Every finding on record at Lutheran Care Center

Based on interview and record review the facility failed to safely transfer a resident using a mechanical lift for 1 of 3 residents (R53) reviewed for accidents in a sample if 29.The Immediate Jeopardy began on 9/14/2025 at 7:45AM, when the facility failed to provide a safe transfer using a mechanical lift. The failure resulted in (R53) falling from the mechanical lift and sustaining a head injury leading to R53's death. V1(Administrator), V2 (Director of Nursing/DON), and V14 (Licensed Practical Nurse/ Quality Assurance Nurse/QAC) were notified of the Immediate Jeopardy on 9/26/25 at 10:10AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 9/15/25, prior to the start of the survey and was therefore past noncompliance. Past noncompliance-no plan of correction required.Findings include:R53's document titled Face Sheet includes an admission date of 12/12/2023 with a discharge date of 9/17/2025. R53's diagnoses include chronic combined systolic congestive and diastolic heart failure, transient ischemic attack, pneumonia, osteoporosis, dyspnea, and altered mental status. R53 was admitted under Hospice care on 12/11/2024 with diagnosis of acute respiratory failure with hypoxia. R53's MDS (Minimum Data Set) dated 6/21/2025, includes a BIMS (Brief Interview for Mental Status) documents resident is rarely understood. Section GG Functional Abilities documents R53 is dependent with oral hygiene, toilet hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left to right and tub/shower transfer. Document shows shower/bath self, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer and toilet transfer were not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. R53's care plan documents under problem dated 6/21/2025, dependent of 2 staff for ADL's (Activity of Daily Living) related to declining health. Alert with confusion, aphasic. On hospice care. Transfers per mechanical lift. Non-ambulatory per staff. Vision impairment, wears glasses. Hearing impaired. Section of goal dated 9/21/2025, shows R53 will complete transfers using mechanical lift and 2 staff assist by review. Approach dated 6/21/2025, R53 is transferred per lift. On bath days transfer her directly from the bed to the shower lift and after bathing directly from the shower lift back to bed. Ensure R53 is secured to the shower lift while in transport. R53 transfers with mechanical lift. Instruct R53 in safe and proper technique with the lift. Give verbal cues for hand placement and proper positioning as she can assist. On 9/16/2025 under approach, if mechanical lift is used for transfers slings/belt is tattered, torn, worn, remove immediately from circulation and notify nursing supervisor or replace.R53's Incident Report dated 9/14/2025 at 7:45AM documents, R53's condition before incident was checked normal. Assistive device used was yes, mechanical lift sling. Description of exactly what happened is documented as CNA (Certified Nursing Assistant) transferring resident in sling attached to mechanical lift, a strap on sling broke, right blue upper strap broke with resident over the floor. She fell out of sling laying on her right side x 2 raised areas on upper back of head and 1 raised area on upper right side of head. Assessment of upper and lower extremities within normal limits. Right upper extremity forearm bruising. Will continue neuro checks within normal limits. Level of consciousness: Alert and oriented x 2. Authored by V9 (Licensed Practical Nurse/LPN).R53's Nurse's Notes document as follows:9/14/2025 at 9:30AM, CNA reported during transfer with mechanical lift, right upper strap on sling broke. R53 fell out of sling, was on her right side on floor in resident's room. Upper and lower extremities within normal limits, posterior upper head x2 swollen areas and right upper head. Neuro checks, right upper extremity bruise on forearm, vital signs 151/82, Temp 98 degrees, pulse 106, Respirations 32 and Oxygen saturation at 84% on room air. Power of Attorney aware and son aware. Hospice aware and fax to physician. 9/14/2025 at 9:55AM, CNA came and got nurse, R53's respirations through her mouth. Oxygen saturations 88%, 2 liters per nasal cannula, message sent to hospice for oxygen mask due to mouth breathing. 9/14/2025 at 2:00PM, R53 had 2 large emesis undigested food. Vital signs 156/92, temp 97.7, pulse 130, respirations 32, and oxygen level at 88 % with 5 liters per nasal cannula.9/15/2025 at 12:00AM, R53 opens OU (both eyes) no verbal response, grimaces with touch. Pupils sluggish and equal round. No response when asked to squeeze hands. Followed finger movement for 1-2 seconds. 7 centimeter round soft area to upper crown of head. Purple bruising to right forearm. Medications given.9/15/2025 at 4:00PM, R53 non to minimal responsive. Does not open eyes, pupils round and equal and sluggish. Grimaces when arm moved to do blood pressure check. No change in condition and pulse remains in 130's.9/16/2025 at 9:00 AM, Ativan and Oxycodone given as ordered, Turn and repositioned, non-responsive, bilateral upper and bilateral lower extremities flaccid. 9/17/2025 at 12:00AM, Respiration gurgling, and lung sounds rhonchi (coarse) all throughout. Turned and repositioned medications given.9/17/2025 at 1:45AM, this nurse entered resident's room, upon entering resident noted to be still, no audible pulse, no audible blood pressure, respirations ceased. Family notified of resident passing.R53's Hospice Progress notes document:On 9/14/2025, Skilled nurse visit PRN (as needed) visit due to fall. R53 had emesis x 2. New order for Zofran 4.8 milligrams (mg) as needed. R53 is restful at visit. Pupils sluggish. Waking to verbal stimuli. Respiratory rate at 28. New order to schedule Oxycodone 5 mg every 4 hours and Ativan 1 mg every 4 hours. Discontinue Ativan at bedtime. Skilled Nurse to return on 9/15/2025.On 9/15/2025 Skilled nurse visit, R53 restful at visit 0/10 Pain scale O2 at 4 liters per nasal cannula. Heart rate 150-60's. Report was given to director, daughter and V2. Discontinue scheduled routine medications. Continue Oxycodone 0.25 milliliters every 4 hours and Ativan 1mg every 4 hours. Comfort meds continue. R53 changed to daily visits. Skilled nurse to return tomorrow 9/16/2025. On 9/16/2025 Skilled nurse visit, R53 unresponsive. 0/10 pain scale, decrease urine, breathing steady, even. Getting comfort meds. Skilled nurse to return on 9/17/2025.R53's Neurological Assessment documents neuros started on 9/14/2025 at 7:45AM. Noted changes to Neurological Assessment was on 9/15/2025 pupils were 3 millimeters and sluggish reaction. On 9/16/2025 at 6AM document shows extremities both left and right were flaccid and pupils both Left and Right were 3 millimeters and non-reactive. On 9/16/2025 at 2:00PM assessment documents pupils were 2 millimeters and non-reactive and both right and left extremities were flaccid.An undated final report sent to IDPH on R53 documents in part, This is our final report regarding the incident that occurred on 9/14/2025 . In our initial report, it was reported that there were 2 CNA's present at the time of the transfer and fall. During our investigation and after conducting staff interviews, it was noted that there was one CNA at the time of the transfer and fall. The sling that broke during the transfer was examined and there were not torn or compromised areas to the mechanical lift sling, other than the loop that broke during transfer . The CNA that was transferring the resident was disciplined for not following facility Hoyer lift policy. On 9/17/25 at 1:45 a.m. the resident passed away.On 9/24/2025 at 10:57AM, V6 CNA (Certified Nurse Assistant) stated she was the only CNA that was using the mechanical lift to transfer R53 from the bed to the wheelchair on 9/14/25. V6 stated the transfer was in motion when the strap broke and R53 fell to the ground headfirst hitting her head. V6 stated she immediately yelled for help and the nurses came down and assessed R53. V6 stated R53 had bumps noted to the right side of her head which is the side of the head that R53 landed on. V6 stated that she has since received education that mechanical lifts must only be used with 2 qualified staff members present. V6 stated that using 1 staff member for mechanical lifts was not unusual on the weekends due to staffing shortage but she will never do that again. V6 stated she only works the weekends on dayshift.On 9/24/2025 at 11:58AM, V8 (Hospice Nurse) stated she has cared for R53 and is familiar with her. V8 stated R1's baseline was mostly nonverbal; she was up in wheelchair for meals, and she required a mechanical lift for transfers. V8 stated R53 required assistance for all her ADL's. V8 was asked if she felt R53's fall that occurred on 9/14/2025 attributed to R53's death, V8 stated, Yes definitely. V8 then stated, I can't confirm that without scans of course but she had a rapid change in condition that consisted of a change and decrease in her level of consciousness, she began to have vomiting, and inability to eat and keep food down. V8 was asked if she felt like R53 was at the end-of-life cycle prior to the fall on 9/14/2025, V8 stated, I do not feel like she was at that point prior to the fall. V8 then stated, She was not in the condition yet that I would have talked with the resident's family to inform them that death was near or even a month away. V8 stated it was the family that did not want R53 sent to the hospital. V8 stated after the fall R53 had a rapid decline and then passed away soon after the fall. V8 stated she was not aware of the death certificate being completed or what the cause of death would be documented on the death certificate.On 9/24/2025 at 2:00PM, V9 (LPN) stated she was the nurse in charge of R53 on 9/14/2025. V9 stated she was asked to go to R53's room because R53 had fallen out of the sling of the mechanical lift onto the floor. V9 stated the lift sling broke. V9 stated V6 was in the room with R53 and was taking the sling out from under R53. V9 stated R53 was still alert as her normal and was lying on her right side. V9 stated she did neuro checks and checked all of her extremities. V9 stated at the time of assessment R53 had a knot to her right side of her head and one in the middle of the back of her head. V9 stated we then placed another sling under her and put her back to bed via mechanical lift. V9 stated R53 ate breakfast and lunch, and a little later R53 started having emesis and had a look of pain and fear. V9 stated hospice was called and told us to give her Ativan and Oxycodone every 4 hours. V9 stated she did see a decline in R53's condition but the decline was the vomiting and increased pain. V9 stated she worked the next day on 9/15/2025 and when she got to work, she was told that R53 was no longer responsive to anything. V9 stated R53's condition pretty much stayed the same throughout the day. V9 stated R53 was no longer able to tolerate eating or drinking. V9 stated R53 did have a change in condition after the fall. V9 explained by saying R53 would be assisted up for meals and assisted with feeding and was alert but answer sometimes with a yes or no answer. V9 stated the family did not want R53 sent to the hospital.On 9/24/2025 at 3:54PM, V10 (Physician) stated R53's care was managed by Hospice, but he would check in on R53 when he did rounds. V10 stated would usually see R53 sitting in the dining room when he was making rounds. V10 stated R53 had a long hospital stay a few months ago and the family decided to send R53 back under the services of Hospice. V10 stated R53 was declining slowly after the long illness and was an aspiration risk. V10 was asked if he was aware of the fall that R53 had on 9/14/2025, V10 stated yes. V10 was asked if he felt this contributed to R1's death, V10 stated with a head injury to a resident of her age it is never good. V10 then asked, What did hospice say about this? V10 was told that the hospice nurse felt the fall and injury attributed to R53's death. V10 then stated, I have to agree with Hospice on that statement.On 9//26/2025 a 10:20AM, V1 (Administrator) and V2 (DON) were present and V1 stated, We know the fall caused the change in condition and death of R53. It was an unfortunate accident. V1 stated we immediately started working on everything the day of the event and V14 was already here working and started by inspecting all slings and educating the nursing staff.R53's death certificate has date/time of death as 9/17/2025 at 1:45AM with cause of death Respiratory Failure with Hypoxia. On 9/26/2025 at 11:49 AM spoke with V7 Coroner regarding R53's death certificate. V7 verified that the death certificate listed a cause of death as respiratory failure with hypoxia. V7 stated she and the physician were unaware of R53 falling out of a mechanical lift causing a head injury that led to death. V7 stated the Hospice Physician will have to make the changes to the death certificate due to the death certificate should have cause of death was accidental instead of respiratory failure. Policy titled Mechanical Lift with revision date of 9/15/2025 documents under 'Policy Use care, discretion and 2 staff members to maintain resident's safety during transfers. Under Procedures #13 mechanical slings are to be inspected daily prior to use per CNA, #15 if sling is tattered, torn, worn; remove immediately from circulation and notify nursing supervision for replacement.The Immediate Jeopardy that began on 9/14/2025 was removed and corrected on 9/15/25 when the facility took the following steps to systemically correct the noncompliance prior to the start of the survey:On 09/14/25, V14 was present and gave verbal education on Hoyer transfers to all nursing staff present.On 09/14/25, all Hoyer slings in use were examined by QAC Nurse for torn or compromised areas.On 09/15/25 and 09/18/25, a QA/QAPI meeting was held to discuss the incident and initiate corrective actions. On 9/15/25 a QAPI was created to prevent reoccurrence of such incident. A monitoring tool was created to audit over the next 4 weeks: 5 Hoyer lifts daily times 4 days, then 3 Hoyer lifts daily times 3 days, then 1 Hoyer lift daily times 6 days to ensure that 2 staff members are using the Hoyer lift properly on the residents who require a Hoyer lift for transfers. The QAPI will be overseen by QAC or designee. 09/15/25, Hoyer lift policy was reviewed and revised by the DON (Director of Nursing), LNHA (Licensed Nursing Home Administrator) and QAC.On 09/15/25, DON performed 1 on 1 education with nursing staff, that were on duty, in which the Hoyer lift policy was reviewed with emphasis on using two assists with all Hoyer transfers and inspection of slings. The staff that were not scheduled on 09/15/25, were educated on their next scheduled shift. On 09/15/25, all Hoyer slings and Sit to Stand belts were inspected by DON and LNHA. Any slings in question were removed from rotation, discarded and new slings ordered.On 09/15/25, a numbered list of Hoyer Slings and Sit to Stand Belts was created by QAC. From this list a Hoyer/Sit to Stand Sling Quarterly Inspection Log was created. This form was completed by DON, QAC, LNHA or designee.On 09/16/25, QAC or designee completed Mechanical Lift Competency Checklists with CNA staff that were on duty. The staff that were not scheduled on 09/16/25, were educated on their next scheduled shift. On 09/16/25, QAC nurse added the following approach to all resident's care plans. If a mechanical lift is used for transfers, sling/belts are to be inspected daily prior to use. If sling/belt is tattered, torn, worn; remove immediately from circulation and notify nursing supervisor for replacement.The QAPI that has been developed is ongoing.

Based on observation, interview, and record review, the facility failed to provide aseptic catheter care for one of one residents (R5) reviewed for catheters in the sample of 29.Findings include:R5's Face Sheet documented an admission Date of 8/18/25 and listed Diagnoses including, Hypothyroidism and Alzheimer's Dementia. R5's Minimum Data Set, dated [DATE] documented that R5 has minimal deficits in cognition.R5's 9/8/25 Urinalysis documented the presence of 4+ leukocytes, red blood cells, and Enterococcus in the urine. R5's current Physicians Orders documented orders for an indwelling urinary catheter number 16 French with 5 cubic centimeter balloon, and Macrobid 100 milligrams one tablet twice daily start 9/10/25 for 10 days. R5's Care Plan dated 9/7/25 did not document a problem area of nor interventions for a catheter.On 9/23/25 at 1:53pm, R5 was alert and oriented to person, place, and time. R5 stated she was recently hospitalized and came to the facility with a catheter due to having a dropped bladder, and that she has had a history of urinary tract infections (UTIs).On 9/25/25 at 11:17am, V13, Certified Nursing Assistant/CNA, was observed providing catheter care for R5. After handwashing, V13 donned clean gloves, and then picked up an ink pen off the floor. V13 then provided catheter care with the contaminated gloves on. V13 cleansed the perineal area, then placed the contaminated washcloth in a basin of water for rinsing. V13 then put a clean washcloth in the now contaminated water and used it to rinse the perineal area. V13 then took a towel which was being used as a barrier between the basins and the nightstand and used this contaminated towel to dry the perineal area.On 9/26/25 at 8:58 V2, Director of Nurses, stated R5 has a history of UTI's (Urinary Tract Infections) and just finished antibiotics. V2 stated she will be reeducating CNA staff on aseptic catheter care.On 9/26/25 at V12, Registered Nurse/Care Plan Coordinator, stated R5 came back from a recent hospitalization with the catheter, and V12 did not add an associated problem area or interventions to the care plan, but will do so now.An undated Urinary Catheter Care Policy documented, Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling urinary catheter. Routine daily care of indwelling catheters is controversial in reducing catheter associated urinary tract infections. Daily perineal care does however contribute to improved hygiene. Catheter care will be performed three times daily to decrease the risk of nosocomial urinary tract infections and to improve personal hygiene of the residents with indwelling catheters.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 2 of 2 residents (R8 and R28) reviewed for room size in a sample of 29.The Findings Include: On 9/26/25 at approximately 9:30 AM, R13 was sitting in her room. R13 was noted to not have a roommate. The room was a smaller sized bedroom with one bed, a recliner, an overbed table, 1 nightstand, two chairs, and an inset closet inside the room.On 9/26/25 at approximately 10:00 AM, R17 was sitting in his room. R17 was noted to not have a roommate. The room was smaller in size with one bed, recliner, overbed table, a chair, two nightstands, and an inset closet inside the room.On 09/26/25 at 10:30AM, V14 (Quality Assurance Nurse) measured R13 and R17's bedroom sizes. The rooms measured 11 feet 13 feet 6 inches, indicating that the rooms were 151.47 square (sq.) feet (ft.), or 75.74 sq. ft. per bed. The measurements did not include the closet or the inset dresser area.On 9/26/25 at 10:30 AM, V14 stated that both of these rooms, occupied by R13 and R17, have a room size waiver. V14 stated these rooms are double occupancy rooms that are utilized as single bed rooms. V14 stated the rooms occupied by R13 and R17 do not meet the required room size and have a room waiver and are both Medicare and Medicaid certified.A facility room roster provided by the facility on 9/23/25 and dated 9/23/25, documents R13 and R17 reside in the rooms observed.Inquiries regarding the size of these rooms during the survey from 09/23/25 to 09/30/25, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. During an interview, on 09/24/25 with residents between 10:00 AM-10:00 AM, R13 and R17 voiced no concerns with the size of their rooms.Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on interview and record review the facility failed to follow implemented fall interventions for one of three (R1) residents reviewed for accidents in a sample of three. This failure resulted in R1 sustaining a fracture of the distal left radius. This past non-compliance occurred between 03/13/25 and 03/17/25. Findings include: R1's Resident Face Sheet documents an admitted [DATE] with diagnoses including: fracture of other parts of pelvis, initial encounter for closed fracture, Crohn's disease of small intestine with intestinal obstruction, sequelae of cerebral infarction, generalized abdominal pain, gastrointestinal hemorrhage, partial intestinal obstruction, pyridoxine deficiency, vitamin D deficiency, major depressive disorder, chronic pain, macular degeneration, and weakness. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 is cognitively intact. The same MDS documents that R1 requires substantial/ maximal assistance for lying to sitting on side of the bed and sit to stand transfers. R1's current Care Plan documents a problem area starting 02/07/25 of falls with an intervention of: motion alarm to bed and sensor pad to recliner to alert staff of self-transfers dated 03/14/25. On 03/26/25 at 2:20 PM, R1was observed lying in bed with a wrist brace on her left wrist. R1's motion alarm was in place and was turned on. R1 stated she fell and hurt her wrist. R1 said she was reaching for something and fell . R1 said it doesn't hurt too bad. On 03/27/25 at 10:30 AM, R1 was observed sitting in her wheelchair with her left wrist in a brace in the dining room. R1's Nurse's Note dated 03/13/25 at 5:00 PM documents: CNA's (Certified Nurse Aides) noted resd (resident) sitting on the floor by the bed. Resident had tried to get up to go the BRM (bathroom) incontinent BM (bowel movement), alert/confused. R1 c/o (complains of) pain to left wrist/hand, mild edema noted with no discoloration at this time. Flexing the wrist causes pain and tender to the touch. There is redness noted to left knee. Moving all other extremities with pain. R1 is able to bear weight on legs with pain. No other signs of injury and did not hit her head. R1's bed was in the low position. V6 (Medical Doctor) was notified by phone. An x-ray for the left wrist was ordered. R1's Nurse's Notes dated 03/13/25 at 8:00 PM documents (company name) here and x-ray completed. R1's Nurse's Note dated 3/14/25 at 4:29 AM, documents the left wrist x-ray results were sent to the MD (Medical Doctor) and documents Impression: apparent nonarticular fracture of the distal left radius. R1's Post Fall Investigation dated 03/14/25 documents a fall on 03/13/25 at 4:00 PM with the questions what mechanical devises were in use? with personal alarm checked yes, was the mechanical device in good repair? with no checked, and it was not turned on- motion alarm on bed was written in next to the no. The section titled Summary documents: action plan (s)/intervention etc. if warranted: documents that staff were re-educated to turn on R1's motion alarm while she's in bed and not to close R1's room door while R1 is in room due to safety concerns. The same investigation documents factors contributing to the fall of: R1 has a history of falls and requires assistance with transfers, R1 attempted to self-transfer and has poor safety awareness, impaired vision, unsteady gait, and did not utilize the call light. R1's motion alarm was on the bed and was not turned on and her room door was closed. R1's Resident Incident Report dated 03/13/25 at 4:00 PM documents: did resident have a personal alarm? with 'yes' circled and motion alarm written in next to the answer; if yes, was alarm sounding? with 'no' circled; if no, why not? with wasn't on written in. Name and title of witness'/employees that witnessed the incident or was the first staff to come upon incident: with V8 and V9 (Certified Nurse aides) names written in. The section titled, type of injury: documents: with swelling checked and where are injuries with left hand /wrist written in. Does the resident have some kind of personal alarm? with 'yes' checked, if yes, was it sounding? with 'no' being checked, If no, why not? with 'was not in place' written in. On 03/27/25 at 11:07 AM, V8 (CNA) stated, she was working the hall when R1 fell , she did not see her fall, she did not hear the alarm going off. The alarm was not turned on, it must have just been missed by accident. On 03/27/25 at 12:11 PM, V4 (Registered Nurse) stated R1 did have a motion alarm, if she is in bed the alarm should be turned on. R1 is very unsteady and thinks she can get up and walk on her own. R1 now has a pull alarm also. V4 said after R1 fell , all the staff were re-educated on assuring that motion alarms are turned on when residents are put to bed. On 03/27/25 at 12:18 PM, V5 (CNA) stated R1 does have a motion alarm, she had it prior to her fall. V5 said if residents have motion alarms, they should make sure they are turned on when they are in bed. V5 said after R1 fell all the staff were re-educated on making sure alarms are turned on and in place when residents are in bed. On 03/27/25 at 12:35 PM, V7 (Care Plan Coordinator) stated R1 had a motion alarm prior to her falling and injuring her wrist on 03/13/25. After the fall, V7 added the pull alarm, to leave R1's door open if she is in her room, and staff were re-educated to make sure the motion alarms are turned on if residents are in bed. On 03/27/25 at 12:50 PM, V1 (Administrator) stated that prior to R1 falling on 03/13/25, R1 had a motion alarm and the alarm was not turned on. V1 said the alarm was just missed when the CNA assisted R1 to bed. V1 said the alarm will not prevent her from falling but it could alert them to get to her immediately and hopefully prevent her from falling that way and it was an intervention they had in place for R1 and it should have been on. V1 said all staff were educated after R1's fall to make sure all alarms are turned on when residents are assisted to bed. The staff had a QA meeting to discuss the fall, reasoning behind the fall, and methods to prevent the occurrence from happening again in the future. The staff are checking alarms to make sure they are in place and motion alarms are turned on. The undated facility policy titled, Safety Alarm Policy documents under Purpose to monitor movement of residents that have a high risk for falls and alert staff when a resident may be leaving a bed, a chair or other designated location. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 03/17/25. In attendance - V1, V2 (Director of Nursing/DON), V10 (Social Service Director), V11 (Human Resources),V12 (Activities Director), V13 (Maintenance Director), and V15 (Care Plan Coordinator). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2 (DON) provided in-service to nursing staff to ensure personal alarms and motion alarms are turned on after putting residents to bed. Completed on 03/17/25. All motion alarms were checked and in the on position when residents were in bed. 4. Plan to monitor performance to ensure solutions are sustained: motion alarm audits to be conducted weekly x 4 weeks by V2. The first complete facility audit was completed on 03/14/25.

Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for one (R1) of five residents reviewed for abuse in the sample of five. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Major Depressive Disorder, Hypertension, and Cerebral Infarction by history. R1's Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status Score of 14, indicating R1 has minimal deficits in cognition. R1's Care Plan dated 9/6/24 documented problem areas, (R1) may display short-term and long-term memory problems. R1's Nurses Notes, all authored by V7, Licensed Practical Nurse (LPN), documented the following: 11/8/24, 5:00pm, This nurse was called down to (R1's) room for a complaint of a skin tear. When I arrived I noted a large skin tear (to the) left forearm with large amount of bleeding. Pressure was applied to get bleeding to slow down. (V3, Certified Nursing Assistant/CNA) stated resident was in bedside table and he pulled resident wheelchair back and resident got a skin tear from arm being between bed and bedside table. Resident states, 'He grabbed my arm.' Noticing such a large skin tear, asked other nurse to look at it since it didn't look like it could be approximated with (trade name wound closure strips).Decision was made to send to ER (emergency room ) for treatment. Notified (V10, Physician/Medical Director) per fax. Called (V5, R1's Power of Attorney) and made aware. Called and gave report to ER. Called (local medical transport company) for transportation. Resident was confused earlier, asking this nurse to take him to get his truck from his wife. An Abuse Investigation Witness Statement dated 11/8/24 at 7:45pm, signed by V3, CNA, stated, Upon entering (R1's) room, he was reaching down trying to pick something up off the floor. Trying to move the wheelchair to pick up what he was after and I noticed the chair was wedged between the bed, nightstand, and recliner. I lifted the rear of the wheelchair to get him unstuck. I was able to get him turned around and that's when I noticed the injury. Freaking out over the size of it. I hurried to find another CNA to grab a nurse. I found (V6, CNA) in another resident's room and asked her to get (V7). I went back to (R1's) room and he was starting to mess with the skin tear, with a loud, panicked voice I stated, Stop messing with it, grabbed his hands and rested them on the arms of the wheelchair, slowly and gently. (R1) started to blame me for the injury, saying, 'If you didn't twist my arm, that wouldn't have happened.' I stated, I didn't freaking do it, I didn't grab on your arm til you was messing with the laceration, being accused for a second time of causing it, being flustered and overwhelmed by the size of the skin tear. I also said, I wouldn't be that fu**ing stupid. I would not grab your arm and twist it. I apologized for cursing, it just slipped out due to the overwhelmingness of the situation. (V7 and V6) then arrived and took over. An Abuse Investigation Witness Statement dated 11/8/24 at 8:15pm, signed by V6, stated,(V8, LPN) asked me to take a package to a resident on the North Hall. I was talking to the resident and (V3) came running in and told me to grab (V7) because (R1) had a skin tear. On my way up to the nurses station, I heard (V3) yelling at (R1). (V3) said, 'I didn't fu**ing do it. You fu**ing did it .stupid.' (V7) and I went down to (R1's) room and (V3) said he didn't know what happened. (V3) asked if we needed help and (V7) told him that her and I could handle it. (V3) left the room. (V7) tried to dress the wound but since it was bleeding so much, she decided to send him to the ER. On 11/13/24 at 9:50am, R1 was awake and alert to himself, he could not name the facility, nor the current President. He was able to state it was November 2024 but could not give the date or day of the week. R1 exhibited evidence of significant cognitive slowing, in part evidenced by very delayed verbal responses. The Surveyor asked R1 if any staff at the facility had ever hurt him, and R1 stated, Yes, a few days ago, that guy who works here, with R1 pointing to his left forearm which was bandaged, saying, He twisted it.' R1 was unable to state the name of the staff member, but told the Surveyor to look at the report. R1 stated he does not know why the staff member did this, but the staff member was looking through R1's greeting cards, and R1 told him to stop looking at them, and then he twisted R1's arm. R1 stated he was sent to the ER for treatment and came back to the facility the same night. R1 stated he has not seen the staff member since the event occurred. R1 stated the arm is not painful, and he denied having any lasting emotional effects from the incident. R1 stated he did not recall this staff member yelling at him, or calling him names. On 11/13/24 at 10:45am,V7 corroborated the events of 11/8/24 as outlined above in her Nurses Notes. V7 stated V3 reported that R1 was leaning forward in his wheelchair and V3 was afraid he would fall forward, so V3 pulled the wheelchair backward, with the left forearm making contact with something, causing the skin tear. V7 stated R1 told her that V3 was looking through R1's greeting cards and R1 told him to stop doing it. V7 stated she did not report the allegation of abuse to V1, Administrator, because what V3 said happened made sense, and R1 had been confused earlier in the day. V7 stated she was later told by V1 that V7 should have contacted V1 immediately after the allegation was made. V7 stated staff also received re-education on the Abuse Policy. On 11/13/24 at 12:40pm, V3 stated he was working 7am to 7pm on 11/8/24. V3 stated he went into R1's room around 5pm to take him to the dining room, and saw R1, sitting in his wheelchair, wedged between the bed, the nightstand, and the recliner. V3 stated R1 was leaning forward and V3 was afraid he would fall. V3 stated he grabbed the wheelchair and pulled it back. V3 stated there were greeting cards scattered on the floor, and V3 bent over to pick them up. V3 stated R1 then accused V3 of stealing his cards, and at that point V3 saw a large skin tear on R1's left forearm. V3 stated he picked up R1's arm to examine it, and R1 said, You twisted my arm. V3 stated he went to get help, and when he came back, R1 was messing with the skin tear which was then bleeding profusely. V3 stated he told R1 not to touch the area. V3 stated, I get freaked out when I see a lot of blood. (R1) kept saying I twisted his arm, and I was arguing with him, and I said,' 'I'm not that fu**ing stupid, to grab and twist your arm ' V3 stated he did not yell at R1 or call him stupid. V3 stated at that point, V7 came in to deal with the wound, so he went to take care of other residents. V3 stated he worked the remainder of his shift and left at 7:00pm. V3 stated R1 was sent to ER and V3 had no further contact with him. V3 stated he had no previous issues with R1 prior to this event. On 11/13/24 at 1:20pm, V6 corroborated the details of 11/8/24 as per her interview statement as referenced above. V6 stated within minutes of hearing V3 yell at R1, she told V8, LPN, about it, and, (V8) said she would investigate it. On 11/14/24 at 10:25am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated she found out about the abuse allegation on 11/8/24 in the evening when V12, Director of Administrative Services, called her to say the police had called the facility, wanting to come interview residents and staff about an abuse allegation. V1 stated she then began an immediate abuse investigation. V1 stated after the interviews and the incident re-creation, the physical abuse allegation will be unfounded. V1 stated since V3 admitted to cursing in front of R1, which is a violation of the facility's Abuse Policy, verbal abuse will be substantiated and V3 will be terminated from employment. The facility's Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, Facility Abuse Management Policy and Procedures dated November 2024 stated, (The facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of their personal property, corporal punishment and/or involuntary seclusion. (The facility) therefore; prohibits abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, voluntary seclusion, use of physical or chemical restraints not required to treat the resident's medical symptoms, and has attempted to establish a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to immediately report an allegation of staff to resident verbal and physical abuse to the facility's Abuse Coordinator for one resident (R1) of five residents reviewed for abuse in the sample of five. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Major Depressive Disorder, Hypertension, and Cerebral Infarction by history. R1's Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status Score of 14, indicating R1 has minimal deficits in cognition. R1's Care Plan dated 9/6/24 documented problem areas, (R1) may display short-term and long-term memory problems, (R1) has potential for skin breakdown. At present is on aspirin therapy which may increase his potential for bruising and bleeding, and (R1 has) potential for falls related to unsteady gait, weakness and fatigue. (R1 has a) history of falls. (R1 is) alert and oriented with occasional confusion. R1's Nurses Notes, all authored by V7, Licensed Practical Nurse (LPN), documented the following: 11/8/24, 5:00pm, This nurse was called down to (R1's) room for a complaint of a skin tear. When I arrived I noted a large skin tear (to the) left forearm with large amount of bleeding. Pressure was applied to get bleeding to slow down. (V3, Certified Nursing Assistant/CNA) stated resident was in bedside table and he pulled resident wheelchair back and resident got a skin tear from arm being between bed and bedside table. Resident states, 'He grabbed my arm.' Noticing such a large skin tear, asked other nurse to look at it since it didn't look like it could be approximated with (trade name wound closure strips).Decision was made to send to ER for treatment. Notified (V10, Physician/Medical Director) per fax. Called (V5, R1's Power of Attorney) and made aware. Called and gave report to ER. Called (local medical transport company) for transportation. Resident was confused earlier, asking this nurse to take him to get his truck from his wife. 11/8/24, no time noted: Pressure dressing applied to slow bleeding. 11/8/24, 5:30pm: (Transport company) here to transfer to ER. 11/8/24,10:30pm:Returned to facility via facility van. Complaining of right knee pain. Tylenol given. Eating evening meal. Alert. (V5) here. (V5) states (trade name wound closure strips) were applied to the area with (trade name gauze bandage) wrap (at the ER). An Emergency Department Note dated 11/8/24 documented, (R1) is a [AGE] year old male with a past history of Constipation, Cerebral Vascular Accident, Depression, Gastroesophageal Reflux Disease, Hypertension, Serum Lipids high, and Weakness who presents for evaluation of skin tear to left arm. Patient reports that Aid was in room going through his birthday cards when patient told him it was then out of his business to be in his birthday cards. The Aid reached for patient's arm and jerked it away in a twisting manner, causing a skin tear. Medical decision making: [AGE] year old who presents with a skin tear. X-ray shows no acute fractures. Rest, Tylenol, dressing changes twice a day. Return if worsening symptoms. No questions or concerns at this time. A (State Agency) Facility Reported Incident dated 11/8/24 documented,(R1): Date of Occurrence: 11/8/24 at 5:00pm. Large laceration-skin tear. Left forearm, greater than 5cm (centimeters). Bleeding. Sent resident to ER (emergency room ) for sutures. Met with (local) Police Officer this evening around 7:30pm. He informed me he was called to the hospital related to (R1), reporting a staff member twisting his arm. An Abuse Investigation Witness Statement dated 11/8/24 at 7:45pm, signed by V3, CNA, stated, Upon entering (R1's) room, he was reaching down trying to pick something up off the floor. Trying to move the wheelchair to pick up what he was after and I noticed the chair was wedged between the bed, nightstand, and recliner. I lifted the rear of the wheelchair to get him unstuck. I was able to get him turned around and that's when I noticed the injury. Freaking out over the size of it. I hurried to find another CNA to grab a nurse. I found (V6, CNA) in another resident's room and asked her to get (V7 Licensed Practical Nurse/LPN). I went back to (R1's) room and he was starting to mess with the skin tear, with a loud, panicked voice I stated, Stop messing with it, grabbed his hands and rested them on the arms of the wheelchair, slowly and gently. (R1) started to blame me for the injury, saying, 'If you didn't twist my arm, that wouldn't have happened.' I stated, I didn't freaking do it, I didn't grab on your arm til you was messing with the laceration, being accused for a second time of causing it, being flustered and overwhelmed by the size of the skin tear. I also said, I wouldn't be that fu**ing stupid. I would not grab your arm and twist it. I apologized for cursing, it just slipped out due to the overwhelmingness of the situation. (V7 and V6) then arrived and took over. An Abuse Investigation Witness Statement dated 11/8/24 at 8:15pm, signed by V6, stated,(V8, LPN) asked me to take a package to a resident on the North Hall. I was talking to the resident and (V3) came running in and told me to grab (V7) because (R1) had a skin tear. On my way up to the nurses station, I heard (V3) yelling at (R1). (V3) said, 'I didn't fu**ing do it. You fu**ing did it .stupid.' (V7) and I went down to (R1's) room and (V3) said he didn't know what happened. (V3) asked if we needed help and (V7) told him that her and I could handle it. (V3) left the room. (V7) tried to dress the wound but since it was bleeding so much, she decided to send him to the ER. On 11/13/24 at 9:50am, R1 was awake and alert to himself, he could not name the facility, nor the current President. He was able to state it was November 2024 but could not give the date or day of the week. R1 exhibited evidence of significant cognitive slowing, in part evidenced by very delayed verbal responses. The Surveyor asked R1 if any staff at the facility had ever hurt him, and R1 stated, Yes, a few days ago, that guy who works here, with R1 pointing to his left forearm which was bandaged, saying, He twisted it.' R1 was unable to state the name of the staff member, but told the Surveyor to, 'Look at the report.' R1 stated he does not know why the staff member did this, but the staff member was looking through R1's greeting cards, and R1 told him to stop looking at them, and then he twisted R1's arm. R1 stated he was sent to the ER for treatment and came back to the facility the same night. R1 stated he has not seen the staff member since the event occurred. R1 stated the arm is not painful, and he denied having any lasting emotional effects from the incident. R1 stated he did not recall this staff member yelling at him, or calling him names. On 11/13/24 at 10:45am, V7 corroborated the events of 11/8/24 as outlined above in her Nurses Notes. V7 stated V3 reported that R1 was leaning forward in his wheelchair and V3 was afraid he would fall forward, so V3 pulled the wheelchair backward, with the left forearm making contact with something, causing the skin tear. V7 stated R1 told her that V3 was looking through R1's greeting cards and R1 told him to stop doing it. V7 stated she did not report the allegation of abuse to V1, Administrator, because what V3 said happened made sense, and R1 had been confused earlier in the day. V7 stated she was later told by V1 that V7 should have contacted V1 immediately after the allegation was made. V7 stated staff also received re-education on the Abuse Policy. On 11/13/24 at 12:40pm, V3 stated he was working 7am to 7pm on 11/8/24. V3 stated he went into R1's room around 5pm to take him to the dining room, and saw R1, sitting in his wheelchair, wedged between the bed, the nightstand, and the recliner. V3 stated R1 was leaning forward and V3 was afraid he would fall. V3 stated he grabbed the wheelchair and pulled it back. V3 stated there were greeting cards scattered on the floor, and V3 bent over to pick them up. V3 stated R1 then accused V3 of stealing his cards, and at that point V3 saw a large skin tear on R1's left forearm. V3 stated he picked up R1's arm to examine it, and R1 said, You twisted my arm. V3 stated he went to get help, and when he came back, R1 was messing with the skin tear which was then bleeding profusely. V3 stated he told R1 not to touch the area. V3 stated, I get freaked out when I see a lot of blood. (R1) kept saying I twisted his arm, and I was arguing with him, and I said,' 'I'm not that fu**ng stupid, to grab and twist your arm ' V3 stated he did not yell at R1 or call him stupid. V3 stated at that point, V7 came in to deal with the wound, so he went to take care of other residents. V3 stated he worked the remainder of his shift and left at 7:00pm. V3 stated R1 was sent to ER and V3 had no further contact with him. V3 stated he had no previous issues with R1 prior to this event. On 11/13/24 at 1:20pm, V6 corroborated the details of 11/8/24 as per her interview statement as referenced above. V6 stated within minutes of hearing V3 yell at R1, she told V8, LPN, about it, and, (V8) said she would investigate it. On 11/13/24 at 1:40pm, V5 stated some time in the evening on 11/8/24, she was notified by V7 that R1 had sustained a skin tear. V5 stated she was then called by an ER nurse, who said that R1 was there, and, They were calling in a report of elder abuse because he said that one of the staff twisted his arm. V5 stated later that evening, V1 had spoken to her and said the facility was starting an abuse investigation. On 11/13/24 at 2:50pm, V8 stated on 11/8/24 at about 5pm she was alerted by V7 that R1 had a skin tear, and they worked together to assess the wound and control the bleeding. V8 stated R1 told V8, 'He (V3) grabbed my arm. V8 stated V6 reported to V8, 'That she heard (V3) yelling at (R1) but doesn't recall telling (V6) she would investigate it.' V8 confirmed she did not notify the Administrator about the incident. V8 stated after the event, staff were retrained on the Abuse Policy, and V1 told V8 she should have notified V1 immediately of R1's abuse allegation. On 11/14/24 at 9:40am, V2, Director of Nurses, stated R1 has very fragile skin and is prone to skin tears. V2 stated she has heard no complaints from residents or staff about V3, and she has only disciplined V3 for occasional tardiness. V2 stated abuse is to be reported immediately to V1. V2 stated she does not think V7 or V8 violated the abuse policy by not reporting to V1, because they thought the skin tear was an accident, and that R1 was confused when he said V3 hurt him. On 11/14/24 at 10:25am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated she found out about the abuse allegation on 11/8/24 in the evening when V12, Director of Administrative Services, called her to say the police had called the facility, wanting to come interview residents and staff about an abuse allegation. V1 stated she then began an immediate abuse investigation. V1 stated after the interviews and the incident re-creation, the physical abuse allegation will be unfounded. V1 stated since V3 admitted to cursing in front of R1, which is a violation of the facility's Abuse Policy, verbal abuse will be substantiated and V3 will be terminated from employment. V1 stated she did not believe V7 and V8 failed to follow the Abuse Policy by not immediately reporting it to her, because they believed it was an accident and not abuse. The facility's Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, Facility Abuse Management Policy and Procedures dated November 2024 stated, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation Any employee of (the facility) or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. A), Definitions: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again (42CFR 483.13b Interpretive Guidelines).

Based on interview, observation, and record review, the facility failed to supervise a confused resident during toileting for 1 of 2 residents (R32) reviewed for falls in the sample of 25. This failure resulted in R32 falling and sustaining skin tears to the right hand and a laceration to the forehead which required 13 sutures to close. The findings include: R32's Face Sheet documented an admitted [DATE] and listed diagnoses including History of Right Femur Fracture with Surgical Repair, Diabetes Type 2, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF). R32's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status Score of 8, indicating R32 has moderate deficits in cognition. The same MDS documented that R32 requires partial to moderate assistance for toileting, which is defined as, Helper (staff) does more than half the effort: Helper lifts or holds trunk or limbs and provides more than half the effort. R32's Fall Risk Assessment documents an assessment completed on 2/14/24 with a score of 18, and assessments completed on 4/19/24 and 7/1/24, each documenting a score of 16, indicating R32 is at high risk for falls. The Fall Risk Assessment document notes a total score of 10 or above represents high risk. R32's Care Plan with a review date of 7/8/24 documented a problem area, Potential for falls related to unsteady gait, weakness and fatigue. (R32) (was) a new admit to the facility with surgical aftercare from a right femur fracture. (R32) had a fall at home resulting in the fracture. (R32) is alert with forgetfulness, (and) has a diagnosis of Alzheimer's. Transfers with 2 (staff) assist, toe touch weight bearing to right lower extremity, staff propelled wheelchair for long distances. Diagnosis of COPD. Hard of hearing, does not wear hearing aids. Occasionally incontinent of urine and continent of bowel. Does have pain to right lower extremity. (As needed) pain medications. Poor safety awareness. Able to make needs known to staff. This problem area had a corresponding intervention of Supervision when toileting if indicated, which was added to the Care Plan on 5/10/24. On 07/24/24 at 11:04 AM, R32 was observed in her room. R32 was alert only to herself. R32 was noted to have a scar of about 1.5 inches in length to her forehead. V5, Licensed Practical Nurse, who was present, stated the scar was from a fall which occurred a few months ago resulting in R32 requiring stitches. R32's Post Fall Investigation dated 3/3/24 at 8:15am documented, Resd. (resident) (attempted) self-transf. (transfer) from commode to bed. Resd. was noted laying on her back between the BRM (bathroom) et (and) bed. Lac. (laceration) to forehead. Sent to ER (emergency room ). Under Mental Status of Resident, Confused/disoriented is marked for prior to and following the fall. R32's Emergency Department Note dated 3/3/24 documented, Patient is an [AGE] years (sic) female with a history of Diabetes, Hypertension, A-Fib (Atrial Fibrillation), COPD, Dementia, and CHF. Presents today with complaints of (this) morning she tripped over bedside commode and somehow hit her head and caused some skin tears to her right hand. Under Medical Decision Making it documents Due to the patients age, did do a CT (Computed Tomography) of the head which was negative. The laceration/skin tear to her forehead was a bit wide so did my best to repair as much as we could. Under Lac (laceration) Repair it documents the under laceration details the location is forehead, is 4.5 cm (centimeters) in length, and number of sutures is 13. On 07/25/24 at 11:35am, V6, Certified Nursing Assistant (CNA), stated she was working with R32 the morning of the fall. V6 stated she and V7, CNA, who is now retired, put R32 onto the bedside commode with her call light in reach and told her to push the call light when she was done. V6 stated R32 was wearing non-skid socks. V6 stated 8:00am is the busiest time of the day with most residents needing toileting assistance, so she and V7 both left the room to attend to other residents. V6 stated when she and V7 re-entered the room, R32 was on the floor lying on her back and was bleeding from her forehead. V6 stated R32 stated she was trying to get back into bed and fell . V6 stated she cannot remember if R32's call light was on. V6 stated R32's ability to use the call light is, Hit or miss. V6 stated after the fall, CNA staff were educated not to leave R32 alone while on the toilet or bedside commode. On 7/25/24 at 11:52am, V2, Director of Nurses, stated she was not very familiar with the details of the fall and did not really recall the circumstances. V2 stated she was of the understanding that maybe R32 self-transferred onto the bedside commode and then fell while trying to self-transfer to bed. V2 stated she did recall educating staff to respond to R32's call light in a timely manner. A Fall Prevention Policy and Procedure dated 6/16/23 documented, The purpose of the Fall Prevention and Management Program is to 1. Identify residents at risk for falls. 2. Initiate preventative approaches if needed. 3. provide appropriate strategies and interventions directed to resident, environmental factors, and staff.

Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions for 8 of 12 residents (R5, R6, R8, R12, R18, R25, R35 and R41) reviewed for infection control in the sample of 25. The Findings Include: On the initial tour of the facility on 07/23/2024 beginning at 9:25 AM, there was one resident (R21) observed in the facility with signage indicating enhanced barrier precautions. During the tour of the facility R5, R6, R8, R12, R18, R25, and R35 were all observed to have indwelling catheters. On 07/23/2024 a Matrix for Providers (Form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On the same form documented under number 5 under pressure ulcers, R12 and R21 are the only two residents listed. On 07/23/2024 at 1:26 P.M., V3 (Minimum Data Set/Infection Preventionist) stated they have one resident on Enhanced Barrier Precautions. V3 stated R21 was on Enhanced Barrier Precautions for having MRSA (Methicillin-Resistant Staphylococcus Aureas) of the wound. On 07/23/2024 at 1:56 P.M., a tour of north hall noted to have one resident (R21) had signage on their door indicating they were on Enhanced Barrier Precautions (EBP). On 07/23/2024 2:00 P.M., no rooms were observed to have signage on the door indicating they were on EBP on the south hall. On 07/24/2024 at 12:48 P.M., V4 (Registered Nurse) stated a resident on enhanced barrier precautions you have to don gloves to go in the resident room. V4 stated she is unsure of what Enhanced Barrier Precautions are. On 07/24/2024 at 12:52 P.M., V5 (Licensed Practical Nurse) stated that she is not for sure what Enhanced Barrier Precautions means. On 07/24/2024 at 1:36 P.M., V2 (Director of Nursing) stated she was unaware the Enhanced Barrier Precautions are for residents with wounds and indwelling medical devices. V2 stated that V3 writes the polices for isolation and infection control practices. On 07/24/2024 at 2:24 P.M., V3 (Minimum Data Set/Infection Preventionist) stated she was unaware of wounds and indwelling medical devices were part of Enhanced Barrier Precautions. V3 stated she has started educating the nurses and the rest of the staff on Enhanced Barrier Precautions. R5's Resident Face Sheet documented an admitted [DATE]. R5's Resident Face Sheet documented diagnoses including retention of urine and urinary tract infection. R5's Physician Order Form with a date of July 2024 documented an order for a 16 FR (French) indwelling catheter. R6's Resident Face Sheet documented an admitted [DATE]. R6's Resident Face Sheet documented the following diagnoses: pneumonia, acute respiratory failure, weakness, chronic obstructive pulmonary disease, insomnia, chronic pain, chronic combined systolic and diastolic heart failure, vitamin d deficiency, hyperlipidemia, hypokalemia, constipation, arthroplasty, osteoarthritis, gastro-esophageal reflux disease without esophagitis, hypothyroidism and essential hypertension. R6's Physician Order Form dated July 2024 documented an order for a 16 FR indwelling catheter. R8's Resident Face Sheet documented an admitted [DATE]. R8's Resident Face Sheet documented diagnoses including gross hematuria. R8's Physician Orders dated July 2024 documented an order for a 16 French indwelling catheter. R12's Resident Face Sheet documented an admitted [DATE]. R12's Resident Face Sheet documented diagnoses including acute kidney failure, urinary tract infection, neuromuscular dysfunction of bladder, retention of urine, and chronic kidney disease. R12's Physician's Order Form with a date of July 2024 documented an order for a 16 Fr indwelling catheter. R18's Resident Face Sheet documented an admitted [DATE]. R18's Resident Face Sheet documented the following diagnoses: cerebral infarction, dysphagia, hemiplegia and hemiparesis following cerebral infarction, lump in right breast, hypothyroidism, vitamin d deficiency, hyperlipidemia, essential primary hypertension and insomnia. R18's Physician Order Form for July 2024 documented an order for a 16 Fr indwelling catheter. R25's Resident Face Sheet documented an admitted [DATE]. R25's Resident Face Sheet documented diagnoses including neuromuscular dysfunction of bladder. R25's Physician's Order dated July 2024 documented an order for 16 fr indwelling catheter. R35's Resident Face Sheet documented an admitted [DATE]. R35's Resident Face Sheet documented diagnoses including retention of urine. R35's Physician Order Sheet documented an order for a 16 fr indwelling catheter. R41's Resident Face Sheet documented and admitted [DATE]. R41's Resident Face Sheet documented the following diagnoses: anemia, syncope and collapse, hypercholesteremia, vitamin deficiency, generalized anxiety disorder, restless leg syndrome, allergic rhinitis, gastro-esophageal reflux disease, and constipation. R41's Physician Orders documented an order to apply santyl on left outer calf, Apply to necrotic skin / tissue daily then apply nonadherent dressing, and wrap with gauze until healed. According to Centers for Disease Control at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO (Multidrug Resistant Organisms) colonization status and Infection or colonization with an MDRO.

Based on observation, interview, and record review, the facility failed to add fall prevention interventions for a resident at high risk for falls for 1 of 2 (R8) residents reviewed for falls in the sample of 25. Findings include: R8's Face Sheet documented an admitted [DATE], with diagnoses including old Myocardial Infarction, Gastro-esophageal Reflux Disease, and Unspecified Dementia without Behavior Disturbance. A Minimum Data Set, dated dated dated [DATE] documented that R8 requires extensive assistance from at least two staff members for transfers. A 2/20/21 Physicians Order documented an order for,(trade name weighted lap cushion) while up to wheelchair for proper posture and safety. A 1/14/23 Fall Risk Assessment documented a score of 12, indicating R8 is at high risk for falls. A January 2023 Incident Study Form documented that on 1/22/23, on the 7:00am to 3:00pm shift, R8 sustained a fall while in her room. A 1/22/23 Fall Investigation authored by V2, Director of Nurses, documented, Factors contributing to the fall: (R8) had slid down in chair and continued sliding until on the floor. Resident activity at the time of the fall: Preparing for transfer. Action Plan/Intervention if Warranted: (Left blank). A Nurses Note dated 1/22/23 at 12:45pm documented,Resident slid to floor during transfer after lunch. No injuries noted. Didn't hit head. Family aware. Doctor faxed. R8's Care Plan dated 1/21/23 documented a problem area, (R8) has a potential for falls related to confusion and weakness. Transfers per two assist. (Weighted lap cushion) while up to wheelchair to promote safety and a proper sitting position. No new fall interventions had been added to the Care Plan after R8's 1/22/23 fall. On 6/6/23 at 10:40am, R8 was observed in her room sitting in her recliner. R8 was alert only to self. On 6/8/23 at 1:48pm, V5, Registered Nurse/Care Plan Coordinator, acknowledged no new Care Plan interventions had been added following R8's 1/22/23 fall. V5 stated staff felt as though R8's existing fall interventions were effective. V5 stated R8 is not at high risk for falls. On 6/9/23 at 8:17am, V2 stated that on 1/22/23, she and another staff member were preparing to transfer R8 from the wheelchair to the recliner. V2 stated the other staff member went to retrieve the sitting to standing mechanical transfer lift, and V2 then removed R8's weighted lap cushion, which is used for positioning R8 in the wheelchair. V2 stated R8 began sliding out of the wheelchair, coming to a stop when with her buttocks made contact with the floor. V2 stated by herself, she was unable to stop R8 from sliding. V2 stated R8 sustained no injuries. V2 stated no new fall interventions were added to R8's plan of care, as staff felt the existing interventions were working. An undated Fall Prevention Policy and Procedure documented,The interdisciplinary team will .develop interventions to address residents identified as at risk for falling and implement an interdisciplinary plan of care if necessary. Interventions should be based on the level of risk. Post Fall Management: The interdisciplinary team will .review fall prevention interventions and modify the plan of care as necessary.

Based on observation, interview, and record review, the facility failed to administer prescribed medication per physicians orders and manufacturers directions for two residents of ten residents (R9, R8) reviewed for medication errors in the sample of 25. There were thirty medication opportunities observed with a total of three administration errors, making the error rate 10 percent. Findings include: 1. R9's June 2023 Physicians Order Sheet(POS) and June 2023 Medication Administration Record (MAR) documented an order for Fluticasone 50 microgram spray, directions-two sprays in each nostril daily at 8:00am. On 6/7/23 at 7:16am,V3, Registered Nurse (RN) was observed administering medications to R9. V3 read aloud the directions on the MAR as referenced above. V3 did not shake the medication prior to administration. V3 administered one spray per each nostril, washed her hands, returned the medication to the medication cart, documented the administration, and began looking at the MAR for medication orders on the next resident for administration. When the surveyor pointed out the discrepancy between the order and the administration, V3 re-checked the MAR and acknowledged she should have given two sprays to each nostril. V3 then administered the remaining one spray to each nostril. On 6/8/23 at 11:55am, the Surveyor asked V3 if the Fluticasone should have been shaken before administration. V3 stated she was not sure. The Surveyor and V3 checked the directions on the Fluticasone manufacturers packaging which stated, Shake gently before administration. 2. R2's June 2023 POS and June 2023 MAR documented an order for, Humalog 100 units per milliliter Kwikpen, inject 8 units three times daily before meals. If premeal blood glucose is less than 120 mg/dl(Milligrams per Deciliter), inject 4(additional) units. If pre-meal blood glucose is less than 80 mg/dl, hold insulin. If premeal blood glucose is 250-300mg/dl, inject 2(additional) units. If premeal blood glucose is 301-350mg/dl, inject 3(additional) units. If premeal blood glucose is 351-400mg/dl, inject 4 (additional) units. If greater than 400 mg/dl, inject 5(additional) units. Diagnosis: Insulin Dependent Diabetes Mellitus. On 6/7/23 at 11:15am,V4, RN, was observed administering medications for R2. V4 checked R2's blood glucose level, which was 286. V4 retrieved R2's Humalog Kwikpen, and administered 8 units subcutaneously. V4 performed hand hygiene, left the room, and returned the Kwikpen to the medication cart. On 6/7/23 at 11:25am, the Surveyor approached V4 for clarification about the discrepancy between the order and the administration observation. V4 rechecked the order and acknowledged R2 should have had a total of 10 units of Humalog. V4 then administered the remaining 2 units to R2. A Medication Administration Policy dated 5/19/22 documented, Responsibility of the nursing professional is to be aware of the correct dosage prior to administration of medications .The nurse should always be knowledgeable of the medications they have prepared prior to administration .Read and follow any special instructions written on the labels.

Based on interviews, observation, and record review the facility failed to provide at least 80 square feet of living space per resident bed for 2 of 2 residents (R18 and R196) reviewed for room size in a sample of 25. Findings include: On 6/9/23 at 12:20 PM, this surveyor accompanied V6 (Maintenance Supervisor) for the purpose of measuring the 2 resident rooms that V6 stated that are dually certified (Medicare and Medicaid) for 2 beds per room. The 2 rooms measured less than 80 square (sq.) feet (ft.) of living space per bed. The 2 room's measurements are as follows: room [ROOM NUMBER]: 154 sq. ft. (77 sq. ft. per bed) room [ROOM NUMBER]: 154 sq. ft. (77 sq. ft. per bed) A Daily Roster provided by the facility and dated 6/6/23 documents that R18 and R196 reside in the 2 rooms that provide less than the 80 square feet of living space per resident bed. During the survey from 6/6/23 to 6/9/23 rooms [ROOM NUMBERS] were equipped with one bed, one bedside table, one recliner and one chest of drawers. Observations of the undersized resident rooms found the rooms adequate to meet the medical and personal needs for the residents assigned to these rooms. Inquiries regarding the size of these rooms during the survey from 06/6/23 to 06/9/23, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. On 6/9/23 all voiced no concerns with the size of their rooms during interviews. Review of Resident Council meeting minutes from the past 6 months indicated no concerns related to the size of the rooms.

Based on observation, interview and record review, the facility failed to maintain aseptic technique during wound care and perineal care for two (R49 and R7) of 13 residents reviewed for infection control in the sample of 31. Findings include: 1. On 06/15/22 at 2:10pm, a sign reading Contact Isolation was observed on R49's door. At that time, V3 (Licensed Practical Nurse/LPN) was observed performing wound care for R49's knee wound. V3 performed handwashing and donned gown and gloves. V3 placed extra gloves and a tube of a trade name antibiotic ointment onto the overbed table with no barrier underneath. After providing the treatment, V3, without doffing her contaminated gloves, picked up the extra gloves and placed them on the sink counter of the bathroom that R49 shares with two other residents. V3 then doffed the contaminated gloves, picked up the trash can and placed a liner in it, then picked up the tube of ointment and placed it back in the treatment cart. V3 then doffed her gown. Without washing her hands or performing hand hygiene, V3 then pushed the treatment cart back to the nurses' station. R49's Lab Report Wound Culture Left Knee dated 5/18/22 documented, Final Report (positive for) Rare [CONDITION(S)]. 2. On 06/16/22 at 10:15am, a sign reading Contact Isolation was observed on R7's door. At that time, V4 and V5 (both Certified Nursing Assistants/CNAs) were observed providing perineal care for R7. Both performed handwashing and donned gown and gloves. After cleansing the perineal area, V5, without doffing her contaminated gloves, touched R7's clean gown and underwear, the bed linens, R7's oxygen tubing, and R7's call light. R7's 6/2/22 Lab Report Urine Culture documented,Final Report: (Positive for) Escherichia Coli ESBL (Extended Spectrum Beta-Lactamase). An undated Contact Isolation Policy documents Hands must be washed after touching the patient or potentially contaminated articles and before taking care of another resident .articles contaminated with infected material .should be disposed of as infectious waste. On 06/16/22 at 11:00am, V2 (Director of Nurses/DON) acknowledged the above observations represented a breach in infection control protocols. V2 stated V5 had approached her after the observation and reported to V2 that V5 had realized after the fact that she had breached infection control protocols during the above observation.

Based on interview, observation and record review, the facility failed to provide range of motion for one (R49) of one resident reviewed for risk of contractures/range of motion in the sample of 31. Findings include: On 06/15/22 at 1:32pm, V6 (Certified Nursing Assistant/CNA), was observed providing range of motion (ROM) services for R49. R49 was alert but oriented only to herself, displaying word salad and non sensical answers. V6 stated the facility has Restorative Program CNAs, but due to staffing issues, they work the floor now, so CNAs are responsible for doing restorative programming for their own residents. V6 stated as an example, today was his day off, but he got called in to work because two CNAs called in. V6 was asked how often R49 is getting ROM, to which V6 replied, Well, we do the best we can, she's supposed to be getting it daily, she gets it when we have time. V6 stated ROM is documented by the CNAs in a binder which contains the resident's restorative goals. V6 stated R49 is very stiff in the lower extremities and has a lot of pain with movement, so they usually focus on her upper extremities. V6 performed passive ROM to R49's shoulders, arms, and elbows for ten repetitions, but did not exercise the neck, hands, fingers, or wrists. R49's legs were noted to both be very stiff with limited ROM bilaterally. V6 extended R49's right leg slightly twice, and R49 complained of pain so V6 stopped. V6 made no attempt to try any of the other joints below the waist on either side of the body. R49's Minimum Data Set (MDS) dated [DATE] documented that R49 has impairment to both sides of the body of both the upper and lower extremities. R49's Care Plan dated 06/10/22 documented a problem areas, Requires 2 staff assist for transfers, poor weight bearing. Non ambulatory. Uses wheelchair for mobility. Noted spinal deformities with poor posture, limited ROM to all extremities, with a corresponding intervention, Complete voluntary movement/ROM assessment upon admission and review quarterly. Make recommendations to restorative nursing for appropriate placement in program as needed, and (R49) is not consistently active on her own. Some days she is very mobile and other days she does not initiate mobility on her own. An undated Restorative Program Guidelines Policy documented, Goals: Promote resident wellness and prevent decline and loss of independence whenever possible . Each resident on admission will be informally screened by admitting staff as to whether a resident will benefit from placement into a restorative/maintenance program all residents will be (re) assessed quarterly On 06/16/22 at 08:12am, V2 (Director of Nurses/DON) stated she is the staff member responsible for the facility's restorative nursing program. V2 acknowledged R49's lower legs are very stiff with limited ROM. V2 stated R49 does not have a formal program of restorative nursing at this time, so there is no documentation of her getting it. V2 acknowledged R49 needs to be reassessed regarding receiving ROM to prevent decline in level of functioning and contractures, and that she will assess R49 and develop a restorative nursing program for R49.

Based on observation, interview and record review, the facility failed to provide oxygen therapy humidification for 3 (R47, R38, R3) of 3 residents reviewed for oxygen therapy services in the sample of 31. Findings Include: 1. On 06/14/22 at 11:11 AM, R47 was observed wearing O2 (oxygen) via NC (nasal cannula) at 3L (liters). R47 stated she has resided in the facility for a couple weeks, and never wore O2 prior to admitting to the facility after having a fall and [CONDITION(S)] while at home. R47 stated her nose gets awfully dry and stated she has experienced minor nose bleeds which she has not reported to nursing staff. R47's O2 concentrator was observed as having a humidity bottle that was empty and dated 6/3. R47 is alert and oriented to person, place, and time. On 06/15/22 at 12:46 PM, R47 was observed as having a full humidity bottle in place on her O2 concentrator. R47 stated she asked the nurse to replace the empty bottle yesterday to help keep her nose from drying out, in which the nurse did. R47's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Treatment Sheet for June 2022 documents the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment is documented as being completed on 6/10/22, although the bottle observed in place on 6/14/22 was dated 6/3. 2. On 06/14/22 at 11:19 AM, R38 was observed utilizing O2 per NC at 4L. R38's O2 humidity bottle was observed as being empty and dated 6/3. R38 stated during the night last night he had a nosebleed that he didn't report to nursing staff. R38 was alert and oriented to person and place. On 06/15/22 at 10:43 AM, R38's humidity bottle on the O2 concentrator was observed as being empty with the bottle dated 6/3. R38 was observed as having O2 on per NC at 4L. On 06/16/22 at 09:22 AM, R38's humidity bottle on the O2 concentrator was observed as being empty with the bottle dated 6/3. R38 was observed as having O2 on per NC at 4L. R38's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R38's Treatment Sheet for June 2022 documents the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment is documented as being completed on 6/3/22, and next due on 6/10/22 with no initials present, indicating the treatment was not completed. 3. On 06/14/22 at 10:20 AM, R3 was observed with O2 on per NC at 2L. The humidity bottle connected to the O2 concentrator was observed as being empty. The date written on the bottle was 6/3. R3 was alert and oriented to person, place, and time. On 06/15/22 at 12:50 PM, R3 was observed as having a full humidity bottle on her O2 concentrator. R3 stated she had noticed it was empty, so asked for a new one yesterday, which the staff then replaced. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Treatment Sheet for June 2022 documents the treatments of, Change O2 tubing and Humidity bottle wkly and PRN. This is documented as being completed on 6/3/22 and next scheduled for 6/10/22 with the initials circled, indicating the change was not completed. On 06/16/22 at 09:50 AM, V2 (Director of Nursing) stated that the facility had experienced a supply shortage with obtaining humidity bottles for oxygen concentrators after changing companies. V2 stated the facility has changed back to their former supply company and will get the humidity bottles changed on the concentrators. V2 acknowledged that the humidity bottles were not changed weekly by nursing staff in accordance with R47, R38 and R3's Treatment Sheets. V2 confirmed the O2 humidity bottles should have been replaced when empty. The facility policy titled Oxygen Therapy-Mask and Nasal Cannula with a date of 3/17/22 states, Humidification is used in all cases unless ordered otherwise. The same policy goes on to state, Humidity bottles and tubing are changed at least every two weeks and dated by the nurse on duty.

Based on observation, interview, and record reviews the facility failed to prevent and/ or contain the spread of COVID-19 when the facility failed to establish a COVID-19 care unit to house residents with confirmed COVID-19 infection per the Center for Disease Control (CDC) guidelines and failed to ensure appropriate eye protection was worn by staff per CDC guidelines. These failures have the potential to affect all 48 residents residing at the facility. Findings include: 1. On 10/5/21 at 1:30 PM, V1 (Administrator) said that there are currently 48 residents residing at the facility. V1 said that there are currently 4 residents (R4, R13, R14, and R15) that have a confirmed COVID-19 infection at the facility and 3 residents (R2, R3, and R12) with confirmed COVID-19 infection that are hospitalized . V1 said that there have been a total of 11 residents that have tested positive for COVID-19 with the first residents testing positive on 9/17/21. V1 said that they have not been able to establish a COVID-19 unit because they do not have enough staff to run a COVID-19 unit. V1 said that when a resident tests positive for COVID-19 they leave that resident in their room. If the resident that tests positive has a roommate, they would move the roommate to a different room and they would be quarantined. On 10/5/21 at 12:26 PM, R13's room on the North Hall was observed to have a sign hanging outside the door stating Isolation Room. R13's room had a rack containing Personal Protective Equipment (PPE) hanging on the door. R13's door was open and R13 was observed sitting in the recliner in her room. There were no other rooms on the North Hall with Isolation Room signage. All resident's room doors on the North Hall were observed to be open. On 10/5/21 at 12:31 PM, R14's room located on the South Hall was observed to have a sign hanging outside the door stating isolation room. R14's room had a rack containing PPE hanging on the door. R14's room door was open and R14 was observed sitting in her recliner in her room. On 10/5/21 at 12:33 PM, R15's room located on the South Hall was observed to have signage on the door stating Isolation Room. R15's room had a rack containing PPE hanging on the door. R15's room door was open and R15 was observed sitting in her room watching TV. On 10/5/21 at 12:35 AM, R4's room located on the South Hall was observed to have signage on the door stating Isolation Room. R4's room had a rack containing PPE hanging on the door. R4's room door was open and R4 was observed sitting in her room. On 10/6/21 at 12:45 PM, V1 said that the residents that are positive now (R4, R13, R14, and R15) have been left in their assigned room and the door remains open due to safety reasons because they are at a high risk for falls or are confused. V1 said that the residents that are in the rooms next to the resident's that have a confirmed COVID-19 infection, that are NOT positive for COVID-19 infection, remain in their assigned rooms. The document titled Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R8 tested positive for COVID-19 on 9/17/21. The section titled Resident Census in R8's Electronic Health Record (EHR) documents that R8 remained in the same room located on the North Hall. The document titled Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R9 tested positive for COVID-19 on 9/21/21. The section titled Resident Census in R9's Electronic Health Record (EHR) documents that R9 resided in the room on the North Hall across from R8 when the positive COVID-19 result was received. The document titled Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R11 tested positive for COVID-19 on 9/21/21. The section titled Resident Census in R11's Electronic Health Record (EHR) documents that R11 was moved to a room on the North Hall next to his assigned room on the same hall on 9/21/21. The Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R13 tested positive for COVID-19 on 9/28/21. The section titled Resident Census in R13's Electronic Health Record (EHR) documents that R13 resided in the room across from R11 at the time the positive COVID-19 result was received. The document titled Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R3 tested positive for COVID-19 on 9/24/21. The section titled Resident Census in R3's Electronic Health Record (EHR) documents that R3 remained in the same room located on the South Hall. The Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R15 tested positive for COVID-19 on 9/26/21. The section titled Resident Census in R15's Electronic Health Record (EHR) documents that R15 resided in the room next to R3 at the time the positive COVID-19 result was received. The Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R2 tested positive for COVID-19 on 9/28/21. The section titled Resident Census in R2's Electronic Health Record (EHR) documents that R2 resided in the room across the hall from R3 and R15 on the South Hall at the time the positive test result was received. The CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes-Nursing Homes & Long-Term Care Facilities (updated 9/10/21) in the section titled Evaluating and Managing Personnel and Residents documents to identify space in the facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection. The guidelines further state The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. The facility policy titled Infection Control Policy and Procedure COVID-19 Preparedness Plan (revised 9/17/21) in the section titled Preventing the Spread of COVID-19 Within Our Campus section 2 part B(iii) states (the facility name) will designate the North Hall as the COVID-19 designated area when a positive COVID-19 case is identified. 2. On 10/5/21 at 1:30 PM, V1 (Administrator) said that there are currently 4 residents that have a confirmed COVID-19 infection at the facility and 3 residents with confirmed COVID-19 infection that are hospitalized . On 10/07/21 at 10:55 AM, V1 (Administrator) stated that she had told the staff that they could use their eyeglasses as eye protection with the N95 masks during the current outbreak in the facility. V1 stated that she didn't realize that it couldn't just be glasses. On 10/5/21 at 12:05 PM, V12 (Registered Nurse) said that when entering a residents room that is on isolation that all staff entering a residents room on isolation must wear a gown, gloves, and an N95 face mask. V12 said that if the staff wear eyeglasses they do not have to wear a face shield or goggles. V12 was observed at this time wearing eyeglasses. V12 was not wearing goggles or a face shield. On 10/05/21 at 12:20 PM, V5 (Housekeeping Supervisor) was observed wearing an N95 mask properly positioned and eyeglasses. V5 was not wearing goggles or face shield. V5 stated that they were told to wear eye covering. V5 said there was no specification that the eye covering had to be a face shield or goggles, just eye covering. On 10/05/21 at 1:00 PM, V10 (Resident Assistant/RA) was observed working with residents in the Heart to Heart program. V10 was wearing a N95 mask with eyeglasses and no face shield or goggles. V10 said that they were not told to wear goggles or face shields if they had glasses. V10 said they were told to wear the N95 mask and some kind of eye protection. On 10/05/21 at 1:10 PM, V8 (Certified Nurse's Aide) was observed wearing glasses without a face shield or goggles while training V9 (Resident Assistant) how to transfer a resident from a wheelchair to a recliner on the Heart to Heart unit. On 10/05/21 at 9:30 AM, 10/06/21 at 10:30 AM, and 10/07/21 at 10:45 AM, V11 (Registered Nurse) was observed working in the resident care area wearing a N95 mask and eyeglasses. V11 was not wearing goggles or a face shield while in the patient care area. On 10/6/21 at 10:55 AM, V12 was observed wearing eyeglasses. V12 was not wearing goggles or face shields. The facility policy titled Infection Control Policy and Procedure COVID-19 Preparedness Plan (revised 9/17/21) in the section titled Preventing the Spread of COVID-19 Within Our Campus part B section IV subpart l states Donning eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the resident room or care area. The CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/21) in the section titled Implement Universal Use of Personal Protective Equipment for HCP (Healthcare Personnel) it documents Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. A facility Resident Bed List Report dated 10/5/21 documents 48 residents living in the facility.

Based on interview, observation, and record review the facility failed to properly label medications and discard expired stock medications. The failure has the potential to affect all 56 residents residing in the facility. The findings include: 1. On 4/21/21 at 3:00 PM, there was a bottle with a pharmacy label with R24's name and a prescription for [MEDICATION(S)] 40mg twice a day in a drawer of the North Hall med cart. The prescription label documents the prescription was filled on 10/3/19 and to discard the prescription 10/2/20. 1/2 tab is handwritten on the bottle. The bottle contains whole and half tablets. On 4/21/21, V6 (Registered Nurse) said that R24 does have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 said that R24 no longer takes [MEDICATION(S)] 40mg twice a day as labeled on the bottle in the med cart. V6 said she is not sure why there isn't a bottle in the cart with the current prescription as it is ordered now. V6 said that R24 is administered ½ tablets from the bottle to equal his current dose of 20mg twice a day. R24's April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 4/21/21 at 3:05 PM, there was a light blue bottle of liquid medicine in the bottom drawer of the North Hall med cart. The front of the bottle is missing the label. There is no pharmacy label or name of the medication on the bottle. On 4/21/21, V6 said that she thinks the medication is the stock supply of Milk of Magnesia. The label on the back of the bottle documents the active ingredients of the contents as Aluminum Hydroxide, Magnesium hydroxide, and [MEDICATION(S)]. After reading the active ingredients on the label, V6 said that the medication is liquid antacid that can be given to the residents if need but there are no residents that are currently taking it at this time. There was an expiration date of June 2020 documented on the label on the back of the bottle. 3. On 4/21/21 at 3:08 PM, there was a stock card containing 62 tablets of Aspirin 325mg. There is an expiration date of February 2020 documented on the pharmacy label. 4. On 4/21/21 at 3:15 PM, the following medications were found to be stored in a locked cabinet in the medication storage room: 4 full stock cards containing a total of 360 tablets of Aspirin 325 mg labeled with an expiration date February 2020, 3 stock cards containing a total of 92 tablets of Tylenol PM labeled with an expiration date of February 2021, a stock card containing 45 tablets of Tylenol PM labeled with an expiration date of September 2020, and a bottle of Aspirin 325mg labeled with R40's name and an expiration date of August 2020. On 4/21/21, V6 said that R40 has a current order for Aspirin 325mg. On 4/21/21 at 3:35 PM, V6 said that it is the nursing staff's responsibility to go through the med cart and medication storage room and check to see if there are expired medications and discard or return them. On 4/22/21 at 3:20 PM, V2 (Director of Nursing) said that the expectation is for the nursing staff to go through the med carts once a month and discard or return expired medications to the pharmacy. V2 said that she doesn't think the medication carts or medication storage rooms have been checked in a while. The facility policy titled Medication Disposal (dated 2/25/14) documents all controlled and non-controlled medications will be returned to the pharmacy for disposal. The Resident Census and Conditions of Resident form (CMS-672) dated 4/20/21 documents there are 56 residents currently living in the facility.

Based on interview and record review, the facility failed to ensure a resident was free from mental abuse for one resident (R12) of one residents reviewed for abuse in the sample of 27. Findings include: On 04/20/21 at 11:36am, R12 was alert and oriented to person, place, time, and purpose. R12's right arm and hand were in an immobilizing device. R12 stated she has a history of having had a stroke which left her right side weak and impaired with little movement. R12 showed the Surveyor a healing skin tear to her right forearm and a large fading bruise to the right elbow. R12 stated the skin tear had occurred about a week ago, and the bruise had occurred several weeks ago. R12 stated both injuries occurred when staff transferred her from the wheelchair onto the toilet. R12 stated injuries to her right arm during toilet transfers are a fairly common occurrence. R12 was tearful and stated she fears having staff transfer her to the toilet because she is afraid she will get hurt. R12 stated she had told staff about her fears, and believed it to have been the Administrator, but acknowledged sometimes she has issues with her short term memory. R12 stated despite her verbalization of concerns to staff, nothing has changed. R12 stated staff have never tried any assistive devices to immobilize her right arm during transfers. R12 stated she is not sure of the names of the CNA's (Certified Nursing Assistants) who take care of her, except for V7 (CNA). R12 stated V7 is always in a hurry, and rushes R12. R12 stated V7 is not careful, and R12's right arm frequently gets injured. R12 stated she is not sure if V7 is doing this on purpose or not. R12 stated she is aware of other residents who will not let V7 work with them because of similar issues. R12 began crying and stated V7 makes her feel like a burden. On 04/20/21 at 2:16pm, this Surveyor notified V1 (Administrator) of the above conversation with R12, and that there was an allegation that V7 abused R12. On 04/20/21 at 3:30pm, V1 stated she talked to R12, who stated she didn't think staff were trying to hurt her. V1 stated she did not think further action was required. V1 stated she had not asked R12 about V7. V1 acknowledged that another resident will not allow V7 to take care of her Because (V7) is clumsy. On 04/21/21 at 11:02am, V1 clarified that she did not begin an abuse investigation, and V7 was not suspended. V1 stated she spoke with R12 after the surveyors left the previous day, on 04/20/21 at approximately 4:30pm, and V1 asked R12 if R12 felt V1 should begin an abuse investigation, and R12 said no, so she did not start an investigation. V1 then asked if the surveyor felt V1 should now start an investigation. On 04/21/21 at 12:55pm, V1 stated she had started an abuse investigation, and V7 had been suspended pending investigation. On 04/21/21 at 1:30pm, R12 stated V7 came to her room that morning and told R12 she had been accused of causing the bruise and skin tear to R12's arm, and V7 then stated to R12, We both know that didn't happen. R12 was tearful in discussing this. R12 stated she was not sure what V7's intent was in saying this. The Surveyor, with R12's consent, brought V1 into the room so she would be aware. V1 told R12 that she had suspended V7 and is investigating the matter. On 04/23/21 at 10:52am, V1 stated the investigation was ongoing. A Facility Abuse Management Policy and Procedures dated January 2021 documented, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. (The facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation .corporal punishment, and/or involuntary seclusion .(The facility) will thoroughly investigate all alleged violations(of abuse) and document appropriate actions. The following procedures will be followed to protect residents from harm during an investigation.: .The identified or probable involved employee is sent off duty immediately and will remain on administrative leave until the outcome of the investigation is determined. Licensed staff will assess the residents physical and emotional status The residents roommate will be interviewed, if the resident is interviewable. The residents family and physician will be contacted .potential witnesses will be identified and interviewed, including other residents .The Illinois Department of Public Health will be initially notified per phone of (the) alleged violation. This facility will protect residents from harm during the investigation of alleged abuse .This shall include but not be limited to .notification of law enforcement and/or legal authorities, as indicated The facility shall contact local law enforcement authorities in the following situations: Physical abuse involving physical injury inflicted on a resident by a staff member.

Based on interview, observation, and record review, the facility failed to implement its abuse policy by failing to initiate an abuse investigation for an allegation of staff to resident physical abuse, failed to protect a resident from abuse after an allegation of staff to resident abuse was made and failed to report an allegation of abuse to local law enforcement for 1 of 1 resident (R12) reviewed for abuse in the sample of 27., Findings include: On 04/20/21 at 11:36am, R12 was alert and oriented to person, place, time, and purpose. R12's right arm and hand were in an immobilizing device. R12 stated she has a history of having had a stroke which left her right side weak and impaired with little movement. R12 showed the Surveyor a healing skin tear to her right forearm and a large fading bruise to the right elbow. R12 stated the skin tear had occurred about a week ago, and the bruise had occurred several weeks ago. R12 stated both injuries occurred when staff transferred her from the wheelchair onto the toilet. R12 stated injuries to her right arm during toilet transfers are a fairly common occurrence. R12 was tearful and stated she fears having staff transfer her to the toilet because she is afraid she will get hurt. R12 stated she had told staff about her fears, and believed it to have been the Administrator, but acknowledged sometimes she has issues with her short- term memory. R12 stated despite her verbalization of concerns to staff, nothing has changed. R12 stated she is not sure of the names of the CNA's (Certified Nursing Assistants) who take care of her, except for V7. R12 stated V7 is always in a hurry, and rushes R12. R12 stated V7 is not careful, and R12's right arm frequently gets injured. R12 stated she is not sure if V7 is doing this on purpose or not. R12 stated she is aware of other residents who will not let V7 work with them because of similar issues. R12 began crying and stated V7 makes her feel like a burden. On 04/20/21 at 2:16pm, the Surveyor notified V1 of the above conversation with R12, and that there was an allegation that V7 abused R12. On 04/20/21 at 3:30pm, V1 stated she talked to R12, who stated she didn't think staff were trying to hurt her. V1 stated she did not think further action was required. V1 stated she had not asked R12 about V7. V1 acknowledged that another resident will not allow V7 to take care of her Because (V7) is clumsy. On 04/21/21 at 11:02am, V1 clarified that she did not begin an abuse investigation, and V7 was not suspended. V1 stated she spoke with R12 after the surveyors left the previous day, on 04/20/21 at approximately 4:30pm, and V1 asked R12 if R12 felt V1 should begin an abuse investigation, and R12 said no, so she did not start an investigation. V1 then asked if the surveyor felt V1 should now start an investigation. On 04/21/21 at 12:55pm, V1 stated she had started an abuse investigation, V7 had been suspended pending investigation, and IDPH had been contacted to report the allegation. On 04/21/21 at 1:30pm, R12 stated V7 came to her room that morning and told R12 she had been accused of causing the bruise and skin tear to R12's arm, and V7 then stated to R12 We both know that didn't happen. R12 was tearful in discussing this. R12 stated she was not sure what V7's intent was in saying this. This Surveyor, with R12's consent, brought V1 into the room so she would be aware. V1 told R12 that she had suspended V7 and is investigating the matter. On 04/21/21 at 03:05pm, V1 stated she had not contacted local law enforcement about the abuse allegation. On 04/23/21 at 10:52am, V1 stated the investigation was ongoing. A Facility Abuse Management Policy and Procedures dated January 2021 documented, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. (The facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation .corporal punishment, and/or involuntary seclusion .(The facility) will thoroughly investigate all alleged violations(of abuse) and document appropriate actions. The following procedures will be followed to protect residents from harm during an investigation.: .The identified or probable involved employee is sent off duty immediately and will remain on administrative leave until the outcome of the investigation is determined. Licensed staff will assess the residents physical and emotional status The residents roommate will be interviewed, if the resident is interviewable. The residents family and physician will be contacted .potential witnesses will be identified and interviewed, including other residents .The Illinois Department of Public Health will be initially notified per phone of (the) alleged violation. This facility will protect residents from harm during the investigation of alleged abuse .This shall include but not be limited to .notification of law enforcement and/or legal authorities, as indicated The facility shall contact local law enforcement authorities in the following situations: Physical abuse involving physical injury inflicted on a resident by a staff member.

Based on interview, observation, and record review, the facility failed to report an abuse allegation to local law enforcement for one resident (R12) of one residents reviewed for abuse in the sample of 27. Findings include: On 04/20/21 at 2:16pm, this Surveyor notified V1 (Administrator) of a conversation had with R12, and that there was an allegation that V7 (Certified Nursing Assistant) abused R12. On 04/20/21 at 3:30pm, V1 stated she talked to R12, who stated she didn't think staff were trying to hurt her. V1 stated she had not asked R12 about V7. V1 stated she did not think further action was required. On 04/21/21 at 11:02am, V1 clarified that she did not begin an abuse investigation, and V7 was not suspended. On 04/21/21 at 03:05pm, V1 stated she had not contacted local law enforcement about the abuse allegation. A Facility Abuse Management Policy and Procedures dated January 2021 documented, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property This facility will protect residents from harm during the investigation of alleged abuse .This shall include but not be limited to .notification of law enforcement and/or legal authorities, as indicated The facility shall contact local law enforcement authorities in the following situations: Physical abuse involving physical injury inflicted on a resident by a staff member.

Based on interview, observation, and record review, the facility failed to immediately initiate an investigation for an allegation of staff to resident physical abuse, and failed protect the resident from the staff member accused of abuse, for one resident of one resident (R12) reviewed for abuse in the sample of 27. Findings include: On 04/20/21 at 11:36am, R12 was alert and oriented to person, place, time, and purpose. R12's right arm and hand were in an immobilizing device. R12 stated she has a history of having had a stroke which left her right side weak and impaired with little movement. R12 showed the Surveyor a large fading bruise to the right elbow. R12 stated the bruise had occurred several weeks ago, when staff transferred her from the wheelchair onto the toilet. R12 stated injuries to her right arm during toilet transfers are a fairly common occurrence. R12 was tearful and stated she fears having staff transfer her to the toilet because she is afraid she will get hurt. R12 stated she had told staff about her fears, and believed it to have been the Administrator, but acknowledged sometimes she has issues with her short term memory. R12 stated she is not sure of the names of the CNA's (Certified Nursing Assistants) who take care of her, except for V7 (CNA) R12 stated V7 is always in a hurry, and rushes R12. R12 stated V7 is not careful, and R12's right arm frequently gets injured. R12 stated she is not sure if V7 is doing this on purpose or not. R12 stated she is aware of other residents who will not let V7 work with them because of similar issues. R12 began crying and stated V7 makes her feel like a burden. On 04/20/21 at 2:16pm, this Surveyor notified V1 (Administrator) of the above conversation with R12, and that there was an allegation that V7 abused R12. On 04/20/21 at 3:30pm, V1 stated she talked to R12, who stated she didn't think staff were trying to hurt her. V1 stated she did not think further action was required. V1 stated she had not asked R12 about V7. V1 acknowledged that another resident will not allow V7 to take care of her Because (V7) is clumsy. On 04/21/21 at 11:02am, V1 clarified that she did not begin an abuse investigation, and V7 was not suspended. V1 stated she spoke with R12 after the surveyors left the previous day, on 04/20/21 at approximately 4:30pm, and V1 asked R12 if R12 felt V1 should begin an abuse investigation, and R12 said no, so she did not start an investigation. V1 then asked if the surveyor felt V1 should now start an investigation. On 04/21/21 at 12:55pm, V1 stated she had started an abuse investigation, V7 had been suspended pending investigation, and IDPH had been contacted to report the allegation. On 04/21/21 at 1:30pm, R12 stated V7 came to her room that morning and told R12 she had been accused of causing the bruise and skin tear to R12's arm, and V7 then stated to R12 We both know that didn't happen. R12 was tearful in discussing this. R12 stated she was not sure what V7's intent was in telling her this. This Surveyor, with R12's consent, brought V1 into the room so she would be aware. V1 told R12 that she had suspended V7 and is investigating the matter. A Facility Abuse Management Policy and Procedures dated January 2021 documented, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. (The facility)affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation .corporal punishment, and/or involuntary seclusion .(The facility) will thoroughly investigate all alleged violations(of abuse) and document appropriate actions. The following procedures will be followed to protect residents from harm during an investigation.: .The identified or probable involved employee is sent off duty immediately and will remain on administrative leave until the outcome of the investigation is determined. Licensed staff will assess the residents physical and emotional status The residents roommate will be interviewed, if the resident is interviewable. The residents family and physician will be contacted potential witnesses will be identified and interviewed, including other residents .The Illinois Department of Public Health will be initially notified per phone of (the) alleged violation. This facility will protect residents from harm during the investigation of alleged abuse .This shall include but not be limited to .notification of law enforcement and/or legal authorities, as indicated The facility shall contact local law enforcement authorities in the following situations: Physical abuse involving physical injury inflicted on a resident by a staff member.

Based on observation, record review, and interview the facility failed to adequately supervise a resident to prevent falls during toileting for 1 of 4 residents (R2) reviewed for falls in the sample of 7. This resulted in R2 falling after toileting and sustaining a fractured right hip. Findings include: The physician's orders [REDACTED]. The Assessment for use of Personal Alarms, Motion Alarms and Chair Sensor Alarms is dated 11/19/12 and states that an alarm was to be placed on R2's wheelchair, recliner, bed, as well as a motion alarm on the bed. The Fall Risk assessment dated [DATE] indicates that R2 is a High Risk for falls based on a score of 18. ("Total score of 10 or above represents High Risk") E3 (Licensened Practical Nurse/Quality Assurance) stated on 01/03/13 at 2:10PM that R2 was admitted to the facility on [DATE] with a left hip fracture from a fall at home and that R2 was only in the facility a very short time, approximately 12 hours, and was sent back to the hospital. E3 stated that R2 was readmitted to the facility on [DATE] and fell in the facility on 12/01/12 and was sent to the emergency room . R2 sustained a right hip fracture from the fall and was readmitted to the facility on [DATE]. E3 stated that once alarms are placed, she continues the alarms upon the return to the facility and that the alarms were still being used when R2 returned to the facility on [DATE]. The Lutheran Care Center Resident Incident Report dated 12/01/12 at 5:40AM states that R2 was found laying on her right side just outside her bathroom on the floor. A skin tear was noted on her right arm and elbow and R2 complained of pain in the right hip. The Lutheran Care Center CNA (Certified Nurse Aide) Incident Report dated 12/01/12 has a drawing describing the area and position of the resident after the fall and states that R2 was last seen on the toilet, but does not give a written statement as to what occurred. E3 stated that she did interview the 2 CNA's who were in the room with R2 during the incident and was told that R2 was taken to the bathroom and placed on the toilet. E3 further stated that one of the CNA's left the room and went across the hall to assist another resident and the other CNA left the bathroom briefly to assist R2's roommate and that is when the fall occurred. On 01/03/12 at 12:45PM, E7 (CNA) and E8 (CNA) were observed transferring R2 from her wheelchair to her bed. A gait belt and two person assist was utilized in the transfer. E7 and E8 each confirmed that R2 did have alarms being utilized prior to the fall of 12/01/12. E7 stated that if a resident has an alarm, the resident is never to be left alone in the bathroom. On 01/03/13 at 2:15PM, E3 confirmed that if a resident has an alarm they are not to be left alone in the bathroom. E1 (Administrator) stated on 1/8/13,at 4 :00 P.M. that the facility does not have a specific policy to monitor residents who utilize alarms while using the toilet , but it is considered a facility protocol .