Every finding on record at Manor Court of Peoria

Based on interview, record review, and observation, the facility failed to notify a resident's physician/healthcare provider of significant elevated blood glucose results and weight gain for one resident (R1) of three residents reviewed for Physician notification of changes. Findings include:The facility's Weight Monitoring policy dated 9/6/2024 documents: Residents are weighed every month, unless physician's order or resident's condition indicates weighing should be done more frequently. Daily weights are only completed with a physician's order, including parameters for physician notification. The facility's undated Glucose Monitoring policy documents: If blood glucose level is above or below normal range, document the time the physician was notified.R1 is a [AGE] year-old resident admitted to the facility on [DATE] at approximately 11:40 am after right hip surgery. R1's admission diagnoses included: Fracture of lower end of right femur with artificial hip joint; Congestive Heart Failure; Type 2 diabetes Mellitus with Chronic Kidney disease stage 4; Myocardial Infarction; Ischemic Cardiomyopathy; and Cardiac Pacemaker.R1's Physicians Orders include: Accu Checks (fingerstick blood sugars) before Meals and at Bedtime, and Lantus Insulin 8 units subcutaneously at Bedtime, and liraglutide 0.6mg subcutaneously (DX: Type 2 Diabetes with diabetic chronic kidney disease) Once Daily; between 4:00am - 6:00 am. R1's medical record documents the following elevated blood sugar values obtained by Nursing staff: On 7/9/26 at 9:15 pm V6 RN/Registered Nurse obtained a blood glucose value of 400mg/dl (milligrams per deciliter) and at 10:50 pm a blood glucose value of 400mg/dl. On 7/10/26 at 9:25 am V8 LPN/Licensed Practical Nurse documented a blood glucose value of 368mg/dl. On 7/10/26 at 8:29 pm V10 RN documented a blood glucose value of 399mg/dl and on 7/11/26 at 6:19 am a blood glucose value 361mg/dl.There is no documentation of physician's notification of these elevated blood sugars in R1's medical chart, and no interventions identified addressing the elevated blood sugars.On 7/31/26 at approximately 3:00pm, V2 DON/Director of Nursing verified R1's high blood sugars obtained by Nursing staff on 7/9/26, V10/26 and 7/11/26 were not reported to the physician for orders or direction and the physician should have been notified right away.On 7/31/26 at 3:10pm, V8 LPN stated elevated blood sugars should be re-checked within 30 minutes to 1 hour and the resident should be monitored. If there is no sliding scale insulin coverage for blood sugars, the Nurse should notify the physician via on-call service for orders if it is after-hours or on weekends. V8 stated the physician should be notified of any alarm-level blood sugars.On 8/4/26 at 9:30 am V2 DON provided an SBAR/Situation, Background, Assessment, and Recommendation Communication Form, faxed to R1's physician's office on Saturday 7/10/26, by V10, dated 7/10/26 at 9:18pm that documents the blood glucose level of 399mg/dl, obtained at 9:15 pm, and states No Sliding Scale, Scheduled Lantus. There is no record of the SBAR Communication Form or response from the physician's office documented in R1's chart. R1's physician's office is closed on weekends and faxes aren't picked up until Mondays.R1's Discharge Instructions/admission Orders from the hospital dated 7/9/26 included an order for Daily Weights.R1's admission weight on 7/9/26 is documented as 230 pounds. R1's weight on 7/10/26 was documented as 236.4 pounds, indicating a 6.4-pound weight gain from 7/9/26 to 7/10/26. R1's physician was not notified of this weight gain. On 8/4/26 at 9:15 am V2 DON verified R1's physician wasn't notified of R1's documented 6.4-pound weight gain from 230 pounds on 7/9/26 to 236.4 pounds on 7/10/26, citing a 6.4 pound weight gain. V2 stated this weight gain was not flagged or noted as an issue, as it was not a 5 percent weight gain and therefore not an issue to report or act upon. On 7/31/26 at approximately 2:43 pm V7 Nurse Practitioner stated she sees and manages R1's physician's residents of the facility. V7 stated there should have been notification of the elevated blood sugars and significant 6.4-pound weight gain for a Congestive Heart Failure patient. V7 stated she was not on-call for the weekend of Friday 7/9/26 through Sunday 7/11/26, but there is always a physician available on call for Nursing staff concerns in the evenings and over the weekend. V7 stated she receives all communications to the on-call physicians by Nursing staff, even when she is not on-call, and she has no notifications by the facility to the on-call physician from 7/9/26 through 7/11/26. V7 stated, I now see five elevated blood glucose levels documented in R1's chart that should have been reported right away. V7 verified there were no documented notifications to the on-call physician by Nursing staff reporting R1's alarm-level blood sugars or the 6.4-pound weight gain.

Based on interview and record review the facility failed to effectively address a reported ongoing problem voiced by Resident Council. This failure has the potential to affect all 38 residents who reside in the facility. Findings include:The Facility's Grievances policy dated 6/1/22 documents The facility shall ensure that the resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Grievances shall be addressed by the facility and resolved in a timely manner. The Facility's Grievances policy documents Upon receipt of a grievance, the Grievance Officer, or designee shall complete an investigation of the concern as soon as possible and provide appropriate follow through is require. A written decision regarding the grievance shall be made available to the resident upon request. The Facility's Resident Council Minutes dated 7/24/25 documents Residents discussed CNA turning call lights off saying they will come back and not coming back to the room. Residents also discussed call light wait times being long. The minutes from 7/24/25 had an in-service sign in form titled Call Lights with signatures attached to it. The in-service was provided by V2 (RN/DON) The minutes from 7/24/25 had a Resident Council Response Form that listed suggestion/recommendation: call light wait times. No other documentation was on the response form. The Facility's Resident Council Minutes dated 11/28/25 documents Resident mentioned call light wait times are long. Residents stated that staff will put them on the toilet and they have to wait a long time until they get off. The minutes from 11/28/25 had an in-service sign in sheet titled Call Lights. The in-service was provided by V2 (RN/DON). The minutes from 11/28/25 had a Resident Council Response Form attached to it that listed Suggestion/recommendation: residents stated they are waiting long times and getting left in the bathroom. No other documentation was on the response form. The Facility's Resident Council Minutes dated 12/31/25 documents Residents stated that call light wait times need improvement. The minutes from 12/31/25 had an in-service sign in sheet titled Call Lights. The in-service was provided by V2 (RN/DON). The minutes had a Resident Council Response Form that documents Suggestion/recommendation: residents stated that the call light wait times are still an issue. No other documentation was on the response form. The Facility's Resident Council Minutes dated 01/28/26 documents Residents stated that call light wait times are an issue on 2nd shift the most. The minutes dated 1/28/26 had an in-service sign in sheet titled Call Light wait times. The in-service was provided by V2 (RN/DON). The minutes had a Resident Council Response Form attached that listed suggestion/recommendation: call light wait time/call light in reach. The Response Form documents Plan for Implementation: See in-service attached. The Facility's Resident Council Minutes dated 3/25/26 documents Residents stated that they sometimes hit the call light for help and a CNA will cut it off but never comes back to help until the resident hits the call light again. The minutes dated 3/25/26 had an in-service sign in sheet titled Call Light wait times. The in-service was provided by V2 (RN/DON). The minutes had a Resident Council Response Form that listed suggestion/recommendation: post meal response time and call light wait times. Plan for implementation see attached in-service. The Facility's Resident Council Minutes dated 4/29/26 documents Residents stated that sometimes the call lights are answered promptly and sometimes they are not. Residents state that it occurs every shift. The minutes dated 4/29/26 had multiple other in-services, policies and Resident Council Response Forms attached to it, none were in regards to call lights. The Facility's Resident Council Minutes dated 5/27/26 do not contain any documentation of concerns regarding call lights. The minutes 5/27/26 had an in-service sign in sheet titled Call Light wait times. This in-serviced was provided by V2 (RN/DON) The minutes had a Resident Council Response Form attached that listed suggestion/recommendation: call light wait times. Plan for Implementation: see attached in-service.During Resident Group on 7/8/26 at 10:00 AM R20 stated call lights are an on-going problem. R31 stated they (staff) come in and turn them off and then never come back. R31 stated they don't want to get in trouble for the light staying on too long so they come in, turn them off and say they will be right back but then they do not come back.' R20 stated No one except CNAs answer the call lights, I think other staff who don't should get in trouble. On 7/8/26 at 1:00 PM V2 (RN/DON) confirmed that the in-services that she was conducting when residents complained about call lights were all identical and was a review of the already in place call light policy. V2 (RN/DON) could not provide any documentation of any investigation or interviews with residents regarding their concerns. The Resident and Census Form dated 7/7/26 documents 38 residents currently reside in the facility.

Based on interview and record review, the facility failed to offer bedtime snacks to three residents (R20, R25, R31) of nine residents reviewed for snacks in a sample of 27.Findings include:The facility policy, Snack Procedure, adopted 10/21, documents that all residents should be offered a bedtime snack.1. R20's resident face sheet documents R20's date of admission to the facility was 10/16/25 and R20's diagnoses include but not limited to Type 2 Diabetes Mellitus with unspecified complications, Acute on Chronic Diastolic (Congestive) Herat Failure, Chronic Obstructive Pulmonary Disease, and Essential (Primary) Hypertension.R20's Minimum Data Set (MDS) assessment dated [DATE] documents R20 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact and documents R20 has Diabetes Mellitus.On 7/08/2026 at 10:10 AM, R20 stated, I am diabetic, and I don't get any bedtime snacks. I have never seen a snack cart at any time other than 10am and in the afternoon around 2. Sometimes I take extras so I can have something in my room in case my blood sugar drops at night.On 7/08/2026 at 3:38 PM, R20's medical record has no documentation that bedtime snacks were offered from 4/1/26 to 7/8/26.2. R25's resident face sheet documents R25's date of admission to the facility was 5/31/26 and R25's diagnoses include but not limited to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, and Essential (Primary) Hypertension.R25's Minimum Data Set (MDS) assessment dated [DATE] documents R25 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact and documents R25 has Diabetes Mellitus.On 7/07/2026 at 3:21 PM, R25 stated that she has never been offered a snack before bed, I didn't know they had them (snacks) that late. Snacks are offered in the morning around 10 and the afternoon around 2 or 3.On 7/08/2026 at 3:39 PM, R25's medical record has no documentation that bedtime snacks were offered from 4/1/26 to 7/8/26.3. R31's resident face sheet documents R31's date of admission to the facility was 8/27/21 and R31's diagnoses include but are not limited to Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease Stage 3a, and Essential (Primary) Hypertension.R31's Minimum Data Set (MDS) assessment dated [DATE] documents R31 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact.On 7/08/2026 at 10:00 AM, R31 stated, I have snacks because I bought them, they are not provided by the facility. The snack cart used to come around three times a day, but it hasn't been out on second shift/bedtime for at least a year I bet.On 7/08/2026 at 3:39 PM, R31's medical record has no documentation that bedtime snacks were offered from 4/1/26 to 7/8/26.On 7/08/2026 at 11:00 AM V8 and V4 (both Licensed Practical Nurses) and V7 (Registered Nurse) stated that snacks are passed by activity aid during the day and CNA (Certified Nursing Assistant) staff at bedtime, they don't think the CNA's have to document that they have offered them.On 7/08/2026 at 11:30 AM, V15 (Certified Nursing Assistant) stated that activities pass snacks at 10am and 2pm and on second shift the bedtime snacks are hit or miss if we get them and when we do, we do not document anywhere if they were offered.On 7/09/2026 at 9:27 AM, V2 (Director of Nursing) stated that there is no documentation to show bedtime snacks are being offered. V2 stated that there is no way to prove they are being passed except word of mouth.

Based on interview and record review, the facility failed to honor preferences for three residents (R20, R25, R34) of three residents reviewed for choices in a sample of 27.Findings include:On 7/07/2026 at 12:00 PM, During the lunch meal R20 and R25 voiced concerns about facility not doing therapeutic diets for diabetics and feel that there are not many options to choose from to follow one as they would like. R20 stated that if she picked and chose appropriate foods by what was offered or the alternatives available there would be days she wouldn't have anything to eat. R25 stated she would like to follow a diabetic diet as well but agrees the choices are too limited.On 7/07/2026 at 1:35 PM, V5 (Cook) stated, We do not do therapeutic diets like diabetic diets. We just do thickened liquids or mechanically altered diets like pureed and mechanical soft.On 7/07/2026 at 1:47 PM, V6 (Corporate Dietary Support) stated that the facility does not offer therapeutic diets, studies have shown that therapeutic diets in this environment are not therapeutic. V6 also stated that the residents are given a menu preference sheet and they can choose what they want to eat from that (referring to menu preference sheet). We also have alternatives they can choose from and always have fruit available. V6 confirmed that residents should be notified of the menu preference sheet.On 7/07/2026 at 1:50 PM, R20 and R25 both stated that they do not know what a menu preference sheet is and have been told to just pick what we want from the meal offered.On 7/07/2026 at 1:55 PM, V5 (Cook) stated that the menu preference sheet is just a copy of the weeks menus that residents can have if they ask for it (menu preference sheet) so they can write on it if they want something different.R20's resident face sheet documents R20's date of admission to the facility was 10/16/25 and R20's diagnoses include but not limited to Type 2 Diabetes Mellitus with unspecified complications, Acute on Chronic Diastolic (Congestive) Herat Failure, Chronic Obstructive Pulmonary Disease, and Essential (Primary) Hypertension.R20's Minimum Data Set (MDS) assessment dated [DATE] documents R20 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact and documents R20 has Diabetes Mellitus.On 7/07/2026 at 3:05 PM, R20 stated the facility does not let them have a diabetic diet. They tell us to just pick what we want off the menu but the choice for diabetics is very slim and like I said earlier somedays I would not be able to eat anything. There are alternatives available, but they consist of peanut butter and jelly sandwiches, grilled cheese, tomato soup or chicken noodle soup.On 7/08/2026 at 10:10 AM, R20 stated during resident council meeting, I am diabetic, and I don't get any bedtime snacks. The food they give me is so carb heavy and sugar heavy, I have to eat what I can.R25's resident face sheet documents R25's date of admission to the facility was 5/31/26 and R25's diagnoses include but are not limited to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, and Essential (Primary) Hypertension.R25's Minimum Data Set (MDS) assessment dated [DATE] documents R25 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact and documents R25 has Diabetes Mellitus.On 7/09/2026 at 9:27 AM, R25 stated, I wish I could get a diabetic diet. There are not many options to choose from.R34's resident face sheet documents R34's date of admission to the facility was 5/24/26 and R34's diagnoses include but are not limited to Unspecified Fracture of Upper End of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing (Primary), Unilateral Primary Osteoarthritis Left Hip (Admission), and Essential (Primary) Hypertension.R34's Minimum Data Set (MDS) assessment dated [DATE] documents R34 has a Brief Interview for Mental Status score of 15/15, indicating cognition is intact.R34's current care plan documents Resident Care Information intervention of preferred time up 7:00am, Bedtime: 8:00pm.On 7/07/2026 at 10:44 AM, R34 stated, the only concern I have is that I prefer to stay in bed until around 11AM then get up for the day for lunch but at least once a week they make me get up and out of bed before that. I'm ok with being woken up early but just not out of bed early. Today they came in here early and told me it was time to get up and I told them I would like to stay in bed but the CNA's (Certified Nursing Assistants), not sure which ones, stated that the nurse, (V2/Director of Nursing) said it was time to get out of bed now and since we are in here we are just going to get you up. I just went along with them because I didn't want to argue. R34 also stated that she has discussed this in her care plan meetings, and they tell her it is her choice if she wants to stay in bed.07/08/2026 2:27 PM V10 (Minimum Data Set/Care Plan Coordinator) stated, I speak with residents on admit and get their preferences then I care plan them. (R34) stated she wanted woken up at 7am but did not say anything about when she wanted to get out of bed. V10 also stated that (R34) did ask at the last care plan meeting if she wanted to stay in bed is she allowed to do so and was told, it's her choice.On 7/08/2026 at 3:00 PM, V2 (Director of Nursing) stated that the Certified Nursing Assistants/CNA's should listen to the residents in regards to choosing to stay in bed and then come to the nurse to report so they can go in and assess the situation to make sure there isn't something medical going on that makes them want to stay in bed such as pain for example. We do try to encourage residents to not stay in bed but it's their choice. V2 stated that she did not tell the CNA's that (R34) had to get out of bed, and they never reported it to her that (R34) wanted to stay in bed. V2 verified that resident preferences/choices should be honored by staff.

Based on record review and interview, the facility failed to provide R1's medical record to the Power of Attorney (POA) in a timely manner after a request was made for one (R1) of four residents reviewed for medical records requests in a sample of five.Findings include:The facility's Resident Rights Policy, dated 11/28/2017, documents Right to access/Purchase Copies of records. The resident has the right to access personal and medical records pertaining to him or herself. The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holiday); and the facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and two working days advance notice to the facility.R1's Illinois Statutory Short Form Power of Attorney for Health Care, dated 3/2/2004, documents V3 as R1's Power of Attorney.A written correspondence dated 10/14/25 at 8:33 AM from V3/R1's POA to V8/Business Office Manager documents Please provide an updated final billing statement through (R1's) last date of service to reflect the total amount due. Additionally, we request copies of all admission documentation, care plans, and the complete medical chart for our records. Thank you for your assistance. V8/Business Office Manager forwarded this same written correspondence to V2/DON (Director of Nursing) on 10/14/25 at 9:37 AM.A written correspondence dated 10/21/25 at 10:53 AM from V8/Business Office Manager to V3/R1's POA documents I gave your e (electronical) mail to (V2/DON) to get all that info for you.On 10/26/25 at 11:26 AM V3/R1's POA stated she had requested medical records via email to V8/Business Office Manager on 10/14/25. On 10/21/25 V3 stated V8 responded via email on 10/21/25 stating V8 had forwarded V3's request to V2/DON, and that V2 would get all the medical records requested for V3. V3 stated, I still have not received any of (R1's) medical records I have requested.On 10/29/25 at 12:50 PM V1/Administrator verified V3/R1's POA has not yet received medical records for R1 as requested. V1 stated, Our facility policy wasn't followed by (V8/Business Office Manager) and should have been. (V17/Medical Records) and I should have also been made aware of (V3) requesting (R1's) medical records not just (V2/DON). (V3) should have received (R1's) requested medical records within two business days of the request.

Based on observation, interview, and record review the facility failed to provide adequate supervision for cognitively impaired residents and keep hazardous disinfectant, alcohol gel, and hazardous odor eliminating spray secured and out of the reach of cognitively impaired, self-mobile residents for seven of seven residents (R1, R2, R3, R4, R5, R6, R7) reviewed for accidents in the sample of eight. These failures resulted in, on 2-14-25 R1, a cognitively impaired resident, obtaining a bottle of hazardous disinfectant (BNC-15), R1 ingesting the hazardous disinfectant, and R1 requiring emergency room services for treatment. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-10-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Housekeeping Policy dated 1-2023 documents, Purpose: To assure proper housekeeping and facility cleanliness and to have proper guidelines for housekeeping standards. Supplies and Equipment: Cleaning supplies should be kept in locked cupboards or rooms for the protection of the residents. The Chemical BNC-15 Manufacturer's Safety Data Sheet/MSDS dated 4-1-21 documents, (32 ounce) BNC-15 (Disinfectant). Hazard Statements: Harmful if swallowed. Causes severe skin burns and serious eye damage. Response: Immediately call a poison center or physician. If on skin: Rinse cautiously with water for several minutes. Take off immediately all contaminated clothing and shoes. Rinse with water or shower for at least 15 minutes. Ingestion: Rinse mouth. Do not induce vomiting. Storage: Store locked up. Toxicology Information: Skin Contact: Pain, redness, blistering, and possible chemical burn. Ingestion: Damage or chemical burns to mouth, throat and stomach, pain, nausea, vomiting and diarrhea. The Manufacturer's Fresh Odor Eliminators Spray Safety Data Sheet dated 11-9-22 documents, Precautions for Safe Handling: Store at normal room temperature away from reach of small children. Keep container closed. Ingestion: Do not induce vomiting unless directed to do so by medical personnel. Never give anything by mouth to an unconscious person. If potentially dangerous quantities of this material have been swallowed, call a physician immediately. Acute Toxicity: Exposure to solvent vapor concentrations from the component solvents in excess of the stated occupational exposure limits may result in adverse health effects such as mucous membrane and respiratory system irritation and adverse effects on the kidneys, liver, and central nervous system. Symptoms may include headache, nausea, dizziness, fatigue, muscular weakness, drowsiness, and in extreme cases, loss of consciousness. Repeated or prolonged contact with the preparation may cause removal of natural fat from the skin resulting in dryness, irritation, and possible non-allergic contact dermatitis. Solvents may also be absorbed through the skin. Splashes of liquid in the eyes may cause irritation and soreness with possible reversible damage. The Manufacturer's Spectrum Advance Hand Sanitizer Gel dated 7-23-24 documents, Storage: Keep containers tightly closed in a dry, cool and well-ventilated place. Store locked up. Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if applicable, and continue flushing. If symptoms persist, call a physician. Skin Contact: In the case of skin irritation or allergic reactions see a physician. Inhalation: Move to fresh air. Get medical attention immediately if symptoms occur. If breathing has stopped, contact emergency medical services immediately and give artificial respiration. Ingestion: If swallowed do not induce vomiting. Clean mouth with water and afterward drink plenty of water. Never give anything by mouth to an unconscious person. Consult a physician if necessary. Most important symptoms/effects: Burning sensation. Itching. Rashes. Hives. Coughing and/or wheezing. May cause breathing difficulties if inhaled. The facility's current Centers for Medicare and Medicaid Services Form 802 documents R1-R7 have the diagnoses of either Alzheimer's or Dementia and can either self-propel a wheelchair or self-ambulate. R1's current Face Sheet documents R1 is an [AGE] year-old with the diagnoses of Dementia, mild, with Anxiety, Dysphagia, Anxiety Disorder, Alzheimer's Disease, Insomnia, Restlessness, and Agitation. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Progress Notes dated 2-14-25 at 7:06 PM and signed by V3 (RN/Registered Nurse) document, This writer was sitting at nurses' station when another resident (R8) alerted me to Stop him (R1). (R1's) going to drink that. This writer then stood up to see (R1) sitting in wheelchair at nurses' station with lid to purple disinfectant cleanser labeled BNC-15 in hand and liquid coming from (R1's) mouth. (R1) then asked for water and the writer immediately notified (R1's) nurse (V4/LPN/Licensed Practical Nurse) and located MSDS (Material Safety Data Sheet) for BNC-15 in MSDS manual in cabinet at nurses' station and followed sheet advice for ingestion of BNC-15. R1's Progress Notes dated 2-14-25 at 7:31 PM and signed by V4 (LPN) document, (V3) came up to writer and stated that (R1) was possibly observed drinking cleanser. (R1) alert to baseline not showing any signs of distress at this time. (V2/DON/Director of Nursing) immediately notified. EMS (Emergency Medical Services) called for further evaluation and MSDS sheet for cleanser (R1) ingested sent with paramedics. All emergency contacts were attempted to be notified with no response. Voicemail left to return call back to facility. (R1) taken to (local) hospital. R1's emergency room Provider Notes dated 2-14-25 and signed by V9 (emergency room Physician) document, Chief Complaint: (R1) present with accidental ingestion. (R1) presents to ED (Emergency Department) from (facility) after drinking about six oz (ounces) of a cleaning chemical, BNC-15 one step disinfectant cleaner, about 30 minutes ago. Accidental ingestion of caustic alkali (highly corrosive bases that can cause severe burns and damage to living tissues). (R1) has a history of Dementia. Chemical was left sitting on the counter. (R1) did not appear to do this in an attempt to harm himself but did not understand what he was doing. Discharge Instructions: Four to six hours observation. Strict NPO (Nothing by Mouth). GI (Gastro-intestinal) referral for EGD (Esophagogastroduodenoscopy) per poison control. R1's Report of Incident dated 2-14-25 and signed by V1 (Administrator) documents, On 2-14-25 around 7:07 PM, (V1) was notified by (V2) that the nurse on duty reported to her that (R1) long-term resident with a history of advanced Dementia was reported by (R2) to have something (R1) shouldn't have. Nurse (V3) stated that she was sitting at the nursing station when another resident (R8) said to her You better take that from (R1). (R1) is going to drink it. The nurse reports to have looked over the countertop and saw (R1) sitting in his wheelchair with the lid of a bottle of disinfectant in his hand. The nurse states (R1) did not have the bottle of cleaner in his hand, only the sprayer lid, which she reports (R1) took out of his mouth. (V3) immediately notified the nurse assigned to (R1) and they immediately assessed (R1). (R1) has advanced Dementia, very poor hand dexterity, and is unable to communicate clearly, therefore the clinical decision was made to error on the side of caution and send (R1) to the ER for evaluation since no one could say with certainty that (R1) did not ingest the disinfectant. The bottle was around 90 percent full. EMT transported (R1) to (hospital) emergency room where they observed (R1) for around four and a half hours and then returned (R1) to the facility around 2:00 AM on 2-15-25 with orders to follow-up with gastroenterology. R2's MDS assessment dated [DATE] documents R2 is severely cognitively impaired. R3's MDS assessment dated [DATE] documents R3 is moderately cognitively impaired. R4's MDS assessment dated [DATE] documents R4 is severely cognitively impaired. R5's MDS assessment dated [DATE] documents R5 is severely cognitively impaired. R6's MDS assessment dated [DATE] documents R6 is severely cognitively impaired. R7's MDS assessment dated [DATE] documents R7 is severely cognitively impaired. R8's MDS assessment dated [DATE] documents R8 is cognitively intact. On 3-7-25 from 9:45 AM through 11:00 AM a two-ounce bottle of fresh odor eliminators spray was located on top of a handrail in the middle of the hallway and two eight-ounce bottles of spectrum advanced hand sanitizer gel were sitting on top of a cart located in the hallway outside of room [ROOM NUMBER]. There were no staff present during these times, and R2 was walking aimlessly up and down the hallway. On 3-7-25 at 11:10 AM R2 was at a cart located in the hallway outside of room [ROOM NUMBER]. There were two eight-ounce bottles of spectrum advanced hand sanitizer gel and a box of tissues sitting on top of the cart. R2 was standing in front of this cart, pulling tissues out of the box, and placing them on top of the cart. R2 then picked up one bottle of the alcohol gel and sat it back down. On 3-7-25 at 11:15 AM R8 was lying in bed. R8 stated, On (2-14-25) I saw (R1) take the lid off of a cleaner and drink the cleaner. (R1) had the nozzle to the cleaner in his other hand. I was yelling at the nurse look! Look! Look! (R1) is drinking that! The nurse sent (R1) to the hospital and (R1) had to have his stomach pumped. On 3-7-25 at 10:05 AM V4 (LPN) stated, I was (R1's) nurse and was not at the desk when (R1) had drank the disinfectant. Another nurse told me (R1) drank the disinfectant. (V3) came into to me and reported it to me. I called (V2/Director of Nursing) and asked how much (R1) drank and I told (V2) I was not sure. (R1) had the cap off the disinfectant and drank some of it. There was at least a half of a cup of the disinfectant missing out of the container. I called 911 and all emergency contacts. I found the Safety Data Sheet and sent it with EMS. (R1) was being observed the entire time until the ambulance came. I did not rinse (R1's) mouth or skin. I just observed (R1) until EMS arrived. On 3-7-25 at 10:30 AM V7 (RN) stated, (R1) is extremely confused and would not know if he was drinking a chemical. (R1) gets up late every day and self-propels his wheelchair around the facility, using his hands to propel the wheelchair. (R1) is not aware of his surroundings. On 3-7-25 at 10:40 AM V5 (Housekeeper) stated, For some reason (V6/RN) would always ask me for the BNC-15 disinfectant. There were several days before (R1) got ahold of the disinfectant that (V6) would get the disinfectant when I was not aware and leave the disinfectant on top of the nurses' desk. No staff would be around when the disinfectant was being left on top of the nurses' desk. Every time I would find the disinfectant, I would lock it up. I would tell (V6) the disinfectant must be locked up. I know residents can drink the cleaners. That is why the cleaners have to be locked up at all times. On 3-7-25 at 11:56 AM V10 (Housekeeping Supervisor) stated, (V6/RN) asked for a chemical that day and was refused the chemical BNC-15. (V6) would ask for this chemical frequently and was the only nursing staff that would ask for that chemical. (V6) worked that day and (V6) left the BNC-15 chemical on top of the nurses' station and did not lock the chemical back up. All chemicals are to be locked up at all times and the housekeeping cart is to be always visible to keep residents from getting to the chemicals. (R2) observes the housekeeping carts frequently and could try to open a housekeeping cart. Staff should always pay attention to their surroundings. On 3-7-25 at 12:10 PM V6 (RN) stated, On 2-14-25 I got the disinfectant (BNC-15) to clean up a spill that had happened on the nurses' desk and floor. I got busy that day and I forgot to lock the disinfectant back up after I used it. I got told that was part of the reason why I was terminated. On 3-7-25 at 1:00 PM V11 (R1's Family Member) stated, (R1) has no idea what he is doing and is not safe around chemicals. On 3-7-25 at 2:40 PM V3 (RN) stated, On 2-14-25 around 7:00 PM, I heard (R8) yelling, Stop him (R1)! Stop him! I saw (R1) had the top off the chemical BNC-15 and had the tube that goes down into the chemical in his mouth, licking the chemical off the tube. (R8) yelled, (R1) drank that! I saw a very light purple liquid in (R1's) mouth and running out of (R1's) mouth. The BNC-15 chemical is a purple color. The bottle had about four to six ounces missing out of it. I immediately told (V4) and (R1) was sent to the hospital. Whoever left the chemical on top of the nurses' desk should know better. All chemicals should be locked up at all times. On 3-7-25 at 2:30 PM V2 (Director of Nursing) confirmed that all chemicals should be always locked up. V2 also confirmed R1-R7 are cognitively impaired and either self-propel a wheelchair or self-ambulate throughout the facility. The Immediate Jeopardy started on 2-14-25 when V6 (RN/Registered Nurse) left a bottle of BNC-15 hazardous disinfectant unsecured on top of the nurses' desk and R1, a cognitively impaired resident, obtained the bottle of BNC-15, ingested the disinfectant, and required emergency room services for treatment. V1 (Administrator), V2 (Director of Nursing), and V13 (Regional Manager) were notified of the Immediate Jeopardy on 3-10-25 at 10:30 AM. On 3-12-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-10-25 department heads conducted a facility wide walk through to assure all chemicals and hazardous materials were securely stored and out of reach of the residents. On 3-12-25 this surveyor conducted a facility wide walk through to assure all chemical and hazardous materials were securely stored in the housekeeping carts, clean storage utility room, and out of reach of the residents. 2. On 3-10-25 a list of identified residents who are cognitively impaired and self-mobile was placed as the nurses' station by V2 (Director of Nursing). 3. On 3-10-25 all care plans of residents who are cognitively impaired and self-mobile were revised. 4. On 3-10-25 V1 (Administrator), (V2 (Director of Nursing), and V14 (Human Resource Director) in-serviced all staff on which residents are cognitively impaired and self-mobile, where to find the list that indicates residents who are cognitively impaired and self-mobile, proper securement of chemicals and all other hazardous materials, location of the SDS (Safety Data Sheets) and how to read a SDS sheet. All new employees will be in-serviced by V14 prior to their first shift. 5. On 3-10-25 an audit tool was developed and implemented by V1 to track compliance of proper storage of chemicals and all other hazardous materials. Completion Date: 3-10-25.

Based on record review and interview the facility failed to follow physician's order to follow-up with gastroenterology following a resident who ingested a hazardous chemical for one of seven residents (R1) reviewed for accidents in the sample of eight. Findings include: The facility's Special Needs policy dated 11-28-17 documents, To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. If necessary, the facility will assist residents in making appointments with a qualified person or facility and arranging for transportation to and from such appointments. The facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident. Medical conditions will be monitored and managed to prevent complications. The attending physician will assume responsibility for the overall care and treatment of the resident's medical conditions. RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the resident's physicians. R1's emergency room Provider Notes dated 2-14-25 and signed by V9 (emergency room Physician) document, Chief Complaint: (R1) present with accidental ingestion. (R1) presents to ED (Emergency Department) from (facility) after drinking about six oz (ounces) of a cleaning chemical, BNC-15 one step disinfectant cleaner, about 30 minutes ago. Accidental ingestion of caustic alkali (highly corrosive bases that can cause severe burns and damage to living tissues). (R1) has a history of Dementia. Chemical was left sitting on the counter. (R1) did not appear to do this in an attempt to harm himself but did not understand what he was doing. Discharge Instructions: Four to six hours observation. Strict NPO (Nothing by Mouth). GI (Gastro-intestinal) referral for EGD (Esophagogastroduodenoscopy) per poison control. R1's Progress Notes dated 2-15-25 at 1:08 AM and signed by V4 (LPN/Licensed Practical Nurse) document, (R1) arrived back from (local) hospital via AMT (Advanced Medical Transport). (R1) alert to baseline. Denies any pain at this time and ROM (Range of Motion) to baseline. (R1) has orders to follow-up with gastroenterology and to return (to emergency room ) if resident exhibits any symptoms. R1's Electronic Medical Record dated 2-14-24 through 3-7-25 documents no evidence R1's follow-up with gastroenterology or EGD being completed. On 3-7-25 at 1:00 PM V11 (R1's Family Member) stated, We (R1's Family) want (R1) to go to the gastroenterology follow-up to make sure (R1) does not have any internal injuries from the chemical. I am not sure why the facility has not made the appointment yet. On 3-7-25 at 2:30 PM V2 (Director of Nursing) stated, (R1's) follow-up appointment with gastroenterology was missed and did not get scheduled.

Based on interview and record review, the facility failed to ensure their antibiotic stewardship program was implemented. This failure has the potential to affect all 38 residents residing in the facility. Findings include: The facility's Antibiotic Stewardship policy (Revised 12/18/19) documents the following: It is the policy of the facility to follow an Antibiotic Stewardship program, including the core elements as outlined by the CDC (Center for Disease Control and Prevention). The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. Procedure: Antibiotic Stewardship is part of Infection Control Program, including standardized tools such as UTI (urinary tract infection) SBAR (situation, background, assessment, and recommendation) and McGreer Criteria. The facility will track antibiotic use daily. The facility will communicate with the physician(s) prescribing antibiotics with a Utilization report on a monthly bases and as needed. All nurses, upon hire and as needed, will be educated regarding proper assessment for infection prior to calling physician. The facility will ensure the pharmacy reviews all antibiotic usage for appropriateness. Antibiotic use will be calculated on a monthly basis for QAPI (quality assurance and performance improvement) purposes. The facility will monitor for all adverse reactions/outcomes related to antibiotic therapy. The facility will involve the laboratory in our QAPI meetings as applicable. Information gathered will be communicated to all staff. On 05/16/24 at 02:30 PM, V11 (Registered Nurse/Infection Preventionist) stated she took on the role of the facility's Infection Preventionist in December 2023. V11 stated that she does not have a log of resident infections, antibiotic use or employee illnesses to provide for review. V11 stated, We are supposed to follow McGreer's criteria. I am supposed to keep a log of antibiotic use, and it hasn't been done. Not all of the nurses are completing the form that is supposed to be completed for this, so forms are not being completed regularly and I have found some residents who were prescribed antibiotics, and I have had to complete the form after the fact. I am not logging any of it, so I have nothing I can show you. Antibiotic use was not discussed at the last two QA (Quality Assurance) meetings since I did not have the information compiled.' The facility's Daily Staffing Sheets (dated 04/29/24 - 05/12/24) document that V11 (Registered Nurse/Infection Preventionist) was assigned to work the floor providing direct resident care on nine of the 14 days. On 05/16/24 at 11:15 AM, V2 (Director of Nursing) confirmed that V11 does work on the floor often, It is not for her entire shift, but she does go work the floor when needed. V2 stated she was not aware that logs required for the facility's infection control program, specifically pertaining to resident infections/illnesses, antibiotic use, and employee illnesses was not being maintained, and stated it should have been. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 05/13/24 and signed by V1 (Administrator), documents 38 residents currently reside in the facility.

Based on interview and record review, the facility failed to perform infection surveillance regarding logging, tracking and trending of resident and employee illnesses and infections. This failure has the potential to affect all 38 residents residing in the facility. Findings include: The facility's Infection Control policy (12/17/19) documents the following: Infection Control Committee Members: Administrator, Director of Nursing, Infection Preventionist, Maintenance/Housekeeping Supervisor, Food Service Supervisor, Medical Director, and Facility Pharmacist. The Infection Control Committee: Shall be responsible for surveillance of any suspected or known nursing home potential infection, the review and analysis of actual infections, the promotion of a preventative and corrective program designed to minimize infection hazards. Also process surveillance and correction of infection potentials in all nursing facility departments. This policy also documents the following: The Infection Control Committee should do the following: Review system for reporting, evaluation and keeping records of infections among resident and personnel in order to provide an indication of the endemic level of all nosocomial infections, to trace the source of infection and to identify epidemic or potential epidemic situations; To accomplish our objectives, the committee shall meet on a quarterly basis and, when necessary, hold additional meetings to consider problems arising in this area of responsibility. This same policy documents, Data Collection by Surveillance: Person to be responsible for surveillance will be appointed by the Director of Nursing. This person will be responsible for gathering the (1) Who, (2) What, (3) When, (4) Where, and (5) How of the suspected infectious condition. Data to be collected will answer the above (5) requirements. General information may be obtained from the nurse's infection control sheet, obtaining the following data: Nursing staff will develop weekly reports on antibiotics, including review to ensure appropriate use of antibiotics; Residents with abnormal drainage or broken areas in the skin which may be media for infection, including surgical incisions; Residents complaining of upper respiratory difficulty which may be infectious in nature; Residents with indwelling catheters; Residents with IV's (intravenous access); Resident with gastro feeding tubes. From the information gathered, a visual observation of the resident should be made and evaluated. The above gathered information will be reviewed and compiled into numbers and types of infections. A report will be prepared with the total number, types, and severities or infection and will be submitted to the Infection Control Committee. The Infection Control Committee will review the information and try to establish a pattern of infection. Based on the information received, the Infection Control Committee will evaluate policies and procedures for the prevention and control of infections and recommend corrective measures when and where necessary. The surveillance data will be kept on file for future reference. On 05/16/24 at 02:30 PM, V11 (Registered Nurse/Infection Preventionist) stated she took on the role of the facility's Infection Preventionist in December 2023. V11 stated that she does not have a log of resident infections or a log of employee illnesses to provide for review. V11 confirmed that no infection logging, tracking or trending is being conducted at the facility. V11 stated, I do MDS (Minimum Data Set Assessments), Restorative, and I am also the Infection Preventionist. I did the Infection Preventionist training, but that's about it. I have not had the opportunity to start any of it. I have seen three different people in the roles for the Dietary Manager and Social Service Director, so I have been having to complete the areas of the MDS that they are typically responsible for. V11 confirmed that she is often pulled to work the floor providing direct resident care when there's a call in at the facility. V11 then stated although her portion of infection control and antibiotic use is supposed to be discussed at the facility's Quarterly Assurance Meetings, it has not been discussed at the past two meetings since she has been in the role as the Infection Preventionist. The facility's Daily Staffing Sheets (dated 04/29/24 - 05/12/24) document that V11 (Registered Nurse/Infection Preventionist) was assigned to work the floor providing direct resident care on nine of the 14 days. On 05/16/24 at 11:15 AM, V2 (Director of Nursing) confirmed that V11 does work on the floor often, It is not for her entire shift, but she does go work the floor when needed. V2 stated she was not aware that a log for resident infections and illness and an employee illness log was not being maintained and stated it should have been. The Long-Term Care Facility Application for Medicare and Medicaid form dated 05/13/24 and signed by V1 (Administrator), documents 38 residents currently reside in the facility.

Based on interview and record review, the facility failed to have a Practitioner Order for Life-Sustaining Treatment/ POLST in the Medical Record one resident (R191) reviewed for Advanced Directives in the sample of 24. Findings include: The Advanced Directives policy dated 2/2018 documents Policy: The facility shall support the resident's right to request, refuse and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Purpose: To ensure that the resident and/or representative has been informed and educated about the right to formulate an advance directive, and the facility's policy regarding these rights; and the resident has been assisted in exercising these rights; and the residents' choices regarding these rights have been incorporated into the treatment, care and services. Procedure: Staff will determine, at the time of admission, whether or not any advance directives are present, and make an effort to obtain pre-existing directives. Staff shall then ensure that they are placed in the resident's medical record. Pertinent facility staff and the physician shall be made aware of the existence of these directives. If no directives are in place, staff shall provide education, verbally and in writing, to the resident regarding their right to develop advance directives and to refuse medical or surgical treatment per State law. Assistance will be provided as necessary. Findings include: R191's current computerized medical record, documents R191 was admitted to the facility on [DATE] with a diagnosis of Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity (Primary), Permanent Atrial Fibrillation (Admission), Neuralgia and Neuritis, Other Lack of Coordination, Difficulty in Walking, Muscle Weakness (generalized), Muscle Wasting and Atrophy, Right Hand and Left Hands, Unsteadiness on Feet, Hyperlipidemia, Permanent Atrial Fibrillation, Parkinson's Disease, Hypothyroidism, Essential (Primary) Hypertension, and Heart failure. R191's MDS (Minimum Data Set) dated 5/16/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating R191 is cognitively intact. On 5/13/24 at 11:28 AM, there was no Advance Directive for R191 found in R191's Electronic Medical Record. On 5/14/24, V1/Administrator was asked what the code status was for R191. At 12:00 PM, V1 provided a Hospital discharge date d 5/10/24 for R191 that documents Shock OK, no compressions. Before V1 left the room, V1 was shown the Electronic Medical Record that documented R191 was a Full Code. V1 stated she did not know how that got put in the system. On 5/14/24 at 12:21 PM, V2/Director of Nursing stated that there has not been any paperwork signed by R191 or V4/R191's Power of Attorney for R191's Code Status. V2 also stated, Until there is paperwork signed the resident is a Full Code. I have nothing that pertains to the Code Status. On 5/14/24 at 12:35 PM, V3/Social Service Director stated that the POLST is signed when a resident is admitted . V3 stated she did not get the POLST signed when R191 admitted and V3 does not know what R191's Code Status is supposed to be. V3 also stated (R191's) cognition is fine but I didn't ask (R191) about her Code Status. On 5/14/24 at 1:01 PM, R191 stated, I thought they (the facility) already had it from the hospital. I don't want to have my ribs broke. I want a DNR (Do Not Resuscitate). V4/R191's Power of Attorney was in the room and stated, I would think you would want to be a Full Code, but it is your choice. V3/Social Service Director was also in the room and stated that there were other choices that could be made. V3 showed V4 the paperwork and the options. V4 stated to R191, You could do Full Code with selective treatments. R191 agreed and signed the paperwork. On 5/14/24 at 1:21 PM, V4 stated I was in here on Friday and was not asked about the code status. Then today I got a call (V4 pulled out her phone) at 11:24 AM, 11:31 AM, and 11:35 AM asking me to come in and sign the paperwork. On the third call I was yelling at them to stop harassing me and I would be in as soon as I could. If they had done this on Friday, they would not have to harass me. V4 also stated that R191 knows what she is doing and can make her own decisions. On 5/15/24, the facility provided R191's POLST dated 5/14/24, that was signed by R191 The POLST documents that R191 wants Cardiopulmonary Resuscitation with Selective Treatment. The POLST form was signed by R191's Primary Physician on 5/15/24.

Based on observation, interview and record review, the facility failed to ensure showers and nail care were provided for two of two residents (R4 and R191) reviewed for activities of daily living in the sample of 24. Findings include: The Personal Care of Residents policy dated 12/2002, documents It is the policy of the facility to provide a plan of personal care for residents. To provide that residents of the facility receive adequate care. Procedure: 1. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatment ordered by the physician. 2. Each resident shall have at least one complete bath and hair wash weekly, and as many additional baths and hair washes as necessary for satisfactory personal hygiene. 1. R4's current computerized medical record, documents R4 was admitted to the facility on [DATE] with a diagnosis of Chronic Kidney Disease, Stage 2 (mild)(Primary, Admission); Stiffness of Right and Left Shoulder; Other Reduced Mobility; Muscle weakness; Hereditary and Idiopathic Neuropathy; Tachycardia; Edema; Urinary Tract Infection; Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity; Pain; Mild Cognitive Impairment of Uncertain or Unknown Etiology; Venous Insufficiency (Chronic) (Peripheral); Essential (Primary) Hypertension; Peripheral Vascular Disease; Congenital Hypothyroidism with Diffuse Goiter; Hypothyroidism; Hyperlipidemia; Hypo-Osmolality and Hyponatremia. R4's MDS (Minimum Data Set) dated 4/9/24 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating R4 is cognitively intact. R4 has upper extremity impairment on both sides and requires partial assistance for showering and is occasionally incontinent of bowel and bladder requiring set up/cleanup assistance. On 5/15/24 at 1:23 PM, R4's fingernails were observed and had pink fingernail polish on them that was chipped. The fingernails were dirty and all different lengths. The shorter nails were uneven with some sharp, jagged edges. R4's index finger fingernails were the longest and had a dark brown, black debris adhered underneath them. On 5/15/24 at 1:23 PM, R4 stated, My fingernails are all different lengths. I'd like my fingernails shorter than what they are. They need to be cut. They are too long and break. I have hangnails that bother me. They put paint on my nails but don't cut them. I have asked but it doesn't get done. On 5/16/24 at 11:18 AM, V2/Director of Nursing stated that the Certified Nursing Assistants are responsible for nail care when showers are given unless the resident is diabetic. If the resident is a diabetic, then a nurse should cut the nails or there is a Podiatrist that comes to the facility. 2. R191's current computerized medical record, documents R191 was admitted to the facility on [DATE] with a diagnosis of Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity (Primary); Permanent Atrial Fibrillation (Admission); Neuralgia and Neuritis; Other Lack of Coordination; Difficulty in Walking, Muscle Weakness (generalized); Muscle Wasting and Atrophy, Right Hand and Left Hands; Unsteadiness on Feet; Hyperlipidemia; Permanent Atrial Fibrillation; Parkinson's Disease; Hypothyroidism; Essential (Primary) Hypertension; and Heart failure. R191's MDS (Minimum Data Set) dated 5/16/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating R191 is cognitively intact, has lower extremity impairment on both sides and requires partial assistance for showering. On 5/14/24 at 1:26 PM, R191 stated I would sure like to have a shower. On 5/14/24 at 1:27 PM, V4/R191's Power of Attorney (in R191's room) stated (R191) came in on Friday and still has not had a shower. On 5/15/24 at 12:43 PM, V2/Director of Nursing stated that R191 did not get a shower on Friday because R191 came in late. On 5/15/24 at 1:13 PM, R191 stated I finally got a shower last night after supper. I came in on Friday and had not had a shower for five days before that in the hospital. I didn't ask for one on Friday, but I did on Saturday, Sunday, and Monday. They said they were too busy. (V4/R191's Power of Attorney) came in yesterday (Tuesday) and insisted I get a shower. R191's Nursing Note dated 5/10/24 at 3:16 PM, documents R191 was readmitted the facility from the local hospital at 2:50 PM (Friday). The facility Shower Schedule (not dated) documents that R191 is to have a shower on day shift on Tuesdays and evening shift on Fridays.

Based on observation, interview, and record review the facility failed to complete psychotropic assessments prior to the use of antipsychotic medications, document the resident's response to non-pharmacological interventions to manage behaviors/symptoms, and to ensure the resident has behaviors that warrant the use of antipsychotic medications for two of three residents (R5, R22) reviewed for antipsychotic medication use with the diagnosis of Dementia or Alzheimer's Disease in the sample of 24. Findings include: The Facility's Psychopharmacologic Drug Usage Procedure dated 10/18/17, states Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. 1. On 5/13/24, 5/14/24, and 5/15/24, during random observations, R5 was confused but exhibited no behaviors. R5's electronic diagnosis list documents R5 has a diagnosis of Vascular Dementia. R5's current computerized Physician Orders document R5 receives Zyprexa (antipsychotic medication) 10 mg (milligrams) by mouth every morning and Zyprexa 2.5 mg by mouth every evening for a diagnosis of Bipolar Disorder. R5's Care Plan last updated 4/29/24, documents R5 has a diagnosis of Bipolar Disorder and takes Zyprexa twice a day. This same care plan does not document R5's target behaviors for the use of Zyprexa. R5's electronic medical record dated 1/1/24 through 5/15/24, does not document R5 has any behaviors to warrant the use of Zyprexa, a psychotropic medication assessment that was completed prior to initiating Zyprexa, or R5's response to non-pharmacological interventions. On 5/15/24 at 1:30 p.m., V8 (Certified Nurse Aide) stated R5 cusses and will hit at staff but not residents. V8 stated, (R5) only cusses at us or occasionally swings his arms when cares are being given. If you have a conversation with him, he is very pleasant. He has more behaviors in the late afternoon and evening time. On 5/15/24 at 1:35 p.m., V6 (Certified Nurse Aide) stated R5 has no behaviors that put him at risk for harming himself or another resident. V6 stated (R5) cusses a lot and he will get a little aggressive (with direct care staff) when providing cares. He doesn't want us to mess with him and wants to be left alone. Any other time he doesn't have behaviors. I think his cussing is just his normal way to talk. It's not really a behavior. It's just him. On 5/15/24 at 1:40 p.m., V7 (Certified Nurse Aide) stated R5 does not have any behaviors that put him at risk to harm himself or other residents. V7 stated R5, Really just cusses a lot. Not really at us, but in general. He will try swinging at staff when providing cares like toileting or getting him dressed. He's never aggressive with other residents. His behaviors are worse in the evening. I think it may be sundowners from his Dementia. 2. On 5/15/24 at 12:52 p.m., R22 was sitting in his wheelchair in the lounge. R22 was pleasant and talkative. R22 did not exhibit any negative behaviors. R22 watched television while peers around him participated in different activities. R22's electronic medical record documents R22 has a diagnosis of Vascular Dementia. R22's current computerized Physician Order Sheet documents R22 receives Seroquel (antipsychotic medication) 100 mg (milligrams) every morning and Seroquel 125 mg at bedtime for a diagnosis of Unspecified Psychosis. This same Care Plan does not document R22's target behaviors for the use of an antipsychotic medication. R22's MDS (Minimum Data Set) assessment dated [DATE], documents R22 has severely impaired cognition; no documented behaviors; and receives Antipsychotic medication on a regular basis. R22's electronic medical record dated 1/1/24 through 5/15/24, does not document R22 had any behaviors to warrant the use of Seroquel, a psychotropic medication assessment that was completed prior to initiating Seroquel, or R22's response to non-pharmacological interventions. On 5/15/24 at 1:00 p.m., V7 (Certified Nurse Aide) stated R22 had no behaviors to justify the use of an antipsychotic medication. V7 stated R22 was never aggressive or pose any harm to himself or others. On 3/15/24 at 12:40 p.m., V2 (Director of Nursing) stated the only behavior monitoring is done by the licensed nurses. V2 stated, The nurses monitor the resident each shift and if a behavior or side effect is noted, then they document the occurrence in the progress notes. There is no behavior tracking completed by the Certified Nurse Aides. We have no psychotropic medication assessment that we complete. I have not seen (R5 or R22) have behaviors to warrant the use of (antipsychotic medications). On 5/16/24 at 1:20 p.m., V1 (Administrator) stated the facility does not have a specific policy on Antipsychotic medication use.

Based on interview and record review, the facility failed to develop a Care Plan for two of 16 residents (R16 and R27) reviewed for care plans in the sample of 24. Findings Include: The Care Plan policy dated 6/1/22, documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. R16's current computerized medical record, documents R16 was admitted to the facility on [DATE] with a diagnosis of Non-Pressure Chronic Ulcer of Buttock with Unspecified Severity (Primary); Type 2 Diabetes Mellitus with Unspecified Complications; Chronic Obstructive Pulmonary Disease; Essential (Primary) Hypertension; Anxiety Disorder; Vascular Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Other feeding difficulties; Dysphagia, Oropharyngeal Phase; Transient Cerebral Ischemic Attack; Vascular Dementia, Mild, with Agitation; Malignant Neoplasm of Bladder; Complete Traumatic Amputation of One Left Lesser Toe. R16's MDS (Minimum Data Set) dated 3/24/24 documents a BIMS (Brief Interview for Mental Status) Score of 11/15, indicating moderate cognitive impairment. On 5/14/24 at 11:12 AM, R16 stated that he has lost weight but doesn't know why. R16's Dietician Note dated 5/8/2024 at 12:44 PM, documents that R16 has recent weight changes. Current weight at 159 pounds, a decrease of 25 pounds in the past three months. R16's current Care Plan has no mention of R16's recent weight loss. R16's weight log documents R16's weight on 3/20/24 was 177.2 pounds, and R16's weight on 5/8/24 was 158.8 pounds. This is a 18.4 pounds lost, 10.38 percent in three months. On 5/16/24 at 11:11 AM, V2/Director of Nursing verified there is no Care Plan in place for R16's weight loss. 2. R27's current computerized medical record, documents R27 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease with Late Onset (Admission); Essential (Primary) Hypertension; Gastro-Esophageal Reflux Disease without Esophagitis; Other Specified Diseases of Anus and Rectum; Chronic Kidney Disease, Stage 2 (mild); Overactive bladder; Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms; Pain, Unspecified; Vitamin D deficiency; Hyperlipidemia; and Generalized Anxiety Disorder. R27's MDS (Minimum Data Set) dated 3/21/24 documents a BIMS (Brief Interview for Mental Status) Score of 14/15, indicating R27 is cognitively intact. On 5/15/24 at 1:15 PM, R27 stated that he has scrotal pain often and is given an ice pack and pain medication. R27's Nursing Note dated 5/4/24 at 5:41 AM documents that R27 complained of 10/10 sharp, needle-like pain to an isolated superficial/fleshy area of his scrotum. R27 stated that these abrupt painful episodes occur frequently and intermittently. There were no evident visual issues nor any palpable abnormalities. There was no redness, but antifungal cream was applied, and Tylenol 650 mg (milligrams) PO (by mouth) was given. R27's Nursing Note dated 5/4/24 at 3:08 PM, documents that R27 complained of throbbing pain to his scrotal area this morning. Pain was rated at 8/10. As needed Tylenol was given with minimal effectives. An icepack was applied to the area, R27 states pain is now 0/10. Scrotal pain is chronic for R27. R27's Base Line Care Plan dated 3/15/24 documents Pain management as needed. A Comprehensive Care Plan was not developed for R27 addressing R27's pain. R27's Medication Administration Record dated 5/1-5/15/24 documents R27 has experienced back and scrotal pain 12 of 15 days ranging from 2/10 to 8/10. On 5/16/24 at 11:15 AM, V2/Director of Nursing verified there is no Care Plan in place addressing R27's scrotal pain.

Based on observation, record review, and interview the facility failed to assess a resident with a history of leaning forward in her wheelchair for safe positioning while in her wheelchair and failed to apply foot pedals to the resident's wheelchair prior to transporting the resident for one of three residents (R1) reviewed for falls with injury in the sample of three. These failures resulted in R1 leaning forward in her wheelchair and abruptly dropping her feet to the floor, which caused R1 to fall face first onto the floor out of her wheelchair, sustaining a three-centimeter laceration to the right forehead that was bleeding and required closure with six sutures in the hospital emergency room . Findings include: The facility's Resident Assessment policy dated 12/2002 documents, It is the policy of the facility to provide a means of determining the physical and mental needs of each resident. Purpose: To define the physical and mental abilities and disabilities and to determine the maximum potential or function of the individual. Evaluation defines needs, problems, approaches short and long-range goals. This composes the nursing care plan. Evaluation is continuous. It begins prior to admission and continues through discharge. 1. Evaluating Persons: Everyone in the resident's environment-physician, family, resident, nurse aide, nurse, activity department, dietary, social service, physical therapy, housekeeping, etc. 2. Importance of evaluation: Good evaluation will result in a good plan of care that effectively meets the resident's needs, thus enabling him/her to attain and maintain his/her maximum functioning level. Poor evaluation will result in a plan of car that does not fully meet the resident's needs, and the attainment of his/her maximum function may not be realized. 3. Nurse Role in Evaluation: Evaluates by communication and observation. Responsible for documentation of evaluation. 4. Areas of Evaluation: A. Physical function of body symptoms. 2. Muscle weakens, complaint of pain in muscles, tightness in ROM (Range of Motion), atrophy, contractures, spasm, rigidity flaccid. 3. Skeletal deformity, arthritic joints, contracture, limited ROM, posture. 12. Activities of daily living-transfer, washing and dressing, gait, and wheelchair mobility. The facility's Accident/Incident Preventions undated policy documents,Physical therapy evaluation as needed for muscle strengthening and balance. R1's Physician Order Report dated 12-5-23 to 1-5-24 documents R1 is an [AGE] year-old with the diagnoses of Dementia with Severe Anxiety, Restlessness, Agitation, and Muscle Weakness. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Fall Risk Assessment Tool dated 10-5-23 and signed by V6 (Care Plan Coordinator) documents R1 requires assistance or supervision for mobility, transfers, or ambulation, has a lack of understanding of one's physical and cognitive limitations, and is a high fall risk. R1's Progress Notes dated 12-6-23 at 9:03 AM and signed by V3 (RN/Registered Nurse) document, (R1) was being pushed down hallway from dining room from breakfast in her wheelchair. (R1) leaned forward while wheelchair was being pushed, resulting in (R1) falling out of chair and hitting head on floor. Dime sized laceration noted to middle of forehead, with moderate amount of blood noted. Pressure applied to forehead. Bleeding stopped. (R1) at baseline with cognition. AMT (Advanced Medical Transport) notified to take resident to ER (emergency room ) for eval (evaluation) and tx (treatment). This nurse attempted to call POA (Power of Attorney). No answer. Left message to call back. R1's Progress Notes dated 12-6-24 at 9:08 AM and signed by V6 (Care Plan Coordinator) document, Hospice notified of fall and sent out to (hospital). (R1's) right lateral forehead 2.5 (cm/centimeters) by 1 (cm) open area with exposed bone. Area cleansed and ice bag applied. R1's Emergency Department Notes dated 12-6-23 documents, Chief Complaint: (R1) was sitting in her wheelchair and fell forward, hitting her head. (R1) does have a laceration. (R1) is unable to provide any meaningful history. Indication: Presents with a frontal bone laceration. Laceration Repair: Topical anesthetic to forehead. Laceration three cm (centimeters). Six sutures applied. R1's Progress Notes dated 12-6-23 at 5:05 PM and signed by V7 (RN) document, (R1) returned from ED (Emergency Department) with six sutures to right side of forehead. No drainage noted. New order to remove sutures in 7-10 days. R1's IDPH (Illinois Department of Public Health) Final Investigation dated 12-11-23 documents, Incident Description: (R1) is a long-term resident in our facility. (R1) needs assistance from staff with ADLs (Activities of Daily Living). On 12-6-23 at 9:05 AM (R1) had a fall with injury in the hallway. The incident happened after breakfast when (R1) was wheeled down the hallway form the dining room. (V8/CNA/Certified Nursing Assistant) states (R1) was leaning forward and (V8) was bringing (R1's) shoulders back, (V8) got close to the nurse's station and (R1) fell forward and hit her head on the ground. (R1) was assessed immediately by nurses. Noted open area to forehead and moderate amount of blood. Pressure applied and bleeding stopped. One nurse stayed with (R1) while the other nurse made notifications to providers and POA. Order received to send to ER for evaluation and treatment. Staff in-serviced initiated immediately on safe transfers. (R1) returned in the building the same day at 5:05 PM. (R1) obtained six sutures. R1's Fall with Injury Investigation dated 12-6-23 documents, (V8) was pushing (R1) down the hall after breakfast. (R1) leaned forward and fell . (R1) wheelchair did not have footrest. Inservice staff: Wheelchair foot pedals store in the bag for easy access to staff. Foot pedals in place when transporting residents. The Facility's In-Service Education/Meeting Report dated 12-8-23 and instructed by V2 (Director of Nursing) documents direct care workers were in-serviced on ensuring every resident wheelchair needing to have foot pedals and wheelchair foot pedals needing to be in place when transporting residents. On 1-5-24 at 8:55 AM R1 was in a high back, padded, low, four-wheeled chair. R1 was leaning forward during this time and had her feet elevated on the chair's footrest. R1 had a linear pinkish-reddish three cm scab to the right side of her forehead. On 1-5-24 at 9:00 AM V3 (RN) stated, On 12-6-23 (V8/CNA) was pushing (R1) in her wheelchair from the dining room to the common area. (R1) put her foot down abruptly and fell forward out of her wheelchair onto her head. (R1) had a lot of bleeding and a laceration to the right side of her head. There was a lot of bleeding. I applied pressure to (R1's) laceration until the paramedics got to the facility and took (R1) to the emergency room . (R1) had to have stitches. When (V8) was pushing (R1) in the wheelchair, (V8) did not put foot pedals on (R1's) wheelchair which caused (R1) to put her foot down and fall out of the wheelchair. When (V8) was pushing (R1) she should have had foot pedals on her wheelchair. On 1-5-24 at 9:08 AM V8 (CNA) stated, On 12-6-23 I was pushing (R1) in her wheelchair from the dining room to the common area across from the nurse's desk. (R1) kept swinging her feet and leaning forward numerous times while I was pushing her. I kept grabbing (R1) by the shoulders and trying to pull her backwards. Once I got to about the nurses' station, (R1) put her feet down suddenly, leaned forward, and fell face forward out of her wheelchair onto the floor. (R1) hit her right side of her head and there was lots of bleeding A lot of staff responded immediately and pressure was applied to (R1's) head until the ambulance arrived. I did not put (R1's) foot pedals on her wheelchair that morning and (R1) did not have foot pedals on her wheelchair when I was pushing her down the hallway and should have had foot pedals on her wheelchair. I could not find (R1's) foot pedals that morning. I was educated later by (V2/Director of Nursing) that (R1) should have foot pedals on her wheelchair at all times to prevent (R1) from falling out of the wheelchair. I feel really bad and know I should have put wheelchair pedals on (R1's) chair to prevent her from falling. When (R1) was leaning forward, I should have stopped pushing her and got other staff to assist me in re-positioning (R1). It was common for (R1) to lean forward in her wheelchair all the time even before the day she fell . On 1-5-24 at 10:48 AM V9 (Lead PTA/Physical Therapy Assistant) stated, I know (R1) is non-verbal. If (R1) was leaning forward in her wheelchair prior to the fall on 12-6-23, (R1's) wheelchair positioning should have been assessed by nursing or therapy to try and figure out why (R1) is leaning and to prevent (R1) from falling out of her wheelchair and sustaining an injury. (R1) leaning could have been indicative of (R1) needing to relieve pressure from her bottom, or (R1) trying to walk. No one knows because an assessment was not done. If a resident is not self-propelling a wheelchair, then the resident should have wheelchair pedals on to prevent the resident from putting their foot down while staff are pushing them in their wheelchair. The staff (V8) that was pushing (R1) on 12-6-23 should have stopped pushing (R1) in the wheelchair when she noticed (R1) was leaning forward and swinging her feet. On 1-5-24 at 11:35 AM V10 (CNA) stated, I have worked here awhile and (R1) has always leaned forward while in her wheelchair. I do not know why (R1) leans forward. After (R1's) fall, (V2) in-serviced us (staff) that residents are to have foot pedals on their wheelchairs whenever we are pushing the residents in their wheelchairs. On 1-5-24 at 11:05 AM V2 (Director of Nursing) stated, I in-serviced staff right after (R1) fell out of her wheelchair on 12-6-23. (V8) should have put foot pedals on (R1's) wheelchair when she was transporting (R1) to prevent (R1) from putting her feet down while being pushed in the chair. (R1) has never been assessed by staff or referred to therapy for wheelchair positioning to address (R1) leaning forward in her wheelchair.

Based on record review and interview the facility failed to update fall care plans with newly developed fall interventions for two of three residents (R1 and R3) reviewed for falls in the sample of three. Findings include: The facility's Care Plan Policy dated 6-1-22 documents, It is the policy of this facility to develop and implement a base line care plan, a comprehensive person-centered care plan, and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's mental, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility's Accident/Incident Preventions undated policy documents, When a resident has been identified as a high risk for accidents/incident, interventions will be put into place per the individual resident assessment and care plan. 1. R1's Fall with Injury Investigation dated 12-6-23 documents, (V8/CNA/Certified Nursing Assistant) was pushing (R1) down the hall after breakfast. (R1) leaned forward and fell . (R1) wheelchair did not have footrest. Inservice staff: Wheelchair foot pedals store in the bag for easy access to staff. Foot pedals in place when transporting residents. R1's Fall Care Plan dated 12-6-23 through 1-5-24 does not include the newly developed fall intervention dated 12-6-23 to ensure foot pedals are in place when transporting R1 and to ensure R1's foot pedals are stored in a bag when not in use for easy access of staff. 2. R3's Event Report dated 12-27-23 documents, (R3) was found on the floor in sitting position with wheelchair slightly behind (R3) unlocked. Interventions: Educated CNAs on being sure if (R3's) wheelchair is by her bedside it needs to be locked. R3's Fall Care Plan dated 12-27-23 through 1-5-24 does not include the newly developed fall intervention dated 12-27-23 to ensure R3's wheelchair is locked whenever placed by R3's bedside. On 1-5-24 at 11:05 AM V2 (Director of Nursing) stated, (R1's) fall interventions to ensure (R1's) foot pedals were stored in a bag when not in use, and to ensure (R1's) foot pedals were in place when being transported is not on (R1's) fall care plan. (R3's) fall interventions to ensure (R3's) wheelchair is in the locked position when placed beside (R3's) bed is not on (R3's) fall care plan. On 1-5-24 at 11:15 AM V6 (Care Plan Coordinator) stated, I am responsible for updating fall care plans. I have not had time to update (R1 and R3's) fall care plans with their newly developed fall interventions after (R1's) 12-6-23 fall and (R3's) 12-27-23 fall.

Based on observation, interview, and record review the facility failed to ensure a call light was within reach for four of four residents (R1, R2, R3, R4) reviewed for accommodation of needs in the sample of ten. Findings include: The facility's Call Light policy dated 01/2004 documents, Objective: To respond to resident's request and needs. Offer further services before leaving resident's room. Be sure call light is within reach before leaving the room. 1. On 10-6-23 from 7:30 AM through 8:35 AM R1 was sitting in her wheelchair in her room. During this time R1's call light was on the floor next to the right side of R1's wheelchair. R1 stated, I cannot reach my call light on the floor. 2. On 10-6-23 from 7:30 Am through 8:35 AM R2 was lying in bed on her right side. During this time R2's call light was laying on the floor beside the right side of R2's bed and out of R2's reach. On 10-6-23 at 8:40 AM V9 (CNA/Certified Nursing Assistant) stated, The last time someone took care of (R2) was on third shift around 6:00 AM. I am not sure how long (R2's) call light has been on the floor. 3. On 10-6-23 from 7:20 AM through 8:15 AM R3 was lying in bed on his back. During this time R3's call light was laying on the floor on the right side of his bed and was out of R3's reach. R3 stated, My call light is always on the floor. On 10-6-23 at 8:20 AM V7 (CNA) and V8 (CNA) both stated they were taking care of R3 and had not attended to R3 since 6:00 AM when they made rounds with the third shift CNA's. V7 verified that R3's call light should not have been on the floor. On 10-7-23 from 2:25 AM through 4:00 AM R3 was lying in bed on his back. During this time R3's call light was laying in the chair next to R3's right side of the bed and out of R3's reach. On 10-7-23 at 4:00 AM V17 (CNA) verified that R3's call light was not within his reach from 2:25 AM through 4:00 AM. 4. On 10-6-23 from 7:25 AM through 8:35 AM R4 was lying in bed on her back and R4's call light was on the floor behind her headboard. At 8:35 AM R4 stated, I do not know how long my call light was on the floor. All I know is I could not reach it. The staff never brush my teeth. On 10-6-23 at 8:35 AM V7 (CNA) stated that R4's call light was on the floor and was unsure how long the call light was on the floor. On 10-6-23 at 12:55 PM V1 (Administrator) stated, All resident call lights should be within reach at all times.

Based on observation, interview, and record review the facility failed to provide oral care/personal care to four of four residents (R1, R2, R3, and R4) reviewed for ADL (Activities of Daily Living) Care in the sample of ten. Findings include: The facility's Personal Care of Residents policy dated 12/2002 documents, Purpose: To provide that residents of the facility receive adequate care. Each resident shall have proper daily personal attention and/or care including skin, nails, hair, and oral hygiene. 1. R1's Care Plan dated 1-6-23 documents R1 needs one assistance of staff for mouth care. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is moderately cognitively impaired and requires extensive assistance of one staff physical assist for personal hygiene. On 10-6-23 at 8:35 AM R1's natural teeth were yellow stained. R1 stated, The staff never help me brush my teeth. I do not think I have toothpaste. 2. R2's Care Plan dated 9-9-23 documents, Mouth Care: Perform oral care before breakfast and before bed. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is severely cognitively impaired and requires extensive assistance of one staff physical assist for personal hygiene. On 10-6-23 from 8:35 AM through 8:40 AM V9 (CNA/Certified Nursing Assistant) provided morning care to R2. R2 had no false or natural teeth. R2 did not have mouthwash or swabs at the bedside or in her restroom. During these cares V9 did not provide oral cares to R2. On 10-6-23 at 8:40 AM V9 stated, I am not sure if (R2) has teeth or not. I do not think (R2) has teeth. (R2) does not have mouthwash or swabs in her room. 3. R3's Care Plan dated 9-20-23 documents staff must assist R3 with oral hygiene. R3's MDS assessment dated [DATE] documents R3 is moderately cognitively impaired and requires limited assistance of one staff of physical assist for personal hygiene. On 10-6-23 at 8:20 AM V7 (CNA/Certified Nursing Assistant) and V8 (CNA) both provided personal cares to R3 and then transferred R3 from the bed to the wheelchair. During these personal cares V7 and V8 did not provide oral care to R3. On 10-6-23 at 8:20 AM V7 stated she thinks third shift should be brushing R3's teeth. On 10-6-23 at 9:45 AM R3 stated, I never get my teeth brushed. 4. R4's MDS assessment dated [DATE] documents R4 is moderately cognitively impaired and requires extensive assistance of two staff physical assist for personal hygiene. On 10-6-23 at 8:35 AM V7 (CNA/Certified Nursing Assistant) and V8 (CNA) provided incontinence cares and grooming to R4. R4's natural teeth had food debris between the teeth R4 had two long curly facial hairs to the left side of her chin. V7 and V8 then transferred R4 from the bed to the wheelchair. V8 proceeded to push R4 in her wheelchair from her room down to the dining room. Both V7 and V8 did not provide oral cares during this time. V7 (CNA) stated, Third shift should be brushing (R4's) teeth. (R4) does not have a toothbrush, toothpaste, or mouth wash. (R4) has been back from the hospital for a couple days and I am not sure if anyone has gotten her a toothbrush or toothpaste or shaved her. On 10-6-23 at 8:40 AM R4 stated, The staff never brush my teeth. I prefer to be shaved and do not like having hair on my face. On 10-6-23 at 10:45 AM R4 still had two long curly facial hairs to the left side of her chin. (V8) stated, (R4's) hairs need to be shaved.

Based on observation, interview, and record review the facility failed to provide a resident with pureed meat as ordered by the physician for one of four residents (R2) reviewed for meals in the sample of ten. Findings include: The facility's Pureed to Liquid Consistency Diet Order Procedure dated 05/2020 documents, All foods pureed to liquid consistency should be smooth with no lumps or particles. All food on the pureed to liquid consistency diet should be prepared in the kitchen. R2's Physician's Order Report dated 9-6-23 through 10-6-23 documents R2's diet order as puree. On 10-6-23 at 9:30 AM R2 was sitting in a high back padded wheelchair in the dining room. R2 was feeding herself a bowl of mechanical soft (crumbled pieces) of a sausage patty with gravy on top. V7 (CNA/Certified Nursing Assistant) was sitting next to R2 and stated, (R2) is supposed to have a pureed diet. (R2) always gets mechanical soft sausage. On 10-6-23 at 9:40 AM V9 (CNA) stated (R2) is always served mechanical soft sausage. On 10-6-23 at 10:00 AM V12 (Dietary Manager) stated, (R2's) sausage is mechanical soft and should have been pureed. When (V11/Cook) warmed the sausage up it turned the sausage into crumbles. (V11) should have ensured (R2's) sausage was pureed. On 10-6-23 at 12:55 PM V1 (Administrator) stated the machine blade used to make pureed meat was broken and that is why the meat was not pureed.

Based on observation, interview, and record review, the facility failed to ensure monitoring of high temperature sanitization of dishes. This failure has the potential to affect all 38 residents who receive meals from the kitchen. Findings include: Facility Policy/Dish Machine High Temperature Recording Procedure dated (Adopted 08/19) documents: Hot Water is used for sanitizing in High Temperature Dish Machines, not chemical sanitizer. Therefore, it is important to record wash temperatures and final rinse temperatures Three Times per Day. ABC: After all, three meals, before you wash meal dishes, Check and record dish machine wash and final rinse temperatures. Procedure: 1. Record temperatures on a High Temperature Dish Machine Temperature Log. 2. Goal temperatures are located on the metal plate located on the front of the dish machine. Appropriate temperatures are as follows: Wash Temperature: 150-160 degrees F. Final Rinse Temperature: 180 degrees or higher. 3. Do not wash dishes from meals until you have checked the dish machine temperatures. Staff will test the dish machine periodically with 180-degree Fahrenheit test strips for accuracy. On 5/16/23 at 10:20am, V15 (Dietary Aide) was putting dirty breakfast dishes through the high heat dish machine. At that time, V15 stated he had not put test strip through the machine yet I didn't get here till 9 (am). V15 then placed a 180-degree test strip on a whisk and put it through the dish machine. The strip turned from blue to orange, the dish machine displayed digital temperature display of 156 degrees. Two Dish Machine Test Strip Logs were displayed on the bulletin board directly behind the dish machine. One of the logs had two dates 4/22/23 and 4/23/23 with strips attached. The High Temperature Dish Machine Temperature Log dated May 2023 did not have following dates entered at the time the dishwasher test strip was tested : May 8, 9th not entered for entire day. May 10th missing dinner (lunch) and supper. May 11th missing supper. May 15th missing dinner and supper. On 5/18/23 at 9:50am, V5 (Dietary Manager) stated V15 was only checking the digital temperature display on the dish machine, he was not used to using the strips. V15 should have checked and confirmed the digital temperature with the test strip prior to putting dishes through the dish washer. He's been educated now on the correct process. V15 stated both logs should include the digital display as well as the test strip result for each meal service. Resident Census and Conditions of Residents dated 5/16/23 indicates there are 38 residents in the facility who receive meals from the kitchen.

Based on interview and record review, the facility failed to follow an Antibiotic Stewardship Program, this failure has the potential to affect all 39 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Policy dated 12/18/19 documents It is the policy of the facility to follow an Antibiotic Stewardship Program, including the core elements as outlined by the CDC (Center for Disease Control). The Facility Antibiotic Stewardship policy documents Antibiotic use will be calculated on a monthly basis for QAPI (Quality Assurance and Performance Improvement). The CDC (Center for Disease Control) website documents As of November 2017 each (long term care) facility must have had an antibiotic stewardship program in place as part of their infection prevention and control program. The Antibiotic Stewardship program must include the use of antibiotic use protocols and a system to monitor antibiotic use. The Facility's unfinished Core Elements of Antibiotic Stewardship in Nursing Homes adopted 11/28/2017 documents Tracking Monitoring Antibiotic Prescribing, use and Resistance: 7. Does your facility monitor one or more measures of antibiotic use a. Adherence to clinical assessment documentation (signs/symptoms, vital signs, physical exam findings) b. Adherence to prescribing documentation (dose, duration, indications) c. Adherence to facility-specific treatment recommendations d. Performs point prevalence surveys of antibiotic use e. Monitors rates of new antibiotic starts/1,000 resident days f. Monitors antibiotic days of therapy/1,000 resident days. January 2023 through May 2023 Monthly Antibiotic/Infection Control Logs did not include clinical symptoms for antibiotic use, no calculations for QAPI (Quality Assurance and Performance Improvement), no point prevalence surveys to include where the resident's infection originated, and no facility specific treatments started prior to antibiotic use. On 5/18/23 at 10:00 AM, V4 (LPN/Infection Preventionist) confirmed that the monthly infection control logs from January 2023-May 2023 do not include signs and symptoms of infections. V4 confirmed monitoring did not include any point prevalence surveys to include if the infection was acquired in the community, hospital or the facility. V4 stated We have no facility specific treatments or recommendations for physicians. I just track what is prescribed. I don't know how to calculate antibiotic use for QAPI meeting. I don't feel like I have been trained very well on what I am doing. The Resident's Census and Condition Report dated 5/16/23 documents 39 residents currently reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure all employees were screened upon entrance to the facility for COVID-19 (Coronavirus Disease 2019) every day before their scheduled work shift, failed to remove a symptomatic employee from work immediately and quarantine this employee, and failed to isolate residents who are unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. These failures resulted in V4 and V6 (CNAs/Certified Nursing Assistant) continuing to provide direct care to all of the residents within the facility for three to five days after exhibiting symptoms of COVID-19 and eventually testing positive for COVID-19. These failures have the potential to affect all 30 residents within the facility, which is located in a high COVID-19 transmission area according to the Centers for Disease Control and Prevention (CDC) COVID-19 data tracker. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-15-22, the facility remains out of compliance at a severity Level II as the facility continues to screen employees prior to their shift for COVID-19, test employees and residents who are symptomatic of COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, isolate residents who are not up to date with the COVID-19 vaccination or are unvaccinated and have direct contact with anyone who is COVID-19 positive, in-service staff concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees, and continue to audit employee screen forms for accuracy and to ensure staff are not working while symptomatic. Findings include: The Resident Census and Conditions of Residents, CMS (Centers for Medicare & Medicaid Services), Form 672 dated 6-7-22 documents 30 residents reside within the facility. The CDC COVID-19 Data Tracker dated 6-2-22 through 6-7-22 documents COVID-19 Community Level of contracting COVID-19 as High for Peoria County, Illinois (the county the facility is within). The facility's COVID-19 policy dated 1-19-22 documents, The infection control program at this facility recognizes novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage, and isolation of potentially infectious residents. Screening: All people upon entering the facility must self-screen at designated area for signs and symptoms of COVID-19 based on the most current recommendations of CMS, CDC, and State Department of Public Health. Documented screening forms will be kept for at least 30 days. Facility will use the CDC COVID-19 Data Tracker Website to carefully monitor the color-coding, which depicts county community transmission levels. Staff who are not moderately to severely immunocompromised may return to work after ten days or may return to work after seven days if asymptomatic or have mild to moderate symptoms that are improving and fever-free for 24 hours. Must have one negative test completed within 48 hours before work shift begins or rapid antigen test prior to shift. Exposure Definition: Exposure is defined as being within six feet of a person with confirmed COVID-19 infection or having unprotected direct contact with infectious secretions or excretions of the person with confirmed COVID-19 infection. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 2-2-22 documents, Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: A positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus), symptoms of COVID-19, or close contact with someone with [CONDITION(S)]-CoV-2 infection or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2. The facility's COVID-19 Screening Checklist for Visitors, Vendors, and Employees dated 1-7-22 documents that if any visitor, vendor, or employee is experiencing any of the following symptoms, they are to be restricted from entering the building: fever, chills, fatigue, diarrhea, congestion, runny nose, nausea/vomiting, headache, sore throat, new/worsening cough, muscle/body aches, new loss of taste of smell, and shortness of breath, or difficulty breathing. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus) Spread in Nursing Homes & Long-Term Care Facilities Website dated February 2, 2022 documents, Manage residents who had close contact with someone with [CONDITION(S)]-CoV-2 Infection: Residents who are not up to date with all recommended COVID-19 (Coronavirus Disease 2019) vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP (Health Care Personnel) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure if they do not develop symptoms. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. On 06/06/22 at 2:00 PM, V6 (Certified Nursing Assistant/ CNA) stated, I was not tested for COVID-19 until 6-3-22 when I tested positive for COVID-19. I started feeling sick on Monday (5-30-22) and for the rest of the week. I had a runny nose, chills and a mucousy cough. I brought a space heater to work because I was chilling so bad. I did not do the pre-screening for COVID before my shifts. The screening is located in another building and that door is locked, so I cannot get to the screening. I took care of all of the residents in the building every day I worked last week. On 06/06/22 at 2:15 PM, V4 (Certified Nursing Assistant/CNA) stated, I tested myself for COVID-19 using a (Brand Name Covid 19 Antigen Rapid Test) rapid test on Saturday (6-4-22) around 10:30 AM when I went out to my car for break. The test came back positive. I had worked since 2:00 AM that morning. I worked until 2:00 PM that day and worked Sunday from 2:00 AM through 2:00 PM and worked Monday starting at 4:00 AM. On Monday (6-6-22) around 8:05 AM V2(Director of Nursing/DON) came in and swabbed me for COVID-19 again, and the rapid test V2 obtained was positive for COVID, so I was sent home. I had worked with all of the residents on every shift that I worked on Saturday, Sunday, and Monday. V6's Time and Attendance Employee Punch History dated 5-30-22 through 6-2-22 documents V6 worked on 5-30-22 from 10:03 PM through 6-1-22 at 6:08 PM, 6-1-22 from 10:15 PM through 6-2-22 at 6:20 AM, and 6-2-22 from 10:10 PM through 6-3-22 at 6:08 AM. V4's Time and Attendance Employee Punch History dated 6-4-22 through 6-6-22 documents V4 worked on 6-4-22 from 2:04 AM through 2:03 PM, 6-5-22 from 1:58 AM through 2:01 PM, and 6-6-22 from 3:59 AM through 8:05 AM. The facility's COVID-19 Screening Checklists for Visitors, Vendors, and Employees dated 5-1-22 through 6-4-22, do not include any screening checklists for V6 (CNA). The CDC COVID-19 webpage dated 5-24-22 documents: Vaccines: Primary Series: Doses of Pfizer-BioNTech given three to eight weeks apart. Fully Vaccinated: Two weeks after final dose in primary series. Boosters: One booster for most people at least five months after the final dose in the primary series. Second booster of either Pfizer-BioNTech or Moderna COVID-19 vaccine for adults ages [AGE] years and older at least four months after the first booster. Up to Date: Immediately after getting all boosters recommended for you. The facility's COVID-19 Vaccine Resident Tracking documents R8's initial COVID-19 vaccination two doses were finished on 10-30-21 and R8 refused the Pfizer boosters. This same tracking documents R30 refused the COVID-19 vaccinations. On 6-6-22 at 8:45 AM and 6-7-22 at 3:10 PM, R30 was lying in his bed in his room. R30 was not in isolation at these times. R30 stated he does not want the COVID-19 vaccination. On 6-6-22 at 12:10 PM, R8 was self-propelling her wheelchair up the hallway and into her room. R8 stated that she does not want a COVID-19 booster and has not been in isolation. R8 was not in isolation at this time. On 6-7-22 at 3:10 PM, R8 was in bed in her room. R8 was not in isolation at this time. On 06/06/22 at 2:30 PM, V2 (DON) stated, I did not know that V4 had symptoms of COVID-19, or that V4 was not screened for COVID-19 symptoms prior to her shifts. V4 should not have worked while having symptoms of COVID-19. All employees are supposed to screen themselves for COVID-19 prior to working their shifts and immediately upon entering the facility. R8 and R30 have not been put in isolation. The Immediate Jeopardy was identified on June 7, 2022 at 11:08 AM. The Immediate Jeopardy began on May 30, 2022, when the facility failed to screen, remove and test an employee V6 (CNA) for COVID-19 who was having active symptoms of COVID, resulting in V6 continuing to work with all residents from 5-30-22 through 6-3-22 (when V6 tested positive for COVID-19). V1 (Administrator) and V19 (Regional Nurse) were notified of the Immediate Jeopardy on 6-8-22 at 11:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) and V2 (Director of Nursing) were in-serviced on 6-8-22 by V19 (Regional Nurse) on COVID-19 testing requirements, screening employees prior the start of their shift, testing employees immediately who have symptoms and sending them home following the CDC/IDPH Guidance, ensuring COVID-19 POC (Point of Care) and PCR (Polymerase Chain Reaction) testing supplies are available for all licensed nurses on each shift and, ensuring licensed trained staff are performing the COVID-19 Testing and reviewing the manufacturer's directions for COVID-19 testing, and ensuring all residents who are unvaccinated or not up to date with COVID-9 boosters were isolated immediately after exposure to COVID-19. 2. V1 and V2 initiated all staff in-servicing on 6/7/2022, concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees. Staff not currently working will be in-serviced prior to the beginning of their next scheduled shift. 3. Staff were actively screened prior to their scheduled shift by the front desk receptionist during normal business hours and by a licensed nurse assigned to the long hall on off hours including on second shift, third shift, and the weekend. Employees reporting or exhibiting any symptoms of COVID-19 were tested and sent home immediately. 4. Adequate testing supplies were located for licensed nurses to access during all shifts in the nurse's medication preparation room. 5. All licensed nurses were trained on the testing kits manufactures guidelines on how to appropriately use the POC (Point of Care) antigen rapid testing device, including when to follow-up with PCR test. 6. Employees are to report to the nurse immediately upon the onset of any signs or symptoms that occur during their shift and will then be COVID-19 tested , sent home, and the licensed nurse will report this or anyone testing positive to V1 and V2. 7. All residents who are unvaccinated or not up-to-date with the COVID-19 vaccinations were placed in isolation after being exposed to COVID-19. 8. V2 completed an audit on 6-7-22 and 6-8-22 to ensure that staff currently working were not symptomatic for COVID-19. 9. Facility wide testing was completed on 6-7-22 and no residents tested positive. One employee in dietary tested positive, who did not have a high- risk exposure to any resident and was sent home immediately. 10. All screening forms were being reviewed by the front desk receptionists or licensed nurses at the time of completion. On 6-9-22 at 2:00 PM, R30 was self-propelling up the hallway in her wheelchair and R8 was lying in bed. Neither R8 nor R30 were in contact/droplet isolation precautions. Due to R8 and R30 not being placed in isolation precautions as stated in the facility's abatement plan, the facility's abatement plan was not completely executed by 6-8-22 as documented by the facility. On 6-13-22 from 9:45 AM through 10:15 AM, V30 (Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant) and V33 (Housekeeper) stated that they had not been educated or in-serviced regarding anything within the past two weeks including COVID-19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. On 6-14-22 from 5:05 am to 5:15 am, V22 (Registered Nurse/RN) could not reiterate any education provided by Administrative staff in the last week and V37 (Agency Certified Nursing Assistant) and V38 (Cook) stated they had not received any education or in-servicing regarding COVID -19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. Based on observation, interview, and record reviews conducted on 6-16-22 the facility completed all measures on the abatement plan to remove the immediacy by 6-15-22.

Based on record review and interview, the facility failed to test an employee who had symptoms of COVID-19 immediately, failed to follow the COVID-19 rapid tests manufacturer's recommendations for accurate testing, failed to ensure COVID-19 testing supplies were readily available for staff to obtain testing on the designated testing days, and failed to utilize trained licensed staff to obtain the staff's COVID-19 tests. These failures resulted in one positive COVID-19 staff member V6 (Certified Nursing Assistant/CNA) working with residents due lack of testing supplies readily available upon entrance to the facility, and then testing positive for COVID-19. This also resulted in another staff V4 (Certified Nursing Assistant/CNA) continuing to provide direct care to all of the residents for two days after a nurse failed to follow the rapid COVID-19 test manufacturer's recommendations by not waiting the allotted time to complete a COVID-19 test resulting in the nurse erroneously reading the result as negative. These failures have the potential to affect all 30 residents within the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-15-22, the facility remains out of compliance at a severity Level II as the facility continues to screen employees prior to their shift for COVID-19, test employees and residents who are symptomatic of COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, in-service staff concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees, in-service all licensed nurses on the testing kits manufacture's guidelines on how to appropriately use the antigen rapid testing device, and continue to audit employee screen forms for accuracy and to ensure staff is not working while symptomatic. Findings include: The Resident Census and Conditions of Residents, CMS (Centers for Medicare & Medicaid Services), Form 672 dated 6-7-22 documents 30 residents reside within the facility. The facility's Infection Control Communicable Disease Testing policy dated 3-15-22 documents, The facility shall conduct testing of residents and staff for the control or detection of communicable disease in the following situations: The facility is experiencing an outbreak. The facility is directed by the department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, pandemics, or epidemics. COVID-19 Testing: c. Facility may utilize rapid point of care tests if available and appropriate. Trained licensed staff will be utilized to obtain the tests. Routine testing for unvaccinated facility staff only will be based on the extent of the virus in the community using the level of community transmission in the past week. High (red)-minimum of twice a week testing. Facility staff will include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents. Facility will prioritize those individuals who are in the facility on a weekly basis. Any staff that has a fever or exhibit symptoms will be tested . The (Brand Name) COVID-19 Antigen Rapid Test Manufacturer's Instructions dated 12/2021 for use document, A positive result must show both a c (control) line and a t (test) line. A positive result means that [CONDITION(S)] antigens from COVID-19 were detected and the individual is positive for COVID-19. Persons who test positive should self-isolate and seek follow up care with their Physician or healthcare provider as additional testing and public health reporting may be necessary. The t line may be faint and is evidence of a positive test. The (Brand Name) COVID-19 Card Rapid Test Manufacturer's Instructions dated 12/2020 document, Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. False negative results can occur if test results are read before the 15 minutes. On 06/06/22 at 2:00 PM, V6 (Certified Nursing Assistant/CNA) stated, I was supposed to test myself for COVID-19 last Thursday (6-2-22) at 10:00 PM but there were no rapid COVID tests available for me to test. All of the tests were locked up in V2's (Director of Nursing/DON) office. I worked that night from 10:00 PM through 6:00 AM (6-3-22). V2 came in at 6:00 AM on Friday (6-3-22) and I tested positive for COVID. I was sick all last week. I started feeling sick on Monday (5-30-22) and for the rest of the week. I had a runny nose, chills and a mucousy cough. I brought a space heater to work because I was chilling so bad. On 06/06/22 at 2:15 PM, V4 (Certified Nursing Assistant/CNA) stated, I tested myself for COVID-19 using a (Brand Name Covid 19 Antigen Rapid Test) rapid test on Saturday (6-4-22) around 10:30 AM when I went out to my car for break. That test requires three drops of solution. The test came back positive. I had worked since 2:00 AM that morning. I took the test into V3(Licensed Practical Nurse/LPN) and showed her it was positive. V3 took a different rapid test and re-tested me and (V3 told me it was negative and to go ahead and work. I worked until 2:00 PM that day and worked Sunday (6-5-22) from 2:00 AM through 2:00 PM and worked Monday (6-6-22) starting at 4:00 AM. On Monday (6-6-22) around 8:05 AM, V2 (DON) came in and said that the test V3 swabbed me with (on 6-4-22) had a positive result. V3 (LPN) had put my test result card in V2's office box. V2 noticed the test was positive and had me re-test. The rapid test V2 obtained on me was positive for COVID, so I was sent home. I had worked with all of the residents on every shift I worked on Saturday, Sunday, and Monday. I have had the Pfizer COVID vaccine and I have been boosted. V6's (CNA) Time and Attendance Employee Punch History dated 5-30-22 through 6-2-22 documents V6 worked on 5-30-22 from 10:03 PM through 6-1-22 at 6:08 AM, 6-1-22 from 10:15 PM through 6-2-22 at 6:20 AM, and 6-2-22 from 10:10 PM through 6-3-22 at 6:08 AM. V4's (CNA) Time and Attendance Employee Punch History dated 6-4-22 through 6-6-22 documents V4 worked on 6-4-22 from 2:04 AM through 2:03 PM, 6-5-22 from 1:58 AM through 2:01 PM, and 6-6-22 from 3:59 AM through 8:05 AM. On 06/06/22 at 1:45 PM, V3 (LPN) stated, V4 took a rapid COVID test out to her car and tested herself on (6-4-22). V4 brought the test to me showing me she had a faint line indicating she was positive for COVID. V4 had used the (Brand Name) antigen rapid COVID test. The staff are able to use either the (Brand Name A) rapid test or the (Brand Name B) COVID antigen rapid test. I took a (Brand Name B) test and re-tested V4. I waited five minutes to read the test and it was negative. I told V4 she was negative and let her stay at work. I took V4's test and placed it in a biohazard bag and placed it into V2's (DON) office box. I put all COVID tests that are done over the weekend in V2's box. The staff are able to test themselves for COVID. On 6/7/22 at 10:20 a.m., V10 (Housekeeper) stated she is tested for COVID-19 twice a week, and she is allowed to swab herself and wait about 15 minutes for results. On 6/7/22 at 10:30 a.m., V11 (Certified Nursing Assistant/CNA) stated she is tested for COVID-19 on Mondays and Thursdays, and she swabs herself. V11 stated, Whoever the nurse is will let us know if there is an issue with the test, like if it's positive. On 6/8/22 at 10:36 a.m., V12 (Certified Nursing Assistant/CNA) stated she is tested for COVID-19 twice a week and she swabs herself. V12 stated, I wait about five minutes for the results (of the COVID-19 test) then go to the floor. On 6/7/22 at 10:25 AM, V9 (Certified Nursing Assistant/CNA) stated, Right now, we are testing two times a week due to having some positive cases. I get here between two and four in the morning, and I get off at two in the afternoon. I am due to test today and I normally do that whenever V2 (DON) gets here. She is here now but I have not tested today. V2 will usually send a message and let us know when are to go to her office and test. When I am tested , I swab myself, and then V2 confirms the results. On the weekends, the on-duty nurse gets the test for me, and I swab myself and then the nurse verifies the results. On 06/06/22 at 2:30 PM, V2 (DON) stated, I did not know that V4 (CNA) had tested herself and was positive. V4 should have gone home as soon as, she was positive. I also did not know that (V3) did not do the COVID rapid test right by waiting 15 minutes before reading the result. When I got to work, I noticed (V4's) COVID test had a line showing it was positive, so I had (V4) do another test on that following Monday and it was positive. (V4) should not have worked while having symptoms of COVID-19 and while testing positive for COVID-19. (V6) did not have a COVID-19 rapid test available for her to test herself, and I live over 45 minutes away from the facility and was not going to come in to get a test for her. The employees are supposed to test every Monday and Thursday. The Immediate Jeopardy was identified on June 7, 2022 at 11:00 AM. The Immediate Jeopardy began on June 2, 2022, when the facility failed to have COVID-19 tests readily available to test V6 for COVID-19, as per the facility's scheduled test days to test facility staff, resulting in V6 continuing to work with all residents and testing positive for COVID-19 the following morning on June 3, 2022, and V4 continuing to work with residents for two days after testing positive for COVID-19 on June 4, 2022. V1 (Administrator) and V19 (Regional Nurse) were notified of the Immediate Jeopardy on 6-8-22 at 11:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) and V2 (Director of Nursing/DON) were in-serviced on 6-8-22 by V19 (Regional Nurse) on COVID-19 testing requirements, screening employees prior the start of their shift, testing employees immediately who have symptoms and sending them home following the CDC/IDPH Guidance, ensuring COVID-19 POC (Point of Care) and PCR (Polymerase Chain Reaction) testing supplies are available for all licensed nurses on each shift and, ensuring licensed trained staff are performing the COVID-19 Testing and reviewing the manufacturer's directions for COVID-19 testing, and ensuring all residents who are unvaccinated or not up to date with COVID-19 boosters were isolated immediately after exposure to COVID-19. 2. V1 and V2 initiated all staff in-servicing on 6/7/2022, concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees. Staff not currently working will be in-serviced prior to the beginning of their next scheduled shift. 3. Staff were actively screened prior to their scheduled shift by the front desk receptionist during normal business hours and by a licensed nurse assigned to the long hall on off hours including on second shift, third shift, and the weekend. Employees reporting or exhibiting any symptoms of COVID-19 were tested and sent home immediately. 4. Adequate testing supplies were located for licensed nurses to access during all shifts in the nurse's medication preparation room. 5. All licensed nurses were trained on the testing kits manufacture's guidelines on how to appropriately use the POC antigen rapid testing device, including when to follow-up with PCR test. 6. Employees are to report to the nurse immediately upon the onset of any signs or symptoms that occur during their shift and will then be COVID-19 tested , sent home, and the licensed nurse will report this or anyone testing positive to V1 and V2. 7. All residents who are unvaccinated or not up-to-date with the COVID-19 vaccinations were placed in isolation after being exposed to COVID-19. 8. V2 (DON)completed an audit on 6-7-22 and 6-8-22 to ensure that staff currently working were not symptomatic for COVID-19. 9. Facility wide testing was completed on 6-7-22 and no residents tested positive. One employee in the dietary department tested positive, who did not have a high- risk exposure to any resident and was sent home immediately. 10. All screening forms were being reviewed by the front desk receptionists or licensed nurses at the time of completion. On 6-9-22 at 2:00 PM, R30 was self-propelling up the hallway in her wheelchair and R8 was lying in bed. Neither R30 nor R8 was in contact droplet isolation precautions. Due to R8 and R30 not being placed in isolation precautions as stated in the facility's abatement plan, the facility's abatement plan was not completely executed by 6-8-22 as documented by the facility. Therefore, the immediacy could not be removed on 6-8-22. On 6-13-22 from 9:45 AM through 10:15 AM, V30 (Agency Licensed Practical Nurse/Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant) and V33 (Housekeeper) stated that they had not been educated or in-serviced regarding anything within the past two weeks including COVID-19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. On 6-14-22 from 5:05 am to 5:15 am, V22 (Registered Nurse/RN) could not reiterate any education provided by Administrative staff in the last week and V37 (Agency Certified Nursing Assistant/Agency CNA) and V38 (Cook) stated they had not received any education or in-servicing regarding COVID -19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. Based on observation, interview, and record reviews conducted on 6-16-22, the facility completed all measures to remove the immediacy for F886 by 6-15-22.

Based on observation, interview and record review, the facility failed to interview the family of a confused resident to accurately assess elopement risk prior to admission, screen for supervision needs and develop an elopement care plan, failed to provide adequate supervision to prevent an elopement, failed to ensure all exit doors were secured and/or alarmed and the exit door alarm system was in working order, and failed to investigate an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. These failures resulted in R27, a severely cognitively impaired resident with a diagnosis of Dementia, who is normally independent with ambulation and with a known history of eloping prior to admission to the facility, eloping from the facility on 5/30/22 and being found outside in the back of the building, walking across the grass heading towards the facility, from an unknown location. The facility was unaware that R27 was missing until V20 (Dietary Aide) observed R27 outside and notified facility staff. R27 was found and required extensive assistance of two staff members to return inside of the facility due to R27 being physically exhausted. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6/15/22, the facility remains out of compliance at a severity Level II as the facility Maintenance Director and Administrator continue to monitor all exit doors to ensure they are alarmed and functioning. Residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan for ongoing monitoring. The facility is also awaiting a local electronic maintenance company that has been scheduled to provide service to evaluate and repair keypad and magnetic-locking door system on the fire door leading into the assisted living. In addition to this, parts have been ordered for adding an announcer speaker to sound the front door alarm when it is breached. This installation will be scheduled as soon as parts arrive. Findings include: The facility's Missing Resident policy dated 2/25/19, states, Purpose: To provide 24-hour supervision of the resident's safety. Staff responsible: 1. Administrator 2. Maintenance 3. Director of Nursing 4. All Staff; Missing Resident: the following criteria shall be met prior to determining whether a resident is missing: The resident is not capable of making safe decisions regarding their safety and welfare and they are unattended. Procedure: All exterior doors shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device. 2. Residents at risk for wandering shall be assessed and addressed on the Care Plan. Immediately following the alarm signal, staff shall check the alarm panel and respond to the door indicated. Prevention: Check and test door alarms regularly, Identify and monitor residents at risk; Response to Resident Leaving the Building: Assist back to building, When resident returns to facility, a thorough exam should be completed, to assess for injuries; Missing Resident Protocol: The facility shall notify the resident's Physician and the legal representative or family member; Once the resident is found, an internal investigation will be conducted by the Administrator. R27's electronic medical record documents R27 was admitted to the facility on [DATE] with diagnoses which include, Dementia with behavioral disturbances, Cerebral Infarction with left sided weakness, [CONDITION(S)], Unsteadiness on feet, and [CONDITION(S)]. R27's MDS (Minimum Data Set) assessment dated [DATE], documents the following: R27 has severely impaired cognition with short and long-term memory problems, wanders daily which places R27 at significant risk of getting to a potentially dangerous place (such as stairs, outside of the facility); and R27's wandering also significantly intrudes on the privacy or activities of others. This same MDS assessment documents R27 ambulated once or twice with one staff assistance. R27's Elopement Risk assessment dated [DATE] at 3:56 p.m., and completed by V13 (Activity Director), documents R27 is not at risk for elopement. R27's Care Plan initiated on 5/4/22, does not address R27 being a risk for elopement or wandering until it was revised on 6/1/22 (after R27 eloped on 5/30/22). This same Care Plan states, Activities: R27's barriers are cognitive decline due to Dementia, physical and verbal behaviors to other residents and staff when upset about wanting to go home or see husband. R27's Behavior Tracking dated 5/10/22 through 5/30/22, does not document R27's exit seeking/wandering. R27's Progress Notes dated 5/14/22 9:50 a.m., state R27 has continual supervision in waking hours. Unable to reorient. R27 does not remember fall occurring earlier in day. R27 self ambulates often raising her voice and cussing at staff. R27's Progress Notes dated 5/15/22 at 11:05 a.m., state, R27 has to have one-on-one supervision at almost all times (due to) her behaviors and fall risk. R27's Progress Notes dated 5/16/22 at 10:19 a.m., state, R27 states, 'My husband is not here yet. You hate me and I am not listening to you. I am tired of this bulls**t. I am leaving, maybe I will die'. On 6/06/22 at 12:53 p.m., V25 (R27's Husband) stated that R27 lived at home with him prior to her hospitalization and admission to the facility on [DATE]. V25 stated R27's Dementia was progressing, and she was no longer safe to stay at home with V25. V25 stated R27, got lost three times in our hometown after she wandered off from home. Luckily, it's a small town and people knew who R27 was. R27 even went to (her old place of employment) and walked in like she was going to work. R27 can walk independently, and I take her on a lot of walks when I'm here. R27 has tried to leave this facility at least twice, according to staff. R27 says she wants to go home so she is frequently trying to get to an exit door. I can't remember the date that she tried to elope. R27's Nursing Progress Note dated 5/31/22 and completed by V2 (Director of Nursing) states, Spoke with V25 that (R27) is an elopement risk and R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by (the apartments down the street) and brought back by dietary staff member. No injury noted. R27 placed on frequent checks by night shift nurse and wander guard placed. R27's Nursing progress Note dated 5/31/22 at 12:42 p.m., states Nursing implemented (wander management device) this morning. On 6/8/22 at 11:48 a.m., V20 (Dietary Aide) stated V20 was sitting outside of the service door (the exit door located by the kitchen) at the end of his shift on 5/30/22. V20 stated R27 came walking towards the facility, through the grass in the back of the building. V20 stated, I have no idea where R27 came from or how she got out of the facility. I knew she needed help, so I ran inside the building and got V21(Cook) to come outside to help me with R27. I quickly tried to call nursing staff when V21 headed outside but no one answered the phone, so I went back outside to help V21 get R27. R27 was walking but appeared exhausted. It took V21 and I both taking R27 by the arms to assist her back inside to the nurse's station. R27 was worn out. I'm glad I saw her when I did, or I don't know what would have happened to her. There were no alarms heard from the kitchen. The (service door exit) does not have an alarm on it. On 6/8/22 at 10:30 a.m., V21 (Cook) stated, I was in the kitchen when V20 came running in telling me that R27 was outside by herself. V20 tried to call nursing staff for help, and I ran outside to R27. When I got to R27 she was completely exhausted. I have no idea where all she had been or how long she was outside. It took both V20 and I to hang on to R27 and help her to get back inside to the nurse. I didn't ever hear any alarms. The service door (exit by the kitchen) is not alarmed. The door that comes from the hallways to the kitchen area is unlocked by kitchen staff in the morning and not locked until approximately 8:00 p.m. at night. On 6/8/22 at 9:34 a.m., V2 (Director of Nursing/DON) stated, I was notified on 5/30/22 at approximately 8:00 p.m., that R27 had somehow gotten outside of the facility. R27 has a diagnosis of Dementia and cannot make safe decisions. Her cognition is severely impaired. I did not do any type of investigation after R27's elopement on 5/30/22. I just had nursing staff attach a (wander management device) on her clothes the next morning. R27's nurse V22(Registered Nurse/RN) did not document R27's elopement, an assessment of R27 to check for any type of injuries, or that R27's Physician or husband were notified of the elopement. I don't recall hearing R27 verbalize that she wanted to go home or that she had made attempts to leave the facility. I did call V1 (Administrator) on 5/30/22, after I was notified of R27 being found outside. We (facility staff) had been trying to find her alternative placement due to her behaviors. I did not know that R27 had a history of eloping when she was still living at home. I don't do the elopement risk assessments. Those assessments are completed by the Activity Director in this facility. The elopement risk assessment should have been completed with the assistance of R27's husband since R27 is confused. I have no idea if R27's Care Plan addressed her risk for elopement prior to 5/30/22. I have not watched any video surveillance or conducted any interviews with the staff that found (R27) outside or any other staff on duty on 5/30/22. I cannot say where she exited the building or how long she was outside. I screened R27 for admission to the facility. I don't recall reading anything about her history of elopement. I don't have any documentation of my screening that was completed prior to accepting R27. I don't recall what all I reviewed from the hospital. There is no specific form that I follow. I probably wouldn't have taken (R27 as a resident) if I had known she had a history of eloping at home. We aren't a locked unit. I absolutely would have made sure R27 had a (wander management device) in place on admission at the very least. On 6/8/22 at 9:50 a.m., V13 (Activity Director) stated R27 is very impulsive and easily becomes agitated. V13 stated, I do a lot of one on one's with R27 and at times she is very hard to re-direct. I take her for a lot of walks because that seems to keep her content. She likes to be up moving. R27 was admitted on [DATE] and I completed her Elopement Risk Assessment. I don't know why this facility has the Activity Director doing those assessments. I don't have access to residents' medical records or anything like that. I was not formally trained on completing the Elopement Risk Assessments. I don't recall involving V25 while completing R27's Elopement Risk assessment. I wasn't aware that R27 escaped from her home prior to admission. I would have made her high risk for elopement if I had known that. I don't make the decision to put a (wander management device) on residents. R27 is always telling staff she wants to go home and asking where V25 (R27's Husband) is. I know she has tried to get out the exit doors and she has done a lot of wandering since she was admitted . On 6/8/22 at 11:20 a.m., V1 (Administrator) stated V2 notified her of R27's elopement from the facility on the night of 5/30/22. V1 stated V1 did not consider it an actual elopement because R27 was still on (facility owned property). V1 stated R27 has severely impaired cognition and is not safe to be outside of the facility without supervision. V1 stated, I thought V2 (DON) was handling the elopement issue. I told V2 to put a (wander management device) on R27 and do frequent checks. I have not completed any sort of investigation of R27's elopement on 5/30/22. I don't know what happened. V2 was responsible for the investigation at that point. We don't know what door R27 exited from or how long she was outside unsupervised. I do not have access to video surveillance and I'm not sure what is monitored by the video surveillance. I doubt the exit doors are on video. All exterior doors should be alarmed. Staff should have been aware of R27's history of elopement when she was admitted if they had interviewed V25 (R27's Husband) or properly screened R27 prior to admission. On 6/6/22, at 11:10 a.m., R27 was ambulating independently towards the nurses' station, with no staff supervision. On 6/7/22 at 9:50 a.m., R27 was ambulating independently in the main hallway. On 6/8/22 at 9:47 a.m., R27 ambulated into V2's office and sat at the table. On 6/8/22 at 10:07 a.m., R27 was up independently ambulating in the common area with only socks on her feet. A staff member assisted R27 back to the wheelchair and took R27 to her room. On 6/08/22 at 10:40 am, R27 was ambulating on the main hall of the facility with standby assistance from staff. R27 repeatedly stated get me out of this place and when am I going home. R27 had a small device attached with a clip to the hood of her sweatshirt. V2 (DON) was questioned as to what that device was. V2 stated the device was a wander guard that would alert staff if R27 passed through an exit door. V2 stated that the facility typically uses a wander guard that is placed on the resident's wrist or ankle as a bracelet, but they only have two of those devices and they are being used by other residents. On 6/8/22 at 3:30 p.m., R27 was walking outside with her husband. On 6/08/22 at 10:37 am, the facility was toured with V2 (DON) to identify all exterior doors and if they were secured and alarmed. The corridors that separate the Skilled Nursing side of the facility from the Assisted Living Side of the facility were not alarmed. V2 explained, at that time, that the only way a staff member would know if a resident went through those doors, was if they had a wander guard bracelet/alarm on. V2 then stated, R27 did not have a wander guard on when she eloped from the facility on 5/30/22, so R27 likely went through those doors into the Assisted Living portion of the facility. Once on the Assisted Living side of the building, the Service Entry door that leads to the Kitchen and another exterior door, was not locked, or alarmed. That exterior door led to the parking lot behind Assisted Living. At 10:45 am, V21 (Cook) stated that Service Entry door is unlocked and not alarmed from the time Kitchen staff arrive early in the morning, until they are gone at 8:00 pm. An additional exit door on the [NAME] Hall, which led directly to the parking lot in the front of the facility was able to be opened without an alarm sounding. V2 stated, at that time, that the exit door on [NAME] Hall should alarm when opened. The Immediate Jeopardy was identified on 6/8/22. The Immediate Jeopardy began on 5/4/22 (R27's admitted ) upon admission when the facility failed to identify R27's risk for elopement and implement interventions to help prevent R27 from eloping from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 6/9/22 at 8:55 a.m. On 6-13-22 from 9:45 AM through 10:15 a.m., it was confirmed through interviews that V30 (Agency Licensed Practical Nurse/ Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant), and V33 (Housekeeper) had not been in-serviced as stated on the abatement plan, the facility's abatement plan was not completely executed. On 6/14/22 at 5:00am, the same fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit were not alarmed, as outlined in the Abatement Plan for F689. On 6/14/22 at 5:05 am, V22 (Registered Nurse/RN) was the only Licensed Nurse working 3rd shift. V22 was unable to reiterate any of the education provided by V2 (DON) and V1 (Administrator) regarding the Immediate Jeopardies identified the week prior. V22 was unaware of the Elopement Book, that was outlined in the Abatement Plan for F689. Upon further interview, V22 (RN) explained that R27 had attempted to elope two times the evening of 6/13/22, once out the front door and once out of the corridor that connects the Assisted Living Unit to the Skilled Nursing Unit. V22 verified that R27 was supposed to be on one-to-one supervision due to the elopements throughout the evening; however, V22 stated that the facility did not have the staff to provide 1:1 supervision and R27 was not on 1:1 supervision at the time. At 5:15 am, two additional staff, V36 (Agency Certified Nursing Assistant/ Agency CNA) and V38 (Cook) stated they had not received education as identified in the Abatement Plans. On 6/14/22 from 6:35 a.m.-6:37 a.m., The fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit did not alarm on two separate instances when one visitor and one staff member V11(Registered Nurse/RN) came through those doors. On 6/14/22 at 5:21 a.m., review of the Shift Door Check sheet dated 6/13/22, did not document any of the 19 listed doors were checked to ensure they were properly functioning on the 2nd and 3rd shift. On 6/14/22, R27, R119, and R194's Care Plans had not been revised with resident specific interventions related to their elopement risk. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 6/8 and 6/9/2022 V17 (Maintenance Director) verified that all exit doors were alarmed when opened and reported findings to V1 (Administrator). 2. On 6/13/22, R27s elopement investigation from 5/30/2022 completed by V1 (Administrator). 3. On 6/9/22, R27s Care plan and interventions were reviewed and updated by V24 (Minimum Data Set/MDS Care Coordinator) and the Interdisciplinary Team. 4. On 6/9/22, V2 (Director of Nursing) In-serviced all staff on R27's Elopement Interventions. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 5. On 6/9/22, V2 (DON) and Department Heads In-serviced all staff on all residents at risk for elopement, individualized resident interventions, and monitoring needs, and Missing Resident Protocol. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 6. On 6/9/2022, V2 (DON) and V24 (MDS Coordinator) completed new Elopement Risk Assessments on all residents. On 6/15/22, the Care Plans for those residents Identified as high risk for elopement were updated adding resident specific interventions to meet the resident's needs. 7. On 6/9/2022, all nursing staff, including V2 and V24 were in-serviced on Elopement Risk Assessments needed for all new admissions, to include reviews on a quarterly basis and with significant changes. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 8. On 6/9/2022, V1 (Administrator) and V2 (Director of Nursing) verified that the appropriate information on residents with exit seeking behaviors were properly placed in binders and at designated locations. All staff were in-serviced on the locations of binders. 9. On 6/9/2022, V17 (Maintenance Director) activated an alarm on fire doors directly leading to the Assisted Living Facility. 10. On 6/9/2022, V17 (Maintenance Director) in-serviced exit doors needing checked by staff every shift to assure they are alarmed and functioning. These Logs will be reviewed by the Maintenance Director and presented to the Administrator daily with issues being addressed as they occur. 11. On 6/9/22, the residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan by V1 (Administrator) for ongoing monitoring. 12. On 6/14/22, all staff were provided additional in-servicing on the above-mentioned trainings by the Regional Nurses along with a post-test for proof of training and understanding. Abatement completion date: 6/15/2022 Based on observation, interview, and record reviews conducted on 6-15-22 the facility completed all measures including the in-servicing of working staff and updating care plans for high-risk elopement residents as stated on the abatement plan.

Based on interview and record review, The facility failed to provide wound management including assessing, documenting and notifying the medical provider of worsening signs and symptoms of infection for one resident (R1) of three residents reviewed for wound management. This failure resulted in R1, with a wound infection, requiring hospitalization , intravenous antibiotics, and surgery. Findings include: POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Progress Note dated 4/17/21 at 4:49pm, indicates R1 was admitted to the facility at 3:50pm (from the hospital). Note indicates R1 had surgery to left gluteal area due to [CONDITION(S)] area was debrided due to left gluteal and peri-anal [CONDITION(S)]. Note indicates wound vac to be placed on buttock wound. Admission Skin assessment dated [DATE] at 7:18pm indicates: Coccyx wound 15cm (centimeters) x 32 cm x 10cm (depth) Sacrum wound 15cm x 32cm x 10cm Assessment indicates Wound vac in place, continuous No other descriptors of wound were documented. TAR (Treatment Administration Record) dated 4/17/21 to 5/17/21 indicates weekly skin checks were to be done every Saturday (4/17, 4/24, 5/1, 5/8 - 2021). TAR also indicates wound vac dressing was to be changed three times per week on Monday, Wednesday and Friday. All Focused Skin Observations (5/13, 5/12, 5/11, 5/10, 5/9, 5/8, 5/6, 5/4, 4/26, 4/25, 4/24, 4/20, 4/19, 2021) indicate R1's wound vac in place - no description or assessment of R1's wound was documented. Wound Management Assessment date 4/28/21 at 1:14am (coincides with wound vac change date on MAR) indicates right buttock wound measures 17cm x 12cm and wound healing status as stable. No other descriptors of wound were included in assessment. No other wound assessments were found or presented on days wound vac was changed. Nurse Progress Notes dated 4/19/21, 4/20/21 and 4/30/21 indicate R1's wound vac was changed - no description or assessment of wound was included. Nurse Progress Note dated 5/5/21 at 11:17am, indicates V8 (Nurse Practitioner/NP) was in to see R1. Note indicates labs were ordered and pain medications ordered to be given 30 minutes prior to dressing/wound vac change. Note also indicates for staff to call V9 (Wound Surgeon) to see if he wanted a wet to dry dressing to be placed on R1 on the day of wound appointment on 5/25/21. No documentation was found to indicate V9 had been called per V8's recommendation. Nurse Progress Note dated 5/10/21 at 7:17pm indicates Wound vac changed, R1 having extreme pain during treatment; peri-wound is red, beefy, angry, area toward right buttock has several areas of green slough, area in center draining green pus-like liquid, tunneling noted to upper area on right side; several areas noted to be purple, bruise-like with foul odor also noted. On 5/5/22 at 10:43am V5 (Licensed Practical Nurse/LPN) stated The way I described the wound (on 5/10/21) was just the normal way the wound looked. The wound was all the way to the bone. On that day it did seem like the pus was increasing - newer changes. V5 stated that she faxed V8's office to notify of the wound changes/condition. V5 stated that generally R1's wound stayed pretty much the same size but the redness, pus and odor were signs of infection. V5 stated I think I did request an antibiotic - at least 2 times - especially when the green pus was showing up. At some point V8 (NP) told us to contact the wound physician or surgeon - I don't recall if they were contacted. We send a request or notifications to the clinic then we shred the request. V5 stated that wound assessments are dependent on who changed the dressing. V5 stated they were aware R1's WBC's (White Blood Cells) were also going up. No evidence V8 (NP) or V9 (Wound Surgeon) were ever notified of R1's wound condition or request for antibiotics was ever found or presented. On 5/4/22 at 1:20pm, V4 (Registered Nurse/RN) stated she was R1's nurse and changed R1's wound vac many times. V4 stated that R1's wound had signs and symptoms of infection from the beginning. V4 did not recall ever notifying V8 or V9 of wound condition. On 5/5/22 at 11:15am V6, RN (Registered Nurse) stated that from day one R1's wound had bad odor, then it got worse and permeated out into the hallway. V6 stated they had to empty R1's wound vac canister three times per day. There was so much drainage and that most wound vac canisters only get emptied when the vac gets changed every three days. V6 stated that she doesn't recall ever notifying V9 (Wound Surgeon) at any time. V6 stated that weekly skin assessments are usually in the nurse progress notes. On 5/6/22 at 11:05am, V8 (NP) stated that with a wound as complex as R1's, if the nurses had notified her of issues with the wound - including signs and symptoms of infection - she would have told them to contact R1's wound physician or surgeon for orders. V8 stated that determining when to send a resident to the hospital with increasing WBC's (Leukocytosis) depends on individual resident status and other clinical information. NP Notes dated 5/5/21 and 5/13/21 both indicate R1 was seen by V8 on those dates. Both notes indicate: [CONDITION(S)]/left gluteal area Excisional Debridement - managed per general surgeon; wound team to follow at facility. Both notes indicate the wound vac was in place during both visits on 5/5/21 and 5/13/21, so the wound was not actually visualized by V8. Pharmacy manifest dated 4/17/21 to 5/14/21 indicates R1 had not received any antibiotics while at the facility. Emergency Department note dated 5/14/21 at 6:12pm, indicates CBC (Complete Blood Count) is notable for leukocytosis. Wound is foul-smelling. R1 started on IV (Intravenous) [MEDICATION(S)] (antibiotic used to treat bacterial infections) and [MEDICATION(S)] (antibiotic used to treat serious bacterial infections) after blood cultures obtained. Surgery was consulted given wound and recent [CONDITION(S)]. Surgery noted R1 had a developing abscess which may have been the cause of her leukocytosis. Surgery recommends admitting R1 to medicine service given her multiple medical issues and desire to be placed in a different skilled nursing facility. Surgery will plan for debridement. Emergency Department Note dated 5/14/21 at 8:37pm, indicates R1's wound vac was removed and pocket drained pus and blood. Surgery team advising surgery tomorrow. Clinical Impression: Wound Infection Facility Policy/Wound Care dated 03/04 documents: 1. Observe all wounds and notify physician of signs and symptoms of infection, swelling of the affected part, redness of affected part, and a sensation of heat, along with throbbing pain, tenderness, fever, evidence of pus or red streaks leading from the wound. 5. Current wound status must be documented no less than once per week and should be done on the Treatment Sheet or in the Nurses Notes as they occur. 6. Wound changes and other pertinent observations must be documented in the Nurses Notes as they occur. 7. The Physician must be notified of change in wound status. 9. In the case of drainage containing pus, and/or presence of odor, the physician should be consulted regarding culture and sensitivity of the wound.

Based on interview and record review, the facility neglected to follow their Pressure Injury Prevention and Treatment Protocol for R1 who was admitted to the facility with a pressure ulcer, resulting in R1 being readmitted to the hospital for multiple surgical debridements and a diversional [CONDITION(S)]. R1 is one of three residents reviewed for pressure sores in the sample of three. Findings include: The facility's Pressure Injury Prevention and Treatment Protocol (revised 07/16) documents the following: 3. All high and moderate risk residents may have the following, and if so, they will be addressed on the care plan: D. Turning and positioning schedule, E. Skin checks. 7. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size ((measure length x (times) width x depth)), wound bed, drainage, odor, tunneling, undermining or [MEDICATION(S)] tract, wound edges/ surrounding tissue and pain at site. B. Determine the injury's correct stage of development. C. If pressure injury is showing no improvement, Physician will be notified so change of treatment may be obtained. E. Pressure ulcer will be care planned. H. Weekly individual treatment report will be done and put on clinical chart. J. For those residents that cannot turn themselves, transfer self out of bed or cannot turn and position themselves in bed, staff will be responsible for. The facility's Change in a Resident's Condition policy (revised 12/02) documents 1. The nurse will notify the resident's attending physician when: b. There is a significant change in the resident's [physical, mental, or psychosocial status], and 4. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. R1's medical record documents admission to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden Scale for predicting pressure sore risk dated 6/10/21 documents R1 is is at moderate risk for developing pressure sores. R1's Care Plan documents R1 is at risk for developing pressure sores, but does not document any pressure sores. R1's History and Physical note dated 5/24/21 from the hospital and included in the transfer records sent to the facility documents paralysis of lower extremities. Also included in R1's transfer record was a Physician note dated 6/7/21 documenting a midline coccyx wound. These records were provided on 6/23/21 by V1, Administrator. R1's Admission Observation Report dated 6/10/21 and completed by V6, Registered Nurse (RN) documents Alteration in skin? No. R1's Pressure Injury Information/Observation dated 6/10/21 and completed by V11, Licensed Practical Nurse (LPN) documents under Description new admit, and there is no documentation of any coccyx wound or measurements of the wound. On 6/23/21 and 6/24/21, V6 was not available for interview as V6 would not answer attempted phone calls. On 6/24/21 at 9:01am, V11 stated she did not check R1's skin when he was admitted , but completed the Pressure Injury Information/Observation form for V6 who told her R1's skin was intact. V11 stated she knew she should not document what she did not do, or document for other nurses, but V11 was busy with two admissions to the facility and she was trying to help him out. R1's medical record including all Progress notes from admission (6/10/21) through 6/14/21 do not document the presence of a pressure sore, measurements or assessments of R1's pressure sore, or any skin checks following admission. On 6/24/21 at 12:20pm, V17, Certified Nursing Assistant (CNA), stated on 6/14/21 she was cleaning R1 up and the pressure sore on his coccyx looked very bad, dark red and the skin was peeling off. V17 stated she told V9, LPN, about how bad R1's pressure sore was at about 6:30pm. On 6/24/21 at 2:30pm, V1, Administrator, confirmed that V17 worked 6/14/21 and then not again until 6/18/21. On 6/23/21 at 2:26pm, V9, LPN who worked the 6:00pm-6:00am shift on 6/14/21, stated a CNA had reported to her that R1's pressure sore looked worse, so she told V4, RN, day nurse, the next day (6/15/21). The communication faxed to V18, R1's Primary Care Physician (PCP), notifying V18 of R1's pressure sore was sent on 6/15/21 at 3:40pm and documents Unstageable pressure ulcer noted to coccyx/buttock measuring 15.4 cm (centimeters) by 11.2 cm, with necrotic tissue present. On 6/23/21 at 10:40am, V4, RN, stated that on 6/15/21 the CNAs had reported R1 had a skin issue so she looked at the wound and also had V1, Administrator, look at the wound. V4 stated she sent a fax to the (Physician) office to notify V18, PCP, of R1's coccyx wound. V4 stated R1 needed a lot of help, and he couldn't move his legs, but could move his arms, and he was not on a turning and positioning program until 6/15/21. On 6/24/21 at 9:55am, V14, LPN, stated that on 6/16/21 she had V15, Advance Practice Nurse (APN) examine R1's pressure sore on his coccyx, V15 conferred with V18, PCP, and a decision was made to transfer R1 to the Emergency Department (ED) for evaluation on 6/16/21. On 6/24/21 at 11:28am, V15, APN, stated she was not aware of R1 having a pressure sore until 6/16/21. R1's Progress Notes dated 6/16/21 at 11:16am documents, Patient (R1) sent to ER (emergency room ) OSF to be evaluated for unstageable coccyx and sacrum deep tissue injury. R1's hospital record dated 6/16/21-6/23/21 documents that R1 was sent straight from the ED (Emergency Department) for debridement of the wound. V19, Physician Assistant, Certified, documented on 6/16/21 in his notes Chart reviewed from recent hospitalization and wound/ostomy evaluation showed small area redness on the sacrum at the time of discharge (6/10/21). There is now extensive necrotic/cellulitic tissue most likely suggestive of [CONDITION(S)]. R1's wound culture of the coccyx dated 6/16/21 documents culture was positive for Pseudomonas, Enterococcus feacalis, and Escherichia coli. R1's hospital Interval History and Physical Note dated 6/23/21 and written by V20, Medical Doctor (MD), documents further debridement of the wound is needed and recommended a diverting [CONDITION(S)]. A hospital consultation note by V21, MD, dated 6/21/21 for R1, documents R1 stated, The care in the nursing home was very poor, he was rarely turned while in bed, he would be left for hours after soiling himself and was treated unprofessionally while being cleaned up. On 6/23/21 R1 was unavailable for interview due to being in surgery, and on 6/24/21 did not answer the phone. On 6/24/21 at 9:20am, V12, CNA, stated R1 was not routinely turned and positioned, but they would position him so that he would not slouch forward. V12 stated R1 was frequently incontinent of stool and had to be changed frequently. V12 stated she saw that R1's bottom was red, but that she thought it was because he was laying on it. On 6/24/21 at 12:20pm, V17, CNA, stated R1 could not reposition himself and it required two CNAs to move him. V17 stated they would offer to roll him to his side, but mostly they moved him up in bed (while on his back). R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan dated 6/11/21 directs staff to Assist resident with turning and repositioning. On 6/24/21 at 2:00pm, V1, Administrator, stated that she could find no other documentation regarding R1's pressure sore from admission until 6/15/21. At this time, V1 provided the annual RN and LPN Task Competency Reviews for V4, RN; V6, RN; V9, LPN; and V11, LPN which included Responsibility of Nurse: 5. Assessing Resident: a. Admission observation, b. Focused observation. 6. Identifying changes in condition. 7. Notifying doctors of any changes in resident condition. Procedures: 3. Skin and Wound Care, 5. Pressure Injury Prevention/Treatment Program. Documentation: 1. Event Charting, 5. Progress Note Documentation. V1 stated V4, V6, V9, and V11 are aware of their responsibilities. V4's Annual Task Competency Review is dated 10/20/20;V6's is dated 8/17/20: V9's is dated 3/23/21, and V11's is dated 3/10/21.

Based on interview and record review, the facility failed to accurately complete and document wound assessments for two of three residents (R1, R2) reviewed for pressure ulcers in the sample of three, and failed to turn/reposition and notify the physician in a timely manner of a worsening pressure ulcer for R1. These failures resulted in R1 being readmitted to the hospital and undergoing multiple wound debridements and a diversional [CONDITION(S)]. Findings include: The facility's Pressure Injury Prevention and Treatment Protocol (revised 07/16) documents the following: 3. All high and moderate risk residents may have the following, and if so, they will be addressed on the care plan: D. Turning and positioning schedule, E. Skin checks. 7. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size ((measure length x (times) width x depth)), wound bed, drainage, odor, tunneling, undermining or [MEDICATION(S)] tract, wound edges/ surrounding tissue and pain at site. B. Determine the injury's correct stage of development. C. If pressure injury is showing no improvement, Physician will be notified so change of treatment may be obtained. H. Weekly individual treatment report will be done and put on clinical chart. J. For those residents that cannot turn themselves, transfer self out of bed or cannot turn and position themselves in bed, staff will be responsible for. The facility's Change in a Resident's Condition policy (revised 12/02) documents 1. The nurse will notify the resident's attending physician when: b. There is a significant change in the resident's [physical, mental, or psychosocial status, and 4. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. 1. R1's medical record documents admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden Scale for predicting pressure sore risk dated 6/10/21 documents R1 is is at moderate risk for developing pressure sores. R1's History and Physical note dated 5/24/21 from the hospital and included in the transfer records sent to the facility documents paralysis of lower extremities. Also included in R1's transfer record was a note dated 6/7/21 documenting a midline coccyx wound. These records were provided on 6/23/21 by V1, Administrator. R1's Admission Skin Observation and Pressure Injury Information dated 6/10/21 document R1's skin is intact. R1's Progress Notes dated 6/15/21 at 3:26pm document, Unstageable pressure ulcer noted to coccyx/buttock measuring 15.4 cm (centimeters) by 11.2 cm, with necrotic tissue present. R1's medical record contains no documentation of R1's pressure ulcer from 6/11/21-6/14/21. On 6/24/21 at 10:00am V1, Administrator, confirmed there is no documentation of R1's pressure ulcers from 6/11/21-6/14/21. On 6/24/21 at 12:20pm, V17, Certified Nursing Assistant (CNA), stated on 6/14/21 R1's bottom (buttocks) looked bad, and that the skin was dark red and peeling. V17 stated she told V9, Licensed Practical Nurse (LPN), about how bad R1's bottom looked at about 6:30pm on 6/14/21. On 6/23/21 at 2:26pm, V9 stated she told V4, Registered Nurse (RN), about R1's pressure sore when V4 came to work on the day shift 6/15/21. The communication faxed to V18, R1's Primary Care Physician (PCP), notifying V18 of R1's pressure sore was sent on 6/15/21 at 3:40pm and documents Unstageable pressure ulcer noted to coccyx/buttock measuring 15.4 cm (centimeters) by 11.2 cm, with necrotic tissue present. On 6/23/21 at 10:40am, V4, RN, stated that R1 needed a lot of help and he could not move his legs. V4 stated that R1 was not on a turning and positioning program until 6/15/21. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/24/21 at 9:20am and 12:20pm respectively, V12 and V17, CNAs, stated R1 was not on a turning and positioning program, and that he usually laid on his back. R1's Progress Notes dated 6/16/21 at 11:16am document Patient (R1) sent to ER (emergency room ) (local hospital) to be evaluated for unstageable coccyx and sacrum deep tissue injury. R1's hospital record dated 6/16/21-6/23/21 documents that R1 was sent straight from the ER (emergency room ) for debridement of the wound. V19, Physician Assistant, Certified, documented on 6/16/21 in his notes, Chart reviewed from recent hospitalization and wound/ostomy evaluation showed small area redness on the sacrum at the time of discharge (6/10/21). There is now extensive necrotic/cellulitic tissue most likely suggestive of [CONDITION(S)]. R1's hospital Interval History and Physical Note dated 6/23/21 and written by V20, Medical Doctor (MD), documents further debridement of the wound is needed and recommended a diverting [CONDITION(S)] which was performed on 6/23/21. A hospital consultation note by V21, MD, dated 6/21/21 for R1 documents that R1 stated The care in the nursing home was very poor, he was rarely turned while in bed, he would be left for hours after soiling himself and was treated unprofessionally while being cleaned up. On 6/23/21 R1 was unavailable for interview due to being in surgery, and on 6/24/21 did not answer the phone. 2. R2's medical record documents he was admitted to the facility on [DATE] and Admission Skin Observation Report and Event Report dated 6/11/21 document Stage 1 pressure ulcers to the right and left gluteal areas. R2's Progress Notes and medical record do not document any measurements or assessments of these pressure ulcers from 6/12/21-6/22/21. R2's Progress Notes dated 6/23/21 document the pressure ulcers are healed and the treatment was changed. On 6/24/21 at 10:00am, V1 stated there are no weekly wound assessments for R2's pressure ulcers and no other wound assessments until 6/23/21 for R2. V1 stated she spoke to V14, Licensed Practical Nurse (LPN) who was responsible for documenting, measuring, and assessing R2's pressure ulcers on 6/18/21, and stated V14 said someone told her the ulcers were healed so she did not check or document them. V14 stated wound assessments are expected to be completed weekly.

Based on observation, interview, and record review the facility failed to do physician ordered wound treatments for one of three residents (R2) reviewed for wound treatment completion in the sample of six. This failure resulted in the deterioration of R2's wound. Findings include: The facility's Wound Care policy, Revised 03/04, documents 1. Follow physician's orders [REDACTED]. Documentation of wound care must be completed each time the treatment is done. This documentation will be done on the Treatment Sheet. R2's face sheet documents R2 admitted to the facility on [DATE] with the following diagnoses, not limited to: Non-pressure chronic ulcer of right calf with necrosis of muscle, non-pressure chronic ulcer of other part of right foot with necrosis of muscle, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and Myelodysplasti[DIAGNOSES REDACTED]s. On 8/21/18 at 2:15 pm, R2 was laying in bed with wound dressings to R2's right foot and right second toe. R2's Physician Orders, dated 7/25/18, documents the wound treatment for [REDACTED]. On 8/24/18 at 10:20 am, V10 LPN (Licensed Practical Nurse) Bridge Nurse, stated she does all residents' wound measurements and treatments weekly on Tuesdays. V10 stated she measured R2's wounds and applied new dressings on 7/25/18 upon R2's admission. V10 also stated that on 7/31/18, the next measuring day, R2 still had the same dressings that V10 placed on 7/25/18. V10 stated R2's wound did show some decline on 7/31/18 from the previous week and even greater the following week. The facility Employee Disciplinary Action form, regarding employee V9 LPN (Licensed Practical Nurse), is signed by V2 Director of Nursing/DON with a date of incident as 7-27-18. This form documents that the DON Was advised by (V10 LPN) Bridge Nurse that (R2's) dressing was not changed as ordered on 7-27-18 resulting in worsened, wound larger in size. Charted as done. R2's Wound Management Information sheet, dated 7/25/18 documents R2's Right Achilles Wound as 6.5 cm (centimeters) x 2.5 cm, no measurable depth, 100% of wound covered with dry eschar tissue, no drainage, no odor, with well defined wound edges. R2's Wound Management Information sheet, dated 7/31/18, documents R2's right Achilles wound measures 6.5 cm x 2.5 cm with the following declines: [MEDICAL CONDITION] (yellow or tan, cloudy and thick) exudate (drainage), and now has 10% sloughing (shedding of dead skin, cream or yellow in color) and 90% eschar (dead black crusty skin). R2's Wound Management Information sheet, dated 8/7/18, documents R2's right Achilles wound is larger at 7.5 cm x 3.5 cm with the following declines: moderate serosanguineous (pale red to pink, thin and watery) exudate, moderate odor, and full thickness wound through dermis and down to subcutaneous tissue, muscle. Information sheet also documents wound bed now covered with 100% slough with irregular edges. R2's Treatment Administration History, dated 7/25/18 through 7/30/18, documents R2's right Achilles wound treatment as completed showing signatures by V8 and V9 Licensed Practical Nurses/LPNs. On 8/24/18 at 10:45 am, V2 DON confirmed V9 LPN did not do R2's wound treatments on 7/26/18, 7/27/18, and 7/30/18 and confirmed V8 LPN did not do R2's treatments on 7/28/18 and 7/29/18. V2 DON stated V9 LPN and V8 LPN were both disciplined for signing out R2's wound treatments being done when they didn't do them.

Based on observation, record review, and interview the facility failed to ensure staff reported an act of physical abuse immediately to the Administrator, failed to protect two residents from physical abuse, and failed to remove the alleged perpetrator (E5/Certified Nursing Assistant/CNA) from the facility immediately after the witnessed abuse for two (R2, R4) of four residents reviewed for abuse in a sample of four. These failures resulted in E5 having continued access to residents after physically restraining R4, causing skin tears to R4's upper left arm and left wrist, and later restraining R2's wrists and arms resulting in hand print bruising to both of R2's upper arms and wrists, and causing fear and mental anguish to R2. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11-17-17, the facility remains out of compliance as the facility revises operational policies and procedures on Abuse, continues to conduct ongoing staff education regarding Abuse Management and managing Patients with Dementia Behaviors, provides education to the newly hired employees, interviews all interviewable residents and staff to determine if any more unreported incidents of abuse occurred, assesses all non-interviewable residents for injuries, completes behavioral analyses of all residents displaying behaviors, continues to monitor all abuse incidents by the Administrator and IDT (Interdisciplinary Team), and develops performance improvements plans to resolve any findings. Findings include: On 11-14-17 at 9:40 a.m., E8 (CNA) stated E8 witnessed E5 holding R4's wrists down on 10-31-17 around 7:00 a.m. resulting in skin tears to R4's wrists and left arm. E8 also stated that E8 witnessed on 11-3-17 around 1:00 p.m. E5 holding R4 down by the arms and wrists roughly and R2 was verbalizing, Help me. Help me please. Let go of me (yelling at E5). E8 stated E5 did not let go of R2 and that caused bruising on (R2's) wrists and arms and (R2) being very scared of (E5). E8 stated E8 did not remove E5 from the witnessed abuse towards R2 on 11-3-17, and did not remove E5 from the witnessed abuse towards R4 on 10-31-17. At that time, E8 also stated that she did not report either incident to the Administrator. 1. On 11-14-17 at 1:00 p.m., R4 was sitting in a wheelchair. R4 had a five cm dark purple v-shaped scabbed area to the left upper arm and a three cm dark purple scabbed area to the left wrist. R4's Event Report dated 10-31-17 and signed by Z2 (Agency Licensed Practical Nurse/LPN) documents R4 has skin tears to the left arm measuring four cm (centimeters) x three cm and to the left wrist measuring three cm. On 11-14-17 at 1:55 p.m., E2 (Director Of Nursing/DON) verified that no one has reported R4's alleged abuse that occurred on 10-31-17 and that E8 should have removed E5 from R4's cares when she witnessed the abuse. 2. On 11-13-17 at 1:15 p.m., R2 had a three cm (centimeter) round dark purple bruise under the left eye, four brown with yellow discolored seven cm bruises with a two cm round bruise below those bruises to the bilateral upper arms and bilateral wrists. These four bruises resembled the fingers and thumb of a hand print. R2's left rib area had a five cm round brown bruise. R2's left elbow had a five cm yellow/brownish bruise. R2's left outer breast had an eight cm light purple bruise. R2's Event Report dated 11-3-17 at 4:40 p.m. and signed by Z2 documents, During care a CNA (Certified Nursing Assistant) noted several bruises to left upper arm, left elbow, left wrist, left eye, right upper arm, left lateral ribs, left outer breast, and right forearm. Color of bruise is black/blue. On 11-13-17 at 1:15 p.m., R2 pointed to the bruise under her left eye and wrists and stated, I got hit. I am scared I will get hurt again. On 11-14-17 at 1:30 p.m., E9 (First Shift CNA Coordinator) stated, I was told from another CNA (E8) that (E5) has held (R4's) wrists down to do (R4's) cares. That is physical abuse. Staff should never hold down a resident's wrists. I did not report what I had heard to anyone either. On 11-14-17 at 11:35 a.m., E2 (DON) stated, (E8) should have immediately reported that (R2) said 'Help me. Help me.' and reported that (E5) held (R2) down to (E1/Administrator) and myself immediately. (E8) should have asked (E5) to leave (R2's) room to protect (R2). On 11-14-17 at 2:30 p.m., E1 verified that (E8) should have removed (E5) from both situations on 10-31-17 with R4 and 11-3-17 with R2, and should have reported to E1 immediately that (R2) was scared and (E5) was holding R2's arms down. On 11-15-17 at 12:00 p.m., E2 (DON) stated, (E5) had access to all residents and worked with all residents after the occurrence with (R4) on 10-31-17 up until the evening of 11-3-17 (after the occurrence with R2). E5's Time Report documents E5 worked in the facility on 10-31-17 from 5:38 a.m. to 2:16 p.m., 11-2-17 from 7:46 a.m. to 2:23 p.m., and 11-3-17 from 5:37 a.m. to 2:18 p.m. The Immediate Jeopardy was identified to have begun on 10-31-17 at 7:00 a.m. when E8 witnessed E5 restraining and injuring R4 and did not intervene or report it immediately to the Administrator. The Immediate Jeopardy was identified at 1:00 p.m. on 11-17-17 to have begun on 10-31-17 when R4 was abused by E5. E1 and E2 were notified of the Immediate Jeopardy on 11-17-17 at 1:15 p.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: E5 was suspended on 11-3-17 and terminated E5 on 11-8-17. E8 was suspended on 11-15-17 and terminated on 11-17-17. The Peoria police were notified on 11-14-17 of R2 and R4's incidents of alleged abuse and E5 and E8's involvement. A re-investigation of R2's original investigation dated 11-3-17 was initiated and R4's initial abuse allegation report and investigation was started 11-14-17. All staff are educated by the Administrator and Director of Nursing regarding abuse management, managing patients with dementia behaviors, and fall management of all staff started on 11-14-17 and continued for other staff prior to giving care. Adult Protective Services educated all staff on 11-16-17 regarding abuse. Abuse Education was incorporated into the new hire orientation on 11-15-17 and all direct care staff education will be completed on 11-17-17. All interviewable residents and staff were interviewed to determine if there were any more unreported incidents of abuse on 11-14-17. All non-interviewable residents were assessed for injuries on 11-14-17. Behavior analysis were completed on all residents displaying behaviors on 11-15-17. All residents with behaviors had their care plan reviewed and revised if needed on 11-15-17. All abuse incidents will be monitored by the Administrator and reviewed by the IDT team. Findings will be submitted to the Quality Assurance Committee monthly and that committee will develop performance improvement plans to resolve the issues.

Based on observation, record review, and interview the facility failed to ensure two residents (R2, R4) were not abused. E5 forcefully restrained R4 and R2 during cares, resulting in skin tears for R4 and causing bruising on R2's wrists, eye, and upper arms and also causing fear for R2. R2 and R4 are two of four residents reviewed for abuse in the sample of four. Findings include: The facility's Abuse Prohibition and Reporting policy dated 02/2017 documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraint not required to treat a resident's symptoms. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Physical restraint is defined as a manual method, physical method, or mechanical devices which restrict movement or normal access to one's body. 1. On 11-14-17 at 1:00 p.m., R4 was sitting in a wheelchair. R4 had a five cm (centimeter) dark purple v-shaped scabbed area to the left upper arm and a three cm dark purple scabbed area to the left wrist. R4's Progress Note dated 3-21-17 and signed by Z5 (R4's Nurse Practitioner) documents R4 has the [DIAGNOSES REDACTED]. R4's Event Report dated 10-31-17 and signed by Z2 (Agency Licensed Practical Nurse/LPN) documents R4 has skin tears to the left arm measuring four cm x three cm and to the left wrist measuring three cm. On 11-14-17 at 9:40 a.m., E8 (CNA/Certified Nursing Assistant) stated that E8 witnessed E5 (CNA) hold R4's wrists down on 10-31-17 around 7:00 a.m. E8 stated that while holding R4 down, E5 caused skin tears to R4's left wrist and left arm, and that E5 and R4 both had blood on them. E8 stated that R4 is a tough man and E5 held R4 down tightly by the wrists and arms while providing cares. E8 stated, Residents (R2, R4) did not like (E5) and would swing at (E5). I would see (E5) hold (R2 and R4's) wrists down. The amount of strength (E5) would use to hold the residents' wrists down would depend on how strong the resident is. 2. On 11-13-17 at 1:15 p.m., R2 had a three cm (centimeter) round dark purple bruise under the left eye, four brown with yellow discolored seven cm bruises with a two cm round bruise below those bruises to the bilateral upper arms and bilateral wrists. These four bruises resembled the fingers and thumb of a hand print. R2's left rib area had a five cm round brown bruise. R2's left elbow had a five cm yellow/brownish bruise. R2's left outer breast had an eight cm light purple bruise. R2's current care plan documents that when R2 displays behavioral symptoms that staff should explain care step by step to assure resident understanding and staff should re-approach R2 at a later time or with a different staff member if R2 appears agitated. R2's Event Report dated 11-3-17 at 4:40 p.m. and signed by Z2 (Agency LPN) documents, During care a CNA (Certified Nursing Assistant) noted several bruises to left upper arm, left elbow, left wrist, left eye, right upper arm, left lateral ribs, left outer breast, and right forearm. Color of bruise is black/blue. E5's (CNA) statement dated 11-3-17 at 8:00 p.m. and recorded by E2 (Director of Nursing/DON) documents, I went in to lay down (R2). No one was with me. (R2) was screaming, pinched my breast, scratched me, and said that I hit her. (R2) dug her nails into me. I tried to stop (R2) from hitting me. I held her lower wrist area. I held both of (R2's) arms so she wouldn't hit me. E8's (CNA) statement dated 11-6-17 and recorded by E2 documents, (R2) had no bruising before lunch on 11-3-17. After lunch someone from front office got me and said they need help in (R2's) room. (R2) was swinging at (E5). (E5) held (R2's) arms down. (E5) held (R2's) arms down while I changed (R2). I feel like (R2) was scared when I went in to help (E5) with her. On 11-13-17 at 2:15 p.m., E5 stated, On 11-3-17 close to 1:00 p.m. I was running behind. (R2) fights, curses, and beats me up. (R2) scratches, bites, and pinches me. I checked to see if (R2) was wet and when I checked to see if (R2) was wet (R2's) screaming went from zero to five thousand. (R2) told me 'Get out of here. You hit me.' A social service person came in and asked if I needed help and I said yes. (E8) came in to help me. I had to hold (R2's) arms down to prevent (R2) from hitting me. (R2) was really peed off at me. I had to hold (R2) down roughly by the wrists to control her. The Director of Nursing called me later that night on 11-3-17 and said she was going to have to educate me on abuse and resident handling because (R2) had a black eye. On 11-3-17 at 2:05 p.m., E4 (Social Service Director) stated, On 11-3-17 around 1:00 p.m., I heard (R2) yelling. I opened (R2's) door and saw (R2) laying on the right side and (E5) was wiping (R2's) bottom. (E5) looked stressed out and I asked (E5) if everything was okay. (E5) replied 'Not really.' I asked (E5) if she needed help and I went and got (E8) to help. (E5) should have asked for help if she was that stressed out and should not have held (R2's) arms down. Holding a resident down is physical abuse. On 11-14-17 at 9:40 a.m., E8 (CNA) stated, On 11-3-17 around 1:00 p.m., a social worker came and got me and said that (R2) needed help. When I entered (R2's) room (R2) was saying 'Help me. Help me please.' While I was helping (E5) change (R2), (R2) was saying 'I don't want her (E5) to touch me. (R2) kept telling me to get (E5) away from her. (E5) was holding (R2's) wrists down tightly towards the bed and (R2) kept saying 'Let go of me.' (E5) did not let go of (R2) and that caused the bruising on (R2's) wrists and arms. (E5) was frustrated and stressed out. (R2) has never swung out at anyone else except for (E5). (R2) was very scared of (E5). (R2) kept yelling 'Please help me. Please help me.' It is physical abuse to restrain and hold a resident's wrists down. (E5) should have just walked away. On 11-15-17 at 10:40 a.m., E13 (CNA) stated, I noticed (R2's) bruises on 11-3-17 around 2:30 p.m. and notified the nurse. (R2) has a black eye and bruises to both wrists/arms. The bruises to the wrists resembled hand print bruising. (R2) said that someone had hurt her. (R2) has been afraid since the bruising and when I change (R2) she says she is worried. On 11-14-17 at 9:00 a.m., Z2 (Agency LPN) stated, On 11-3-17 around 2:30 p.m., (E13/CNA) found bruises on (R2). I did an assessment. The bruises were all fresh and suspicious in nature of abuse to the areas they were located. The bruises on (R2's) arms and wrists looked like hand prints. (R2) knew a staff member did the bruises to her but did not know a name. On 11-14-17 at 1:15 p.m., E6 (CNA) stated, I worked Thursday 11-2-17 and (R2) did not have bruises that day. When I came in on Saturday 11-4-17 I was like 'Oh my God. Who beat (R2) up? (R2) said somebody hit her. It really upsets me that somebody could do that to (R2). (R2) never gets combative with cares and there is no reason for her bruises. On 11-13-17 at 1:35 p.m. E2 (Director Of Nursing/DON) stated, (E5) should have made sure (R2) was safe, got help, and re-approached (R2) later. (E5) said she held (R2's) arms down and that caused the left arm bruising. Bruising under the left eye happened I am assuming during this same incident. (R2) did not have any bruises that day prior to this incident. (E5) should not have held (R2's) arms down. (E8) felt like (R2) was scared when she entered the room. (E5) holding (R2's) arms down is abuse. On 11-14-17 at 2:40 p.m., E12 (CNA) stated, (R2) has good days and bad days. (R2) will say 'Look at my bruises. Somebody hit me.' (R2) is way more on edge and scared since the incident on 11-3-17. It takes a lot more time to take care of her and (R2) is always afraid she will get hurt. There is a big difference with (R2) feeling safe. (R2) always feels unsafe. On 11-13-17 at 1:15 p.m., R2 pointed to the bruise under her left eye and wrists and stated, I got hit. I am scared I will get hurt again.

Based on interview and record review, the facility failed to have fall precautions in place at the time of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a subdural hematoma (beneath the surface swelling) and a C6 anterior interior endplate fracture (neck fracture). Findings include: Facesheet for R1 documents an admitted [DATE] (latest return to the facility from hospital) and lists the following Diagnoses: [REDACTED]. Consult Note for R1 dated 11/26/12 from local hospital admission documentation states, "CT (Computed Tomography) of the head does show a right high parietal subdural hematoma (beneath the surface swelling) that is acute...CT of the cervical spine shows C6 anterior inferior endplate fracture (neck fracture)." Neurosurgery consultation note dated 11/25/12 documents that "patient (R1) was brought to the emergency department today because she has had a fall this morning followed with altered mental status. Per her son, patient wheeled herself into an empty room at the nursing home and then fell off the bed. Staff estimates that patient got out of bed around 5 a.m. and was found around 6:30 a.m." The current Care Plan for R1 dated 9/13/12 states, "Resident at risk for falling related to decreased safety awareness secondary to impaired cognition, moderately impaired decision making, history of falls, [DIAGNOSES REDACTED]. Resident displays periods of altered perception/awareness of her surrounding and occasionally becomes restless. She is also hard of hearing." The current Care Plan for R1 dated 9/13/12 includes the following interventions/approaches: Approach Start Date: 11/25/2012 Ensure is in correct bed Approach Start Date: 9/6/2012 Change battery in alarm Approach Start Date: 4/23/12 Scoop mattress Approach Start Date: 1/13/2012 Chair Alarm Approach Start Date: 11/7/09 Encourage to assume a standing position slowly Approach Start Date: 11/7/09 Low bed with mats at bedsides. 1/5/12 Fall mats at bedside. On 12/4/12 at 7:20 AM, Z1/Family Member stated that R1 had five or six falls since 2002. Safety Event documentation for R1 dated 11/25/12 indicates that R1 was found in vacant resident room, laying next to the bed and had sustained a head laceration. Resident Progress Noted for R1 dated 11/25/12 documents, "At 6:20 AM CNA (Certified Nursing Assistant) supervisor alerted this nurse that the resident was on the floor bleeding in (another resident room). Resident had taken herself to another room to sleep and apparently fell out of bed. Resident noted to have nickel sized laceration to the middle of her forehead. Also another laceration on right side of forehead. Moderate amount of bleeding from both wounds. Resident agitated, not wanting to stay in a laying position...Called 911 at 6:25 AM." On 12/21/12 at 9:45 AM, E3/CNA stated, "We were short staffed and a CNA that works second shift stayed over to help. The second shift CNA reported to E3/CNA that R1 was not in her regular room." E3/CNA verified she checked on R1 at 4:00 AM and the bed was not in the low position and floor mats were not in place." On 12/5/12 at 8:30 AM, E2/DON (Director of Nursing) verified that R1 fell asleep in the wrong bed and the chair alarm did not sound because the wheelchairs were being washed and that the floor mats were not put in place. On 12/27/12 at 9:05 AM, E4/Physician verified that on 11/25/12 R1 fell asleep in the wrong bed. According to E4, the bed was not put in the low position and floor mats were not put in place because the staff did not want to wake her. E4/Physician verified that R1's injuries would probably had not been as serious if the fall mats were in place and the bed was in the low position.