing another referral post hospital re-admission if the issue was still present. On 8-26-2020, at 11:15am, V2 Director of Nursing/DON stated I would expect for any treatment orders for a necrotic wound to be carried out as ordered, but I wasn't here then. Typically for non-pressure wounds we would do weekly skin assessments with documentation. R2's shower sheets/skin audits are as follows: 2-26-2020 R2 refused shower and no body inspection done; 3-1-2020 R2 refused shower and no body inspection done; 3-4-2020 documents pressure to R2's bottom; 3-18-2020 documents R2's bottom is reddened with pressure; 3-22-2020 bruises noted to feet; and 4-1-2020 documents gangrene to fingers of bilateral hands and no new issues. R2's progress note dated 3/01/2020 documents that R2's family member stated that since the facility can't coordinate V32 (facility APN/Advanced Nurse Practitioner) or V19 (R2's MD/nursing home physician) to see R2 at the facility, R2's family member would like the facility to make an appointment with V20 (R2's PCP/Primary Care Physician). R2's physician office visit notes, dated 3-2-2020 and signed by V20 documents R2 was seen by V20 in V20's office for shortness of breath. V20 documented that R2 and R2's family member were unsure of R2's medications since R2 resided in the nursing home and seen by another physician. V20 also documented There are no discontinued medications, and Unclear how much his doctor at nursing home is managing vs (versus) me. On 8-27-2020, at 2:49pm, V20 stated that R2's fingers or treatment for [REDACTED]. V20 stated I wasn't managing that and didn't give any orders for it. V20 also stated There was question about who was managing his care. That was part of the issue too. R2's SNF (Skilled Nursing Facility) Transition of Care order form, dated 3-3-2020 and signed by V32 (facility APN/Advanced Nurse Practitioner), documents R2 has been discharged from V19's (R2's nursing home physician) practice due to being managed by V20 (R2's PCP) and to call PCP office for further orders. R2's nursing Progress note, dated 4-3-2020 at 3:00pm, documents that R2 complained of increased pain to his necrotic fingers on both hands, has increased redness, and that V19 (R2's MD/nursing home physician) was in the facility seeing R2. R2's nursing Progress note, dated 4-3-2020 at 4:00pm and signed by V6 (RN/Registered Nurse), documents orders were received by V19 (R2's MD/nursing home physician) to send R2 to the Emergency Department/ED due to increased pain and redness in both hands and fingers. On 8-27-2020, at 2:35pm, V6 RN stated that R2's fingers were necrotic and had been for months. V6 stated that on 4-3-2020 R2 complained of pain to R2's fingers which was the first time V6 saw that R2's fingers were red. V19 happened to be at the facility seeing R2 and V19 sent R2 out to the hospital. R2's Physician order [REDACTED]. R2's ED notes, dated 4-3-2020 at 4:49pm and signed by V12 Registered Nurse/RN, documents Patient to ED per EMS (emergency medical system) for necrotic finger. Patient states that for the past 4-6 weeks his fingers have been getting worse. Upon arrival fingers are black. Patient states he does not feel safe or that he is being cared for at (named facility). R2's ED Provider notes, dated 4-3-2020 at 4:51pm and signed by V10 Medical Doctor/MD, documents the chief complaint as (R2) has noticed over the past 4-5 weeks that multiple fingers on both right and left hand have become black and the changes were initially accompanied by when (R2) determined to be infection. According to the patient, no medical professional has evaluated his hands over this time. V10's notes continue with a review of R2's systems and documents for skin: Black discoloration of multiple fingers of the right hand as well as the left. Some surrounding redness and warmth with multiple fingers on the left hand. Left hand showed more active signs of infection. In particular the 1st, 3rd, and 4th digits were involved with gangrenous changes but also evidence of [MEDICAL CONDITION]. V10's notes include V10's clinical impression: The patient had signs of infection on the left side with dry gangrene on the right side. It continues to document It concerns me significantly that the patient has had this ongoing for 4-5 weeks and that it has not been addressed by a medical professional. R2's hospital Discharge Summary, dated 4-18-2020 and signed by V12 MD, documents that R2 was admitted to the hospital on 4-3-2020 with wet gangrene of the left hand. Orthopedic surgery was consulted on admission, took patient to OR/Operation Room for amputation of right index, long and ring finger, amputation of left thumb and excisional debridement of right thumb and left ring finger. Wound culture was significant for [MEDICATION NAME] ([MEDICAL CONDITION] Resistant Staph Aureus). This summary continues to document that R2 passed away on 4-17-2020. R2's hospital History and Physical note, dated 4-12-2020 and signed by V13 Medical Doctor, includes that R2's Septic shock is likely secondary to infected fingers with concerns for osteo[DIAGNOSES REDACTED]. Patient's altered mental status is also likely secondary to acute metabolic [MEDICAL CONDITION] in the setting of septic shock. R2's death certificate, date of death [DATE], documents R2's cause of death as: a.) Metabolic [MEDICAL CONDITION]; consequence of b.)[MEDICAL CONDITION]/septic shock; consequence of c.) Progressive bilateral upper extremity [MEDICAL CONDITION] status [REDACTED].

Based on record reviews and interviews the facility failed to safely transfer one of three residents reviewed for transfers in the sample. (R1) R1 was sent to the hospital and was noted to have a fracture through the neck of the left femur and left frontal scalp swelling. Findings include: R1's current physician's orders [REDACTED]. R1's Fall Investigation report dated 7/23/16 reads, fall during attempted transfer/repositioning. Report goes on to say, Unable to be interviewed, admitted to ED. On 8/2/16 at 9:40 A.M. Z1 (R1's son) stated that when he arrived at the the hospital on [DATE], R1 told Z1 that when staff (E7 Certified Nurse's Aide) tried to pull R1 back in the wheelchair by the back of her pants, R1 fell forward out of the chair to the ground. R1 stated that since being in the hospital, R1's condition has worsened and R1 is no longer responding. On 8/2/16 at 8:50 A.M. E6 (Certified Nurse's Aide) stated that E6 helped E7 transfer R1 with a mechanical lift from the bed to the wheelchair on 7/23/16. E6 stated that while E6 was moving the mechanical lift, E7 got behind R1 and attempted to pull R1 back in the wheelchair by pulling the back of R1's pants. E6 verified that R1 has both legs amputated high above the knees. E6 stated that when E7 pulled R1 back by the pants, R1 fell forward out of the chair and on to the floor. E6 stated that she was moving the mechanical lift during the fall and was not in front of R1 to help prevent R1 from falling. On 8/2/16 at 9:05 A.M. E7 confirmed that when E7 attempted to pull R1 back in wheelchair by R1's pants, R1 fell out of the wheelchair to the ground. E7 verified that E6 was in R1's room at the time of the fall but was not in a position to help prevent R1 from falling. Hospital Radiology reports dated 7/24/16 note R1 to have, Basicervical fracture through the neck of the left femur. Hospital CT scan dated 7/27/16 note R1 to have, Left frontal scalp soft tissue swelling. Orthopedic Consutation Note from local hospital, dated 7-24-16 and signed by Z2/Orthopedic Physician Assistant, states, Patient resides at a local skilled nursing facility and apparently had a fall out of her wheelchair yesterday. She presented to the (local hospital) ER (emergency room ) last night with chief complaints of head pain and left hip pain. She was found to have a left hip fracture upon workup.

Based on observation, interview, and record review, the facility failed to identify and assess pain for a cognitively impaired resident, administer pain medications prior to wound debridements and activities of daily living, and failed to follow the Pain Management Policy to anticipate, prevent, and minimize pain for two of eleven residents (R16, R17) reviewed for pain in the sample of fifteen. These failures resulted in R16 trembling and crying with visible tears and R17 screaming out during wound debridement procedures and activities of daily living. Findings include: 1. A Physician order [REDACTED]. A Physician order [REDACTED]. A Minimum Data Set assessment dated [DATE], documents R17 scored nine out of fifteen (impaired cognitive skills) on the Brief Interview for Mental Status, requires assist with all activities of daily living, and weighs 99 pounds. On 2/10/14 at 11:45 a.m., Z1 (Wound Physician) and E4 (Wound Nurse) entered R17 's room to assess and treat R17's wounds. E18 (Certified Nurse Aide) and E19 (Certified Nurse Aide) rolled R17 on her right side to expose R17's pressure ulcers for Z1. R17 screamed as R17 was rolled on the right side where R17 has a [MEDICAL CONDITION]. R17 had a pressure ulcer on the left back that measured approximately 2.2 centimeters (cm) by 2.3 cm. R17 had a pressure ulcer on the mid-back that measured approximately 2 cm. by 2 cm. Z1 assessed the areas and proceeded with sharp debridement of both pressure ulcers on R17 ' s back. On 2/10/14 at 12:00 p.m., R17 screamed out while Z1 debrided both pressure ulcers. E4 left R17's room to report R17's pain to R17's nurse. E4 returned to R17's room and stated R17's nurse gave R17 scheduled pain medication at 11:45 a.m., just as Z1 entered R17's room. On 2/10/14 at 12:07 a.m., Z1 stated "I debrided slough on both back wounds. (R17's) wounds are just past the dermis layer with a lot of nerve endings, which makes it worse for pain. " On 2/9/14 at 10:00 a.m., E18 (Certified Nurse Aide) and E19 (Certified Nurse Aide) transferred R17 from the wheelchair to R17's bed. R17 screamed out when E18 and E19 positioned resident in bed. R17 stated "it hurts my legs." On 2/10/14 at 2:15 p.m., E18 (Certified Nurse Aide) and E19 (Certified Nurse Aide) provided incontinence care and catheter care for R17. R17 screamed when R17 was moved from one position to another. On 2/10/14 at 2:20 p.m., E18 (Certified Nurse Aide) stated "(R17) is always in pain when giving cares. " On 2/10/14 at 2:25 p.m., E17 (Registered Nurse) stated R17's scheduled pain medication, [MEDICATION NAME] 5 milligrams (mg), was given at approximately 11:45 a.m., as Z1 was walking into R17's room. E17 stated R17 was not given the as needed dose of [MEDICATION NAME] 5 mg because " it tends to make her really sleepy. " E17 stated R17 is actively dying and only had approximately 50 milliliters of urine output during the day shift on 2/10/14. E17 stated R17 had a right [MEDICAL CONDITION] in December 2013 and the fracture was not repaired due to R17's poor health condition. Mosby ' s Drug Guide for Nurses (Third Addition), documents the onset of [MEDICATION NAME] by mouth is variable and peak effects are approximately one hour after administration. On 2/11/14 at 10:00 a.m., Z3 (Hospice Registered Nurse) stated R17 does experience pain with minimal movement and receives scheduled pain medication. Z3 stated R17 has an order for [REDACTED]. E4 stated if R17 is screaming "I would think (R17) is in pain." E4 stated as the wound nurse "I should be monitoring pain and make sure residents have pain medication prior to treatments." R17's Physician order [REDACTED]. R17's Pain Flow Sheet dated 1/18/14 through 1/23/14, documents R17's pain has not been assessed since 1/23/14. On 2/11/14 at 2:25 p.m., E17 (Registered Nurse) stated the pain flow sheet is only filled out when an as needed pain medication is given. E17 stated pain is not assessed on any other form or Medication Administration Record. E17 verified R17's pain has not been documented on the Pain Flow Sheet or Medication Administration Record. 2. A Minimum (MDS) data set [DATE], documents R16 scored fourteen out of fifteen (Cognitively intact) on the Brief Interview for Mental Status. A Plan of Care dated 1/27/14, documents R16 has a fractured right fibula and pain is to be assessed every shift. A Plan of Care dated 1/27/14, documents R16 has an unstageable pressure ulcer on the right lateral heel. On 2/10/14 at 11:25 a.m., Z1 (Wound Physician) assessed R16's right heel pressure ulcer. Z1 used a sharp instrument to debride the slough off of R16 right heel wound. R16 was grimacing during the debridement and had tears in her eyes, rolling down R16's cheeks. Z1 finished the debridement and E4 (Wound Nurse) asked R16 if R16 needed a pain pill. R16 stated " yes. " E4 left R16's room to report R16's pain to R16's nurse. E17(Registered Nurse) administered R16 a pain medication ([MEDICATION NAME]) following the wound debridement. E17 did not document a pain assessment on the Medication Adminstration Record before or after the administration of the pain medication. R16's Medication Administration Record [REDACTED]. R16's Pain Flow Sheet dated 10/2013, documents R16's pain was last assessed on 12/25/13 at 6:30 p.m. On 2/11/14 at 10:45 a.m., R16 stated the right heel wound debridement on 2/10/14 was "very painful." R16 stated a pain pill before the treatment would have made "a big difference." On 2/13/14 at 10:20 a.m., E4 (Wound Nurse) verified R16 complained of pain with the wound debridement on 2/10/14 and E4 reported R16's pain to R16's nurse. E4 verified E2 (Director of Nursing) in-serviced all nursing staff on 2/10/14 regarding pain and the importance of anticipating treatments with the potential to cause pain and timely administration of pain medications. A Pain Management Policy dated 11/2009, documents "assess the resident for pain and document reported or observed pain on the Pain Flow Sheet; Consider situations when pain may be anticipated and attempt to prevent expected pain (i.e. dressing changes, therapy session). Treat or modify the underlying source of resident 's pain when possible. " On 2/11/14 at 11:30 a.m., E2 (Director of Nursing) stated R16 and R17 should have been given pain medications before the wound debridement. E2 stated on all three shifts of nursing staff and therapy were in-serviced on 2/10/14 regarding the importance of administering pain medications before treatments, therapy, or anything where pain can be anticipated. An In-service Education Sheet dated 2/10/14, documents E28 (Licensed Practical Nurse/Care Plan Coordinator) inserviced all nursing staff and therapy staff on making " sure residents have had pain medicine before doing therapy/treatments and make sure it has been given ample time to be effective prior to therapy/treatments so resident is as pain free as possible during therapy/treatments. If doing treatments /therapy and resident complains of pain stop, see if pain medication can be given or some alternative relief before continuing treatment/therapy. "