Every finding on record at Mcleansboro Rehab & HLTH C CTR

Based on interview and record review, the facility failed to have a Registered Nurse working 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 35 residents residing in the facility. The Findings Include: Nursing schedules reviewed for June 7, 2024 through June 24, 2024 revealed the facility did not have Registered Nurse (RN) coverage on Saturday, 6/15/24 and Sunday, 6/16/24. On 6/24/2024 at 1:45pm, V5 (Corporate Administrator) said the facility does not have the required 8 hours of continuous RN coverage per day. V5 said the lack of RN coverage occurs on the weekends. On 6/24/24 at 2:00pm, V1 (Administrator) said there are weekends that the facility does not have the required RN coverage of 8 hours a day minimum. V1 said she was just happy to have nurses to work over the weekends even if they are not RNs. V1 verified no Registered Nurse worked 6/15/24 and 6/16/24. The facility's Resident Matrix dated 6/24/2024 documents 35 residents reside at this facility.

Based on interview and record review, the facility failed to have a Registered Nurse working 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 30 residents residing in the facility. The Findings Include: On 6/6/24 at 11:00 AM, V3 (Director of Nursing/DON) stated that there are weekends that she sometimes cannot get covered with a Registered Nurse (RN) working. V3 further stated that they do not use a staffing agency, but they have a PRN (as needed) float pool within the company and a list of facility specific PRN RN's that they attempt to have cover these shifts. V3 stated that they do have advertisements out to hire RN's but if there are times they cannot get RN's to cover the shift they use their LPN (Licensed Practical Nurses) staff. On 6/6/24 at 11:13 AM, V1 (Administrator) stated that there are days that no RN works 8 hours a day minimum, but that all her nursing staff are either licensed or registered. Nursing schedules reviewed for May revealed that no RN worked on 5/18/24, 5/19/24 and 5/31/24. The June scheduled revealed that no RN worked on 6/1/24 or 6/2/24. The Long Term Care Facility Application for Medicare and Medicaid dated 6/4/24, documents that 30 residents reside in the facility.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (R8) of 12 reviewed for accuracy of assessments in the sample of 23. Findings Include: R8's Admission Record documented R8 is [AGE] years old with an Initial admitted to the facility of 01/03/2019. Diagnoses listed on this document included anxiety disorder, schizophrenia, anemia, depression, and unspecified dementia. The OBRA Initial Screen for R8 dated 09/04/2017 documented under Part III, The individual has been formally diagnosed with a mental illness verified by a DSMIV classification which subsequently impairs the person's cognitive, emotional and/or behavioral functioning, excluding organic disorders/dementia, developmental disabilities, and alcohol/substance abuse. This section had an X marked to indicate the answer Yes. This OBRA Initial Screen also documented that R8 had a history of psychiatric hospitalization , a history of outpatient mental health services and listed R8's mental illnesses. The document further notes that R8 was referred to a health system for services on 09/11/17. R8's Interagency Certification of Screening Results dated 09/11/2017 documented screening indicated that nursing facility services are appropriate. R8's MDS with an Assessment Reference Date of 01/16/2024 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? This question had a 0 marked to indicate the answer No. This same MDS in Section I Active Diagnoses had a checkmark under Psychiatric/Mood Disorder with an X marked for I6000 Schizophrenia, indicating this was an Active diagnosis for R8. On 6/05/24 at 8:55 AM, V2 (MDS/Care Plan Coordinator) stated that no one in the facility is a Level II. V2 further stated that R8's dementia diagnosis outweighs her schizophrenia diagnosis, so a Level II was not needed. V2 stated she will check into it. On 06/05/24 at 2:43 PM, V2 stated that she had submitted a new PASARR. On 06/06/2024 at 11:35 AM, V2 stated that the facility should have completed a new PASARR when she was diagnosed with Dementia.

Based on interview and record review, the facility failed to add new person centered fall interventions to prevent falls for 1 (R120) of 2 residents reviewed for falls in the sample of 23. The findings include: R120's Admission Record documented R120 was [AGE] years old with an admitted to the facility of 3/11/2023. Diagnoses listed include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, coronary artery dissection, essential (primary) hypertension, disorder of thyroid, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, insomnia unspecified, unspecified osteoarthritis, unspecified site, muscle weakness (generalized), hypomagnesemia and other forms of dyspnea. R120's Minimum Data Set (MDS) section C, dated 5/8/2024, documents that R120 has a Brief Interview for Mental Status (BIMS) score of 5, indicating R120 has severe cognitive impairment. The same MDS section GG0170, Mobility documents that R120 needs supervision or touching assistance and device uses a cane/crutch. R120's Fall Risk assessment dated [DATE] documents a score of 20, which indicates that R120 was a high risk for falls. R120's Investigation Report for Falls dated 5/8/2024 documents resident was found sitting on buttocks on the floor with back against her bed. Resident attempted to get out of bed related to confusion (chronic) without assist. No new interventions were listed or noted on this document. R120's Care Plan dated 3/11/2023 documents a focus area of The resident is at risk for falls, risk for injury from fall with a documented goal of the resident will be free of falls, free of injury from falls through the next review date. Interventions included call light in reach, personal items in reach, proper footwear, staff assist/standby for all transfers with an implementation date of 3/11/2023 and walk per staff to dining room with an implementation date of 2/15/2024. There were no new interventions listed as being added/implemented to the care plan to prevent further falls after the 5/8/24 fall incident. On 6/05/2024 at 1:42 PM, V3 (Director of Nursing/DON) stated she was not aware that R120 had a fall on 5/8/2024. V3 stated she found the fall investigation today in the to be filed paperwork. V3 stated there was no new intervention put in place for R120 after the 5/8/2024 fall. V3 stated the facility policy does document new interventions should be immediately put in place, the fall reviewed in morning meetings and then additional fall interventions if needed after reviewing the fall investigation. On 6/06/2024 at 9:15 AM, V2 (MDS Coordinator) stated all falls are communicated to V1 (Administration) and V3 (DON) and discussed in the morning meetings. V2 stated new interventions are entered into resident Care Plans by V2 and/or V3. V2 stated she was not notified of R120's fall on 5/7/2024 and no new intervention was added to her care plan. The Fall Prevention policy with revised date of 11/10/2018 documents .5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the certified nurse assistant assignment worksheet .

Based on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one of three residents (R1) reviewed for abuse in the sample of 3. This failure resulted in R1 experiencing burning pain and irritation as a result of hand sanitizer being applied to her bottom and legs, some areas of which had excoriation. A reasonable person would also experience feelings of intimidation, fear, emotional distress, and helplessness as a result. Findings include: R1's face Sheet documented an admitted [DATE], and diagnoses including Alzheimer's Disease, Dementia, Chronic Pain, Excoriation (skin picking) Disorder, Anxiety, Hypertension, Gastroesophageal Reflux Disease (GERD), and Osteoporosis. R1's Minimum Data Set, dated dated dated for 4/17/2024, documents that R1 has a Brief Interview for Mental Status (BIMS) score of 2, indicating that R1 has severe cognitive impairment . The same MDS documents that R1 is totally dependent on at least two persons assist for transfers, bed mobility, dressing, eating, and toileting needs. On 5/1/2024 at 9:40am, attempted interview with R1 but due to severe cognitive impairment, R1 was unable to answer questions appropriately. On 5/1/2024 at 10:26am, V1 (Administrator) stated she was notified on 4/14/2024 at approximately 9:00am by V3 (Licensed Practical Nurse/ LPN) about an allegation of abuse. The allegation of abuse involved staff V11 (Certified Nurse's Assistant/ CNA) to R1. V1 stated through the investigation process, it was discovered the actual incident occurred on 4/10/2024 during the evening/night shift. V1 stated V11 reported to her during the investigation, that V11 used Shear Prep Pads which is a barrier/adhesive skin prep used for a prepping the skin prior to applying tape, on R1's bottom and legs to stop her from scratching. V1 stated Shear Prep pads are 2x 2 in size are kept locked up by the nurses and it would take a million of these to perform peri care. V1 stated, during the investigation her interviews with other CNA's revealed that V11 told them he applied hand sanitizer to R1's coccyx and legs to stop her from scratching. On 5/1/2024 at 1:18pm, V8 (Certified Nurse Assistant/ CNA) stated that V7 (CNA) told her that V7 and V11 were caring for R1 when V11 put hand sanitizer on R1's open areas where R1 scratches. V8 stated she was not sure when this happened, she has never seen abuse, but she knows to report it immediately to V1 (Administrator). V8 stated she did not report to anyone at the time she was told about the incident. On 5/1/2024 2:32pm, V3 (Licensed Practical Nurse/LPN) stated she had abuse reported to her on 4/13/2024 by V4 (CNA). V3 stated V4 told her that V11 threatened R1 to stop scratching and then put hand sanitizer on her scratched areas. V3 stated she instructed V4 to report to V1 immediately. V3 stated she worked the next day and V1 came to the facility and V3 did a head-to-toe assessment on R1. V3 stated the assessment didn't reveal any new issues as R1 always has a red bottom with scratches. R1 did not show any signs of abuse. On 5/1/2024 2:10pm, V10 (family member) stated she was notified by V1 of the incident that involved R1 on 4/14/2024. V10 stated she has not seen any change in V10 since the reported incident. V10 stated R1 has had issues with her skin and scratching for many years and she has seen many doctors to find out what the cause is but the doctors, including dermatologist, do not know what the cause is. V10 stated after the investigation it seems as though the incident did occur, but she wasn't for sure. V10 stated she is surprised because she knew V11, but if he would treat anyone in this way then he doesn't need to work around residents. V10 stated she feels like R1 is safe here in the facility. On 5/1/2024 11:38am, V7 (CNA) stated she didn't report the abuse of R1 herself because she has issues at home with DCFS (Department of Children and Family Services) so she told V8 (CNA), who then told V4 (CNA), who was supposed to tell the LPN (Licensed Practical Nurse). V7 said she is unsure of who the LPN was that was told and is not sure if she was notified. V7 stated she was aware abuse is to be reported immediately but was afraid to do it herself. V7 stated she knows to report to V1 immediately. ON 5/1/2024 at 9:40am, R1 was observed receiving peri care per V4 (CNA) and V6 (CNA). R1 noted to have multiple scratch marks to her peri area, buttocks, and upper thighs, with many areas open with small amount of blood noted. The Abuse Investigation's provided by the facility were reviewed. A document titled Incident Investigation Form contained a phone interview with V11 dated 4/17/2024 at 1:47pm, and documented by V1, stating the resident was cleaned with sheer prep. V11 was asked if he had anything else to state add and V11 said, no I don't. The document was signed by V11. An undated and untimed document titled Incident Investigation Form documents that the Person Conducting Investigation as V1 and the person being interviewed as V7 (CNA). The form had a statement signed by V7 that states one night me (V7) and V11 was working together. After we did 1am bed checks, he (V11) put hand sanitizer on (R1's) legs because he (V11) thought it would be funny. I (V7) asked him why he (V11) did it and he (V11) just smiled. I (V7) didn't go into the room to check her, so I (V7) didn't see the incident happen. An Incident Investigation Form dated 4/14/2024 at 2:00pm, with an interview conducted by V1 with R1 documents Resident (R1) was asked by the investigator if she remembered ever being cleaned up and it burning? Resident (R1) stated, 'yeah it burnt like fire, I don't know why he done that.' Resident (R1) then rubbed upper thigh. This document signed by V1 and witnessed by V6 (CNA). An Incident Investigation Form with an interview conducted by V1 with V3 (LPN) document CNA (V4) reported to me that CNA (V8) had told her about (V11) abusing (R1). I (V3) asked what happened and (V8) told (V4) she was told that he (V11) was threatening (R1) with hand sanitizer if she (R1) would not stop itching so he (V11) rubbed hand sanitizer on her (R1) wounds on her (R1) coccyx. I (V3) told (V4) that is abuse and they need to report it asap to (V1) and or (V2-Director of Nursing ). Nothing can be done unless it is reported. This document has no date or time on it but is signed by V3. The facility policy titled Abuse Prevention Program, dated 11/28/2016, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our resident.

Based on interview and record review, the facility failed to implement abuse policies by not reporting abuse within the designated time frames for 2 of 3 residents (R1 and R3) reviewed for abuse in a sample of 3. Findings Include: 1. R1's face Sheet documents an admitted [DATE] with diagnoses including Alzheimer's Disease, Dementia, Chronic Pain, Excoriation (skin picking) Disorder, Anxiety, Hypertension, GERD, and Osteoporosis. R1's Minimum Data Set, dated dated dated for 4/17/2024, documents a Brief Interview for Mental Status (BIMS) score of 2, indicating that R1 has severe cognitive impairment. The same MDS documents that R1 is totally dependent of at least two persons for transfers, bed mobility, dressing, eating, and toileting needs. On 5/1/2024 at 10:26am, V1 (Administrator) stated she was notified on 4/14/2024 at approximately 9:00am by V3 (Licensed Practical Nurse/LPN) about an allegation of abuse. The allegation of abuse involved staff V11 (Certified Nurse's Assistant/CNA) to R1. V1 stated through the investigation process, it was discovered the actual incident occurred on 4/10/2024 during the evening/night shift. V1 stated V11 reported to her during the investigation, he (V11) had used Shear Prep Pads on R1's bottom and legs, to stop her from scratching. V1 stated Shear Prep pads are 2x 2 in size are kept locked up by the nurses and it would take a million of these to perform peri care. V1 stated, during the investigation her interviews with other CNA's revealed that V11 told them he applied hand sanitizer to R1's coccyx and legs to stop her from scratching. V1 stated she is the Abuse Coordinator. On 5/1/2024 at 2:32pm, V3 (LPN) stated she had abuse reported to her on 4/13/2024 by V4 (CNA). V3 stated V4 told her that V11 threatened R1 to stop scratching and then put hand sanitizer on her scratched areas. V3 stated she instructed V4 to report to V1 immediately. V3 stated she worked the next day and V1 came to the facility and V3 did a head-to-toe assessment on R1. V3 stated the assessment didn't reveal any new issues as R1 always has a red bottom with scratches. R1 did not show any signs of abuse. On 5/1/ at 2:10pm, V10 (family member) stated she was notified by V1 on 4/14/2024 of the incident that involved R1 on 4/10/2024. On 5/1/2024 at 11:38am, V7 (CNA) stated she didn't report it herself because she has issues at home with DCFS (Department of Children and Family Services) so she told V8 (CNA) who then told V4 (CNA) that she was supposed to tell the LPN (Licensed Practical Nurse). V7 said she is unsure of who the LPN was that was told and is not sure if she was notified. V7 stated she was aware abuse is to be reported immediately but was afraid to do it herself. V7 stated she knows to report to V1 immediately. The Final Investigation dated 4/17/2024 addressed to Illinois Department of Public Health documents Please accept this letter as the final report to the initial notification on 4/14/2024 regarding a resident abuse allegation. On 4/14/2024 at approximately 9:00am (V1) was given report of abuse to (R1). (name of city) police department, MD (Medical Director), and POA (Power of Attorney) were notified, and initial report filed, and investigation started immediately. Staff accused, (V11), was suspended upon investigation. 2. R3 's Face Sheet documented an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. R3's Minimum Data Set, dated dated dated for 4/23/2024, documented R3 has a BIMS score of 15, indicating R3 is cognitively intact . The same MDS documents that R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:30am, R3 stated she was abused during a shower. R3 stated V12 (CNA) wadded up a washcloth and jabbed it in her stomach (belly button area). R3 stated it left a big red area and bothered her for a bit. R3 stated she reported it to V1 and things are better now because V1 changed R3's shower times so V12 will not be assisting her with showers anymore. R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:45am, abuse investigation file for R3 was requested from V1. V1 stated it wasn't abuse and the Ombudsman (V13) was here, and she said it wasn't abuse, so I didn't do a reportable. V1 stated she didn't do an investigation. On 5/2/2024 12:33pm, V13 (Ombudsman) stated R3 came to her on 4/4/2024 and said V12 jabbed her in the abdomen with a washcloth during her shower. V13 stated she asked R3 if she reported this to V1, and she stated no. V13 stated she went to V1 a few minutes later and reported it to V1 and V1 stated that R3 had just told her. V13 was asked if she reported the incident with R3 as abuse to V1 and V13 stated, yes I did report it as abuse. V13 stated she returned on 4/10/24 and met with R3 and R3 stated the issue was resolved so she closed the case. V13 stated V1 told her that she took care of the issue. On 5/2/2024 at 12:50pm, V1 stated she was initiating an investigation on the allegation of abuse for R3. On 5/2/2024 at 4:05pm, V12 (CNA) stated she has assisted R3 with a few showers but R3 is mostly requires set up help with showers. V12 states she doesn't recall ever having any issues with R3 and she denied pushing a washcloth into her abdomen. V12 states she doesn't know why R3 would say that as that is abuse and she would never do that. On 5/2/2024 at 4:09pm, V14 (CNA) stated she has never witnessed abuse with R3 or by anyone. V14 states she does help with care for R3 but she has never had any issues and R3 has never reported any type of abuse to her. R3's progress notes from 4/1/2024 through 5/2/2024 were reviewed and no documentation was noted of complaints of abuse or discomfort. A document titled Ombudsman Complaint Form dated 4/4/24 at 1:00pm from V13 documents a reference title of Abuse. The intake description documents Resident (R3) approached (V13) on this visit to report that this past Monday, her shower day, she almost fell out of her shower chair, but didn't and prior to that the shower aid had taken a washcloth and jabbed it into the resident's (R3) stomach. Resident (R3) reported that this hurt, and she felt it was abuse. (R3) did not report this to anyone else. Resident (R3) gave (V13) permission to speak to (V1) and (V13) advised (R3) to report this to (V1). The same complaint form documents on 4/4/2024 at 1:20pm that V13 met with V1 to discuss R3's complaint of a staff member stabbing a washcloth in R3's stomach, and she feels this is abuse. V1 was unaware of this until R3 told her today. V1 is confused about who R3 says had done this to her. V13 informed V1 that she would be following up on this next week. Case Notes by V13 dated 4/10/2024 at 2:05am documents that (V13) returned to the facility to speak with resident (R3). Resident (R3) stated that her showers have been okay and no conflict or aggression by the shower staff. (V13) is closing the case with the permission of (R3). On 5/3/2024 at 12:30pm, V1 provided R3's final investigation report to the initial investigation submitted on 5/2/24 regarding a resident abuse allegation. The report documents that V1 was notified of the allegation of abuse on 5/5/2024. The report documents the (name of city) Police came to the facility on [DATE] in connection with this investigation. On 5/3/2024 at 1:00pm, V1 stated that the allegation of abuse involving R3 was found to be unsubstantiated. The facility policy titled Abuse Prevention Program, dated 11/28/2016, documents under section IV titled Internal Reporting Requirements and Identification of Allegations that Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The same policy documents under section VII titled External Reporting of Potential Abuse that The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but no later than two hours after forming suspicion), Otherwise, the report must be made not later than 24 hours after forming suspicion.

Based on interview and record review the facility failed to initiate and thoroughly investigate an allegation of abuse for 1 of 3 residents (R3) reviewed for abuse in a sample of 3. The Findings Include: R3 's Face Sheet documented an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. R3's Minimum Data Set, dated dated dated for 4/23/2024, documented R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. The same MDS documents that R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:30am, R3 stated she was abused during a shower. R3 stated V12 (CNA) wadded up a washcloth and jabbed it in her stomach (belly button area). R3 stated it left a big red area and bothered her for a bit. R3 stated she wasn't sure of the date that it occurred, but it had been a little while, maybe a few weeks. R3 stated she reported it to V1 (Administrator) and things are better now because V1 changed R3's shower times so V12 will not be assisting her with showers anymore. On 5/2/2024 at 9:45am, abuse investigation file for R3 was requested from V1. V1 stated it wasn't abuse and the Ombudsman (V13) was here, and she said it wasn't abuse, so I didn't do a reportable. V1 stated she didn't do an investigation. On 5/2/2024 12:33pm, V13 (Ombudsman) stated R3 came to her on 4/4/2024 and said V12 jabbed her in the abdomen with a washcloth during her shower. V13 stated she asked R3 if she reported this to V1, and she stated no. V13 stated she went to V1 a few minutes later and reported it to V1 and V1 stated that R3 had just told her. V13 was asked if she reported the incident with R3 as abuse to V1 and V13 stated, yes I did report it as abuse. V13 stated she returned on 4/10/24 and met with R3 and R3 stated the issue was resolved so she closed the case. V13 stated V1 told her that she took care of the issue. On 5/2/2024 at 12:50pm, V1 stated she was initiating an investigation on the allegation of abuse for R3. A document titled Ombudsman Complaint Form dated 4/4/24 at 1:00pm from V13 documents a reference title of Abuse. The intake description documents Resident (R3) approached (V13) on this visit to report that this past Monday, her shower day, she almost fell out of her shower chair, but didn't and prior to that the shower aid had taken a washcloth and jabbed it into the resident's (R3) stomach. Resident (R3) reported that this hurt, and she felt it was abuse. (R3) did not report this to anyone else. Resident (R3) gave (V13) permission to speak to (V1) and (V13) advised (R3) to report this to (V1). The same complaint form documents on 4/4/2024 at 1:20pm that V13 met with V1 to discuss R3's complaint of a staff member stabbing a washcloth in R3's stomach, and she feels this is abuse. V1 was unaware of this until R3 told her today. V1 is confused about who R3 says had done this to her. V13 informed V1 that she would be following up on this next week. Case Notes by V13 dated 4/10/2024 at 2:05am documents that (V13) returned to the facility to speak with resident (R3). Resident (R3) stated that her showers have been okay and no conflict or aggression by the shower staff. (V13) is closing the case with the permission of (R3). On 5/2/2024 at 4:22pm, V1 stated that according to her investigation earlier in the day that she believes this allegation occurred on 4/1/2024 as R3 told V13 on Thursday, 4/4/2024 the incident occurred the Monday prior to R3 reporting which would be 4/1/2024. V1 was unable to provide evidence of an investigation that was initiated on 4/4/2024 when V13 notified V1, who validated she is the Abuse Coordinator. The facility policy titled Abuse Prevention Program dated 11/28/2016, documents in Section VI titled Internal Investigation of Allegation and Response documents that 1. Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property; the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. The Resident Protection Investigation Procedure documents Titles: Preparation, Confidentiality, Definitions of Abuse, Choosing an Investigation Path, Investigation Procedures, The Interview Process, and Final Investigation Report. Under the title of Investigation Procedures it documents Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation shall consist of : Review of the initial written reports, completion of a written report of the status of the investigation of the occurrence, an interview with the person(s) reporting the incident, interviews with any witnesses to the incident, an interview wit the resident, where appropriate, an interview with the resident's attending physician or psychiatrist, a review of the medical records of any resident involved in the occurrence, if the accused individual is an employee, review the personnel file to check for references, background check, and documentation of orientation and training, an interview with staff members having contact wit the resident and accused individual during the period of the alleged incident, where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident, interviews with other residents to which the accused individuals has regular contact, interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual, obtain address, phone number and social security number of the accused individual, and interview with the accused individual or individuals and a review of all circumstances surrounding the incident.

Based on interview, observation, and record review, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 3 residents (R2) reviewed for therapy services in a sample of 3. The findings include: R2's Admission Record documents that R2 was admitted to the facility on [DATE] with a diagnoses of chronic kidney disease, unspecified, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, unspecified, essential (primary) hypertension, unspecified atrial fibrillation, gastro-esophageal reflux disease without esophagitis, depression, unspecified, anemia in chronic kidney disease, hypertensive heart disease without heart failure, edema, unspecified, and other seasonal allergic rhinitis. R2's Minimum Data Set (MDS) dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R2 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R2 requires setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, dependent with toileting hygiene, lower body dressing, putting on/off footwear, bed mobility, and transfers, and requires partial/moderate assistance with upper body dressing. R2's Physician's orders dated 2/6/2024 documents Physical Therapy (PT)/Occupational Therapy (OT): Skilled PT/OT 5 times/week x 30 days. Therapy to include Therapeutic Exercises, Therapeutic Activities, Neurological Re-Education, Gait Training, Group Therapy, Self-Care Management, Wheelchair assessment and management. R2's PT Treatment Note dated 2/05/2024 documents a medical diagnosis of cerebral infarction, unspecified, a treatment diagnoses of muscle wasting and atrophy, necrotizing enterocolitis (NEC), multiple sites, and unsteadiness on feet. R2's PT Treatment Note dated 1/22/2024 - 1/26/2024 documents medical diagnoses of heart failure, unspecified and personal history of COVID-19 (1/14/2024) and treatment diagnoses of muscle wasting and atrophy, NEC, multiple sites, and unsteadiness on feet. R2's PT Note dated 1/22/2024 documents this [AGE] year-old male hospitalized with COVID-19, 1/14/2024 - 1/19/2024, continues to be on isolation here at skilled nursing facility. (R2) was previously hospitalized secondary to heart failure (stage III to almost IV). (R2) presented today with deficits in overall activity tolerance, functional mobility, functional transfers, bed mobility, sitting and standing balance/tolerance, bilateral upper extremity strength, and increased need for assistance with self-care tasks. (R2) would benefit from skilled PT services to improve above deficits to increase independence and safety to prior level of functioning. R2's OT Treatment Noted dated 2/05/2024 documents this [AGE] year-old male was referred to skilled OT services after recent hospitalization secondary to stroke due to unknown causes. (R2) was also recently hospitalized due to COVID-19 and heart failure (stage III to almost IV). (R2) presented today with deficits in overall activity tolerance, functional mobility, functional transfers, bed mobility, sitting and standing balance/tolerance, bilateral upper extremity strength, and increased need for assistance with self-care tasks. (R2) would benefit from skilled OT services to improve above deficits to increase independence and safety to prior level of functioning. While at facility to complete evaluation nursing staff reported that (R2's) vitals fluctuate. (R2) would benefit from skilled OT services to improve above deficits to increase independence and safety as well as reduce caregiver burden. The Monthly Census for January 2024 documents R2 is receiving Medicare days for therapy services from 1/09/2024 - 1/13/2024; 1/19/2024 - 1/25/2024; and February 2024 documents R2 is receiving Medicare therapy services from 2/2/2024 - 2/22/2024. R2's Notice of Medicare Non-Coverage documents services (PT/OT) will end 2/22/2024 related to end of therapy services; reason Medicare may not pay. The facility's document titled Name of Previous Contracted Rehabilitation Service Company dated 2/13/2024 documents in part . Termination of Therapy Services Agreement . failure to maintain payment terms, pursuant to Section 5.2.5 of the Therapy Services Agreement .final date of service will be Sunday, February 18, 2024. The facility's therapy services agreement dated 3/13/2024, documents in part . This Agreement (Agreement) is made of the 12th day of March 2024, by and between newly contracted rehabilitation service company. On 3/14/2024, at 3:35 PM, R2 stated that the first go around he was getting therapy to help him walk better. R2 stated that his blood pressure drops at times and makes it a little hard at times. R2 stated the second go around here, therapy has not been here to give him any help. On 3/18/2024 at 1:05 PM, R2 stated that he gets around with his wheelchair well but can't get up and walk by himself and the staff won't help him walk without therapy approving it. R2 stated that he does not know how many therapy days he has missed. R2 stated that his family is working on getting him moved closer to them. On 3/18/2024 at 1:10 PM, V1 (Administrator) stated that there is no exact date yet when the new therapy service will start. V1 stated the facility is not accepting any new admissions that require therapy services. V1 stated that all primary physicians were notified of therapy services ending on 2/18/2024. V1 stated that V5 (Occupational Therapist) was here on 2/19/2024 - 2/23/2024 and did provide therapy services for R2. V1 stated that R2's last day of coverage for therapy services was 2/22/2024 with 17 days remaining. V1 stated that a referral was sent out to a local facility on 3/13/2024 to transfer R2 to but there has not been any response back yet. V1 stated that R2 was receiving therapy services 5 days a week. On 3/18/2024 at 1:40 PM, left message for V5 (OT) to return call with no call back during this survey. On 3/18/2024 at 1:55 PM, V6 (Family) stated that the facility notified her of R2's therapy services being stopped on 2/18/2024. V6 stated that they are in the process of getting R2 transferred back closer to them to help take care of him. V6 stated that they are trying to acquire veteran benefits for R2 since he is a retired veteran. On 3/18/2024 at 5:55 PM, V7 (Primary Physician) stated that she would expect the facility to acquire therapy services as soon as possible or transfer any resident to another facility as soon as possible so that therapy services would not be disrupted and residents' activity level would not decline any further. On 3/14/2024 and 3/18/2024, there were no observations of therapy services being provided to any resident at the facility.

Based on interview and record review the facility failed to have a registered nurse, at least 8 consecutive hours, 7 days a week. This has the potential to affect all 23 residents who reside at this facility. Findings include: On 11/13/2023, at 1:00 p.m., V2, (Director of Nursing), stated that the following dates in September 2023 (9/9, 9/13, 9/15), October 2023 (10/3, 10/5, 10/6,), and November 2023, (11/04) there was no registered nurse (RN) coverage for those days. The facility's nursing schedules for the months of September, October, & November 2023 documents the following dates with no RN coverage: September 2023 (9/9, 9/13, 9/15), October 2023 (10/3, 10/5, 10/6) and November 2023 (11/4). A facility document titled Daily Census dated 11/13/23 documented the facility had 23 residents residing in the facility.

Based on interview, observation and record review, the facility failed to follow through with a wound referral for a worsening pressure ulcer, failed to timely reassess and identify worsening pressure ulcer, and timely treat new wounds for 1 of 2 residents reviewed for pressure ulcers in the sample of 16. This failure resulted in the worsening and infection of R12's pressure ulcer to the right ankle. Findings: R12's medical record, New Admission Information documents an admitted [DATE] with diagnoses including Hypertension, Edema (multifactorial component of Congested Heart Failure/Venous Stasis). R12's Minimum Data Set (MDS) dated [DATE], documents in Section C, Brief Interview for Mental Status (BIMS) score is 9, moderately impaired cognition, Section G, Functional Status, Extensive Assistance with one-person physical assistance with bed mobility, dressing, and personal hygiene, Extensive assistance with two-person physical assistance with transfers and toileting. R12's Nursing Admission assessment dated [DATE] documents no skin issues noted. R12's Care Plan documents Moderate Risk for Pressure Ulcer per Braden Risk Assessment. Risk factors include impaired mobility and incontinence. Strengths include can turn self in bed, with a start date of 1/30/2023; Will have no new open areas caused by pressure or friction for the next 90 days, with a goal date of 4/30/2023; Interventions: Skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly; Dietary consult to consider nutrition/hydration factors for treating related risk factors; Initiate extra calories, protein, vitamins as recommended; Initiate supplements as needed/recommended; See Physician's Order Sheet for orders; Apply house stock incontinent barrier cream to peri-area after every incontinent episode and as needed; Toilet/change brief when wet and upon rising, at bedtime, and after meals; Maintain clean, dry, wrinkle free linens with a start date of 1/30/2023. R12's Braden Assessments dated 2/12/23, 2/22/23, 3/1/23, and 3/8/23 all documents R12 is considered a high risk for pressure ulcers. R12's Progress Notes dated 2/15/2023, documents R12 has a stage II area to right outer ankle measuring 0.9 centimeters (cm) x 1.1cm, area scabbed over with no drainage or signs and symptoms of infection noted. R12's Physician's Orders dated 2/15/2023, documents 1. Cleanse Stage II area to right outer ankle with normal saline. Apply skin barrier to wound and surrounding area, let dry. Cover area with clean, dry dressing daily and as needed until healed, 2. Heel protectors to be used at all times while in bed. R12's Wound Tracking dated 2/28/2023 documents right ankle measurements of 1.6 cm x 1.7 cm. A fax report from V5 (Nurse Practitioner) dated 2/28/23 documents, Refer to wound care. At the bottom is a handwritten note from V5 that states, cleanse Stage II area to right outer heal bone with normal saline and pat dry. Apply Aquacel to wound and cover with padded dressing. Change every 4 days and as needed. R12's Physician's Orders dated 2/28/2023, documents 1. Add nutritional juice drink twice a day and multivitamin with mineral daily for wound healing, 2. Cleanse Stage II area to right outer ankle with normal saline and pat dry, apply Aquacel to wound bed and cover with padded dressing, change every 4 days and as needed. R12's Wound Tracking dated 3/12/2023 documents right ankle wound measurements of 2cm x 2cm. R12's Progress Notes dated 3/12/2023 documents right great toe, hard, black, scab-like measures 1.75cm x 1.75cm rounded, right third toe measures (1cm x 1cm), wound bed appears yellow colored with red edges. R12's Physician's Orders dated 3/13/2023, documents double protein at breakfast. There we no new orders documented in R12's record to treat the wounds found on the right great or the right third toe for the month of March and no records to indicated R12's physician was notifed of the new wounds. R12's Wound Tracking dated 4/6/2023 documents measurements right ankle of 2.1cm x 1.8cm, right outer great toe 1cm x 0.8cm, and right middle toe 1cm x 1cm. There was no documentation noted in R12's record that R12's physician was notified of the wounds found on the toes on 4/6/23 until 4/16/23. R12's Physician Notification dated 4/16/2023 documents updated wound measurements of right outer ankle 2cm x 2cm, right outer great toe 1cm x 0.75cm, and right middle toe 1cm x 1cm and current treatment orders sent to V8 (Nurse Practitioner) with orders to continue current treatment to right ankle and there were no orders given to treat the wounds on the toes. R12's Physician's Orders dated 4/19/2023 documents skin barrier to right great toe and second toe twice a day as a preventive measure and to monitor twice a day until healed. R12's Physician Notification dated 4/30/2023 documents pressure wounds to right ankle and middle toe are open and have yellow drainage with an odor noted, right ankle measures 2.25cm x 2.25cm and right middle toe measures 1cm x 1.25cm. R12's Physician's Orders dated 5/1/2023 documents obtain culture of all wounds, complete blood count, basic metabolic panel, and start doxycycline 100 milligrams (mg) every 12 hours x 10 days. R12's Lab Results dated 5/3/2023 documents culture wound (ankle), heavy growth of Morganella morganii (Abnormal) with new orders from V8 (Nurse Practitioner) to discontinue doxycycline and start Cipro 500mg every 12 hours x 10 days; if not on probiotic, start daily while on antibiotic. R12's Treatment Record for 2/1/23-2/28/23 documents treatment, start date 2/15/23, apply skin prep to Stage II area and surround tissue. Let dry and cover with clean, dry, dressing twice a day. On the 6AM-6-PM shift the dates 2/22/23, 2/23/23 and 2/24/24 did not contain initials that the treatment was done. On the 6PM-6AM shift the dates 2/21/23, 2/24/23 and 2/27/23 did not contain initials that the treatments were done. On 5/3/2023, at 2:00 p.m., observed R12's right ankle wound to have a yellow-colored wound bed with moderate amount of yellow colored drainage noted, right great toe and right middle toe were scabbed over. R12 stated no complaints of pain noted, the nurse changes his ankle dressing every few days and he wears his heel protectors when he goes to bed. R12 stated that if he has any pain, he tells the staff and the nurse brings him his pain medication and it helps with his pain. R12 stated he does not know how he got the wound on his ankle. On 5/3/2023, at 2:15 p.m., V2 (Licensed Practical Nurse), stated that she has called the wound clinic today to get R12 a referral for his right ankle wound. V2 stated the referral got missed. V2 stated she notified V5 (Nurse Practitioner) on 4/18/2023 that R12's right ankle wound had increased in size from 2.1cm x 1.8cm to 2cm x 2cm and right great toe & middle toe were scabbed over. V2 stated that there was no drainage to any of the areas at that time. V2 stated that when a weekly assessment or treatment has been documented, the assessment and treatment has been completed. On 5/4/2023, at 11:30 a.m., V5 (Nurse Practitioner) stated that R12 had an order for a referral for wound care on 2/28/2023 and it is not an appropriate amount of time to wait and get a referral for wound care until 5/3/2023. On 5/4/2023, at 12:25 p.m., V8 (Wound Clinic Scheduler) stated that yesterday, 5/3/2023, was the first time the facility called the wound clinic to get a referral for R12. V8 stated she received R12's referral for wound care yesterday and R12 has an appointment scheduled for 5/17/2023. The facility's policy Decubitus/Pressure Areas revised 1/18 documents in part, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer .4) Notify the physician for treatment orders. The physician's orders should include: i) type of treatment, ii) frequency treatment is to be performed, iii) how to cleanse, if needed, iv)site of application

Based on interview, and record review the facility failed to provide 8 hours daily, 7 days a week of Registered Nurse coverage for the facility. This failure has the potential to affect all 19 residents living in the facility. Findings Include: The Nursing Schedules from January 2023 - May 4, 2023 documents no RN coverage was provided at the facility on 1/3, 1/14, 1/18, 1/19, 1/20, 1/21, 1/25, 1/26, 1/27, 2/4, 2/7, 2/8, 2/11, 2/18, 3/4, 3/11, 3/14, 3/22, 3/25, 3/26, 3/27, 3/31, 4/7, 4/8, 4/9, 4/14, 4/15, 4/20, 4/21, 4/22, 4/27, 4/28, & 5/1. On 5/4/2023 at 12:00 p.m., V1 (Acting Administrator) stated there are three registered nurses (RNs) that work at the facility. V1 stated that there is not a current Director of Nursing at the facility and that V3 (Regional RN) fills in at the facility at times. V1 verified the nursing schedules for January to May were accurate and they didn't have nurse coverage 8 hours a day 7 days a week. On 5/2/2023 - 5/04/2023, observed V3 (Regional RN) at the facility during this survey. The Resident Census and Conditions Form dated 5/1/2023 documents 19 residents reside at the facility.

Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) working in the facility eight consecutive hours a day, seven days a week. This has the potential to affect all 21 residents residing in the facility. Findings include: The facility's July and August 2022 Nurse Master Schedule was reviewed and showed there was no Registered Nurse (RN) working in the facility eight consecutive hours on July 2, 3, 9, 16, and 30, 2022. On 8/5/22 at 1:55 PM, V2 Director of Nursing (DON) verified there was no RN working in the facility for eight consecutive hours on July 2, 3, 9,16, and 30, 2022. On 8/9/22 at 2:46 PM, V1 (Administrator) said she expected an RN to be working in the facility at least eight hours a day, seven days a week. V1 said the facility was facing some staffing shortages at this time. A Bed List retrieved from the facility on 8/5/22 documented there are 21 residents living in the facility. The facility's undated Nurse Staffing policy documented in part . It is the policy of [the facility] to provide sufficient licensed . nursing staff on each day . Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health . A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by registered nurses .

Based on interview, and record review the facility failed to allow a resident to possess a wallet containing a debit card. This applies to 1 out of 3 residents (R3) reviewed for misappropriation of property in the sample of 3. Findings include: R3's face sheet documented R3 was admitted to the facility on [DATE]. R3's most recent care plan documents diagnoses to include: [CONDITION(S)], heart failure, hypoxemia, hypertension, chronic kidney disease. R3's 5/17/22 Minimum Data Set (MDS) documents a Brief Interview for Mental Status (BIMS) score of 13, meaning R3 was cognitively intact. On 8/5/22 at 9:35 AM, R3 stated on 8/4/22 V4 (Business Office Manager) had came into her room and taken R3's wallet containing her debit/ credit card and locked it up. R3 said she did not consent for V4 to take her wallet but V4 told her she needed to lock it up. R3 said she had her wallet and debit/ credit card in her possession since her admission to the facility and would prefer to keep her wallet containing her debit/ credit card in her possession. On 8/5/22 at 10:15 AM, R3 said the facility staff had told her she could not use any of her money until the Medicaid situation gets cleared up. They said I had too much money. On 8/5/22 at 10:10 AM, V4 (Business Office Manager) said she had locked R3's wallet containing R3's debit/ credit card up in the filing cabinet in V4's office on 8/4/22. On 8/5/22 at 10:20 AM, V4 said V4 had assisted R3 to contact R3's bank to change the address on R3's account so R3 would receive bank statements in the facility. V4 said while assisting R3 with contacting R3's bank V4 had learned R3 had a large sum of money in R3's checking account. V4 said after learning of R3's checking account balance she contacted V6 (Medicaid Application Specialist) via email. V4 said V6 had told V4 the facility had to account for all money spent by R3 with receipts and V4 needed to lock up R3's wallet containing R3's debit/ credit card so the facility would know when R3 spent any money. The 8/1/22 and 8/5/22 email correspondence between V4 and V6 did not instruct V4 to take possession of R3's wallet containing R3's debit/ credit card. V6's 8/1/22 at 12:21 PM email correspondence to V4 documented in part .she (R3) does need to spend her money down, and she is allowed to use it for her betterment Also, please make sure we (the facility) save the receipts for any purchases that she (R3) makes. She (R3) essentially will have to account for every penny she spends . On 8/5/22 at 1:37 PM, V6 (Medicaid Application Specialist) said V6 did not instruct V4 to take possession of R3's wallet containing R3's debit/ credit card and denied any need for the facility to take possession of R3's wallet containing R3's debit/ credit card. V6 stated [R3] can absolutely spend her money as long as we (the facility) get a receipt. On 8/5/22 at 12:05 PM, V5 (Regional Director) stated our standard should be we (the facility) have a discussion with the resident before taking any property to be locked up and progress note should be made regarding the discussion. V5 said all resident's have the right to keep their property in their possession if they choose. R3's 5/10/22 through 8/5/22 Social Service Progress Notes and 7/17/22 through 8/5/22 Nurses Notes were reviewed and did not document any conversation with R3 pertaining to taking possession of R3's wallet containing R3's debit/ credit card. The Illinois Long-Term Care Ombudsman Program's undated Residents' Rights for People in Long-Term Care Facilities documented in part . Your rights regarding you money . You have the right to manage you money. The facility must not require you to let them manage your money . Your personal property rights . You may keep and use you own property . Your facility must try to keep your property from being lost or stolen. If your property is missing, the facility must try to find it . The facility's 3/2022 Abuse Prevention Program documented in part . Misappropriation of resident property means the deliberate misplacement . of a resident's belongings or money without the resident's consent . V. Protection of Residents. The facility will take steps to prevent . misappropriation of resident property .

Based on observation, interview and record review the facility failed to: 1. Ensure disinfectant used to treat non-porous surfaces for Covid-19 was utilized per manufacturer guidelines for effective disinfection. 2. Implement immediate isolation protocols for Covid-19 positive residents to prevent organism spread to non positive residents. 3. Don and doff personal protective equipment (PPE) per current standards of practice. 4. Test and isolate residents displaying respiratory symptoms. These failures have the potential to effect all 15 residents residing in the facility. Findings Include: 1. A.) On 7/27/21 at 10:12 AM, V3 (Housekeeping Supervisor) states that the facility utilizes for the most part bleach and 256 Worx to disinfect the facility. V3 states that both are effective against Covid-19. V3 states that there is no required contact time for these disinfectants, and cleaning is conducted by applying the cleaning substance to surfaces, and wiping it off. V3 states that she would have to read the 256 Worx label to recall the dilution level for mixing as she cannot remember off the top of her head. On 7/27/21 at 11:14 AM, V3 was observed conducting a deep clean of room [ROOM NUMBER], which was located on the non covid designated unit after instructed to do so by V1 (Administrator) due to 1 of the 2 occupants in the room, R1 testing positive for COVID-19 that day. R2, roommate was taken out of the room with a face mask applied, and placed in the general sitting room of the facility, across from the dining room for the cleaning to be complete. V3 was observed completing the cleaning being assisted by V5 (Activity Director). V3 was observed spraying a mist of what she identified as 256 Worx on the walls and immediately wiping the solution off with a dry rag. V3 continued to repeat the procedure around the room on the walls, continuing to change rags to wipe the solution with a dry rag. V3 confirms that after she wipes the surface, it is dry. V3 states she will continue this process throughout the room on all hard surfaces. Information found on https://www.chemnet-systems.com/wp-content/uploads/2020/07/697-256Worx-7-6-20.pdf documents directions for disinfection against Covid-19 as: 1. Mix ½ oz of 256 Worx per gallon of water, 2. Apply solution with a mop, cloth, sponge or sprayer, 3. Allow treated surfaces to remain wet for 5 minutes, 4. Remove excess liquid. Covid testing results provided by the facility documents R1 tested positive for Covid-19 on 7/27/21, as well as R2 testing negative on 7/27/21. B.) On 7/27/21 at 10:12 AM, V3 states that the bleach is diluted at a ratio of 1 gallon of water, to 1 medicine cup of bleach. V3 confirms that the medicine cup she is referring to is 30 (milliliters) in size. Review of manufacturer recommendations for the Clorox Bleach being utilized is 1/2 cup bleach to 1 gallon of water for effective Covid-19 disinfection. On 7/27/2021 at 11:02 AM, V1 was observed cleaning/sanitizing the bathroom on the Covid-19 negative unit that R1, who is Covid-19 positive, had used from approximately 10:10 AM to 10:23 AM. V1 was observed spraying the bathroom with a solution. When asked what the solution was V1 stated she assumed the solution was a bleach mixture since that is what the housekeeper (V3) told her it was. When asked how the bleach solution was mixed V1 stated she did not know how it was mixed or what the bleach to water ratio was. On 7/27/2021 at 10:48 AM, R5 (negative Covid-19 status) was observed, wearing a surgical mask, exiting the bathroom on the Covid-19 negative unit. This is the same bathroom R1 (Covid-19 positive status) was observed using at 10:37 AM. There was no disinfection of the bathroom observed between R1 and R5 using it. On 7/27/2021 at 10:52 AM, V4 (Certified Nurse Assistant, CNA) stated the bathroom R1 and R5 used had not been cleaned after R1 used it. V4 stated she knew the bathroom had not been cleaned because they only had one housekeeper and she (V3) was cleaning R1's room. On 7/28/21 at 2:35 PM, V1 states she would expect staff to follow manufacturer recommendations for effective disinfection of Covid-19. Review of the facility policy titled Cleaning of Non-Critical Resident Care Items with a revision date of 12/7/18 states, 8. Disinfect the items, using the disinfectant provided by your facility. Follow manufacturer's direction for use and dilution. 2. On 7/27/2021 at 9:38 AM, V1 stated they tested facility wide for Covid-19 yesterday (7/26/2021) and received three of the test results back. V1 stated two of those results were positive for Covid-19. V1 stated the two residents who tested positive for Covid 19 were R1 and R4. V1 stated they had not moved R1 and R4 to the Covid-19 unit because they were waiting to get the rest of the resident Covid-19 test results so they could determine where to move the residents. V1 stated they have a Covid-19 unit, but it is smaller and if there are too many residents who test positive, they will need to move the Covid-19 unit. V1 stated R4 did not have a roommate but R1 did have a roommate (R2). V1 stated they are keeping the resident doors shut and wearing full PPE (personal protective equipment) when they enter the rooms. When asked if there were any interventions implemented to protect R2 (R1's roommate) who had not tested positive for Covid-19. V1 stated they had not implemented any interventions because they were considering R2 as having been exposed. R1's facility face sheet (not dated) documents R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's local hospital laboratory results dated [DATE] document [CONDITION(S)] CoV 2 RNA was detected, which indicates R1 tested positive for Covid-19. R2's facility physician's order sheets dated 6/30/2021 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's local hospital laboratory results dated [DATE] documents [CONDITION(S)] CoV 2 RNA was not detected, which indicates R2 tested negative for Covid-19. On 7/27/2021 at 10:10 AM, R2 was observed sitting in his recliner in his room with the door open to the hallway. V8 (Licensed Practical Nurse/LPN) told this surveyor R1 was using the (communal) bathroom (on the Covid-19 negative unit). On 7/27/2021 at 10:23 AM, R1 was observed sitting in the communal bathroom (Covid-19 negative unit) in his wheelchair being assisted by V4 (CNA/Certified Nursing Assistant). V4 was wearing a gown, gloves, N95, and face shield. R1 was wearing a surgical mask. V4 removed her gown and gloves, left the face shield and N95 in place and left the facility bathroom. R1 was sitting in the open doorway of the bathroom. V4 returned to the bathroom and put on a new gown and gloves and escorted R1 from the bathroom and to the Covid-19 positive unit. On 7/27/2021 at 10:37 AM, V8 (LPN) stated R1's positive Covid-19 test results were received by the facility at approximately 7:00 AM on 7/27/2021. This indicates R1 was left in the room with R2 for approximately 3 and ½ hours after the facility was aware R1 had tested positive for Covid-19. The facility Covid-19 Control Measures policy dated 6/24/2021 documents under Monitoring and Surveillance-Residents.5. Doors should remain closed for residents who have a positive [MEDICATION(S)] or PCR, suspected of having Covid-19 or had prolonged exposure to someone with Covid-19 . The facility Covid-19 Cohorting of residents policy dated 8/25/2020 documents under Procedure, .4. Test any resident that develops symptoms consistent with Covid-19 .6. Move resident to Covid-19 designated area if test results are positive for [CONDITION(S)]-CoV-2 . 3. Review of the facility policy titled Covid-19 Control Measures with a revision date of 6/24/21 states the purpose of this policy is To prevent transmission of the Covid-19 Virus and to control outbreaks. The policy states under the heading of Contact Precautions - Post signage on door .6. Remove PPE when leaving a residents room. Additionally, the same policy states under the title heading of Droplet Precautions - Post signage on door . 6. Remove PPE when leaving residents room and perform hand hygiene. Review of article titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 2/23/21, found on https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html states health care professional should follow standard precautions and transmission based precautions based on suspected diagnosis. On 7/27/2021 at 10:10 AM V8 (Licensed Practical Nurse/LPN) was observed entering R4's (Covid-19 positive) room wearing a gown, gloves, face shield, and N95 mask. V8 was observed exiting R4's room wearing the same N95 and face shield after removing the gown and gloves. V8 then provided to care to other residents on the covid-19 negative unit. On 7/27/2021 at 10:18 AM, V4 (CNA) was observed exiting R1's (Covid-19 positive) room. V4 removed her gown and gloves and used hand sanitizer appropriately. V4 did not remove and/or sanitize her face shield and/or N95 mask. On 7/27/2021 at 10:27 AM, V4 (CNA) was observed transferring R1 to the Covid-19 positive unit wearing gown, gloves, face shield, and N95. V4 removed the gown and gloves after transferring R1 to the Covid-19 positive unit but did not remove and/or sanitize the face shield and/or N95. On 7/27/2021 at 11:00 AM, V4 was observed assisting R11 (covid-19 negative status) resident back to her room. On 7/27/2021 at 11:30 AM V4 was observed assisting R5 (covid-19 negative status) resident back to her room. During continuous observations on 7/27/2021 beginning at 10:27 AM through 11:30 AM V4 was continually observed and was not observed changing and/or sanitizing her face shield and/or N95 mask. On 7/27/2021 at 12:08 PM, V9 (LPN) was observed entering the Covid-19 positive unit wearing a gown, gloves, face shield, and N95. V9 administered medications to Covid-19 positive residents (R8 and R9). V9 was observed as she was exiting the Covid-19 positive unit. V9 removed her gloves and gown and washed her hands. V9 did not change and/or sanitize her face shield and/or N95. V9 stated staff wore the same N95 and face shield and did not change and/or sanitize them when exiting the Covid-19 positive unit and entering the Covid-19 negative unit. V9 stated she did not know if the facility had a shortage of PPE and would have to speak to V1 about what to do with the N95 and the face shield when exiting the Covid-19 unit to continue to provide care to the Covid-19 negative residents. On 7/27/2021 at 9:38 AM, V1 stated the facility nurse provided care to both the Covid-19 positive unit and the Covid-19 negative unit. V1 stated the facility had tried to get more nurses to be able to dedicate a nurse to the Covid-19 positive unit but had been unable to. V1 stated the nurses had to use due diligence when going from the Covid-19 positive unit to the Covid-19 negative unit. V1 stated they did not have a shortage of PPE including N95 masks. Review of the July 2021 Infection Tracking Log documents R4 tested positive for Covid-19 on 7/26/21. 4. A.) R1's facility face sheet (not dated) documents R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility progress notes document on 4/26/2021 R1 is up in wheelchair with no complaints and remains on [MEDICATION(S)] (antibiotic) related to pneumonia. R1's progress note dated 5/13/2021 documents R1 had a non-productive cough, wheezes in bilateral lung fields, R1's physician was notified, and ordered an oral steroid for treatment. R1's medical record does not document a Covid-19 test was administered and/or R1 was placed on isolation precautions until the organism could be identified. On 7/28/2021 at 11:38 AM, V1 responded to an email requesting documentation of R1's Covid-19 testing and isolation precautions during the time frame R1 was having respiratory symptoms in 4/2021 and 5/2021, V1 responded with, The physician did not order a Covid-19 swab or precautions. B.) R2's facility physician's order sheets dated 6/30/2021 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress notes document on 5/26/2021 R2 had an occasional cough with clear sputum and requested [MEDICATION(S)]. R2's progress notes document assessments and monitoring from 5/30/2021 through 6/14/2021 with no further documentation of coughing and vital signs within normal limits. On 6/14/2021 R2's progress notes document R2 was up in the dining room, was congested and had audible wheezes. R2's progress note documents R2 reported coughing up phlegm. R2's progress notes document [MEDICATION(S)] inhaler was administered with some continued shortness of breath. R2's vital signs were documented as within normal limits; a chest x-ray was ordered with no abnormalities reported. R2's medical record does not document a Covid-19 test was administered and/or isolation precautions were implemented. On 7/29/2021 at 9:17 AM when asked for documentation of Covid-19 test results and/or isolation precautions for R2 in 5/2021 and 6/2021,V1 (Administrator) responded via email, No testing or isolation was implemented on (R2) 5/2021 or 6/2021. The facility Covid-19 Control Measures policy dated 6/24/2021 documents under Monitoring and Surveillance-Residents. 1. Monitor all residents for new onset of fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell. Complete vital signs and pulse oximetry at least daily. 2. Initiate Contact and Droplet Precautions for residents with respiratory symptoms, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell, regardless of vaccination status . 4. Place resident in a private room, if available, until test results are received and follow facility Cohorting Policy. 5. Doors should remain closed for residents who have a positive [MEDICATION(S)] or PCR, suspected of having Covid-19 or had prolonged exposure to someone with Covid-19 . Under Droplet Precautions-Post signage on door the facility policy documents, 1. Implement when a resident is suspected of having any fever, respiratory illness, sore throat, nausea, vomiting, extreme fatigue, muscle pain, loss of taste/smell. 2. Restrict all residents with fever, respiratory symptoms, sore throat nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste/smell to their room. If they need to leave their room for medically necessary procedures a face mask should be placed on the resident. Place symptomatic residents in a private room. The facility Covid-19 Cohorting of residents policy dated 8/25/2020 documents under Procedure, .4. Test any resident that develops symptoms consistent with Covid-19 .6. Move resident to Covid-19 designated area if test results are positive for [CONDITION(S)]-CoV-2 . The facility census and condition form provided on 7/27/21 documents 15 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ an infection preventionist. This failure has the potential to effect all 15 residents residing in the facility. Findings Include On 7/27/21 at 9:38 AM, V1 (Administrator) states that approximately 2 weeks ago the Director of Nursing (DON) at the facility, quit and the facility currently has no DON or staff member qualified for the Infection Preventionist (IP) role. V1 states she is not aware of any staff working in the facility who have completed the Infection Preventionist training. V1 states that V2 (Minimum Data Set Coordinator) holds a Registered Nurse license and has been helping complete DON and IP duties, although again confirming she has not completed the IP training course. On 7/28/21 at 11:53 AM, V1 states that the facilities former Director of Nursing's last day was July 9, 2021. A facility policy titled Infection Control, Surveillance and Monitoring with a revision date of 12/7/18 states, 1. Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, ICP (Infection Control Preventionist), and DON (Director of Nursing). 2. Monitoring the day to day operation of the Infection Control Program will be conducted by the DON. Included in these duties are: .b. Determine and direct the correct procedures necessary for the prevention of infections On 7/27/21, no Director of Nursing or staff trained in the infection preventionist role was observed to be in the facility. The facility census and condition form provided on 7/27/21 documents 15 residents reside in the facility.

Based on interview and record review, the facility failed to ensure residents are free from verbal abuse for 1 of 4 residents (R3) reviewed for abuse in the sample of 4. Findings include: The facilities final report to IDPH, (Illinois Department of Public Health), dated April 30th, 2021 by V1, regarding a verbal abuse incident between R3 and V3 documents in part, On 4/24/21 at approx 7:50 pm, (R3) reported to Administrator (V1) that CNA (V3) had told him to shut up during the night shift after he had been calling her name .In conclusion, the facility has determined that the alleged verbal abuse is substantiated. The employee has been terminated. On 5/06/2021 at 10:00 AM, R3 recalled the events that he originally reported on 4/24/2021 to the facility staff, regarding V3, (Certified Nurse Aide/CNA), telling him to shut up when he was asking for assistance. R3 stated that (V3) also told him to tell my noisy wife that I was being taken care of and I should be bragging about how well I was being cared for. R3 stated that (V3), was fired but she, brought it on herself. R3 stated that there was nothing wrong with (V3's) work, but that (V3) had no business speaking to him that way and it had been going on for too long. R3 stated that he was happy about the way it was handled by V1, (Administrator). R3 said that he was sure that others were also glad that (V3) was no longer working at the facility. On 5/10/2021 at 2:45 PM, R3 stated that he was still upset about what V3 had said to him. R3 said that he has not had any problems with other facility staff. R3's Admission Sheet documents that he is a [AGE] year old man whom has resided at the facility since 1/04/2021. R3's MDS, (Minimum Data Set), dated 1/11/2021, documents a BIMS, (Brief Interview for Mental Status), score of 15, and indicates R3 is cognitively intact. On 5/10/2021 at 9:40 AM, V1, said that the facility's investigation involving R3 and V3 substantiated verbal abuse. V1 stated that verbal abuse is not tolerated at the facility, so (V3) had to be fired. V1 said that R3 reported the incident to another CNA, whom immediately reported it to V1, on 4/24/2021 at 7:50 PM. V1 stated that she would not have known that V3 had been verbally abusive if R3 did not report it to staff. V1 said that she had not received any other complaints about V3 or about the behaviors of other staff. The facility's Abuse Prevention Program policy, (Revised 11/28/2016), documents in part, This facility affirms that right or our residents to be free from abuse, neglect, misappropriation of resident property and exploitation .page 2, reads: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again.

Based on observation, interview, and record review the facility failed to provide care to prevent the development and worsening of pressure ulcers for 1 of 2 residents (R7) reviewed for prevention and treatment of [REDACTED]. This failure resulted in the new development and or worsening of pressure areas to the back, buttocks, heels and axilla's (underarms/armpits) for R7. Findings include: The facility's undated Face Sheet of R7's medical record documents that R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse's Note dated 12/8/2020 documents R7 was admitted to the facility from the hospital after a fall and fracture of vertebrae, R7 is in a full body brace that is only to be removed during care, and R7 has an order for [REDACTED]. A December 2020 POS (Physicians Order Sheet) has an order dated 12/11/2020 for a TSLO ([MEDICATION NAME] Lumbar Sacral Orthosis) brace to be worn at all times except for ADL's (Activities of Daily Living). A Nurse's Note dated 12/15/2020 documents an order was received from V9 (Nurse Practitioner) for R7 to only wear the brace when R7 is out of bed. The December 2020 TAR (Treatment Administration Record) and January 2021 TAR does not include the order received on 12/15/2020 to wear the brace only when out of bed. The December TAR documents an order to wear TLSO brace at all times except for ADL'S from 12/11/2020 until R7 was transferred to the hospital on [DATE]. The same order is documented again on the December 2020 TAR from 12/26/2020, when R7 returned from the hospital, until 1/31/21. The January 2021 TAR documents the order to wear the TLSO brace at all times except for ADL's from 1/1/2021 until 1/6/21. The December 2020 and January 2021 TAR's include initials on the above dates, indicating R7 continues to wear his brace at all times except for ADL's until 1/6/21. On 2/10/2021, V7 (Registered Nurse) and V11 (Licensed Practical Nurse) said that R7 was admitted to the facility with the brace and it did not fit well. V7 and V11 said that R7 wore the brace at all times, except for bathing, until an order to discontinue the brace was received in January. An admission assessment dated [DATE] documents that R7 had open areas to bilateral axilla. The right axilla measuring 1.1cm (centimeter) x 3cm and left axilla measuring 3cm x 2cm. There were no areas documented to the buttocks, back, or heels. On 2/10/21 at 12:25 PM, V7 (Registered Nurse) stated that R7 acquired the wounds from the brace and he did not come to the facility with the wounds. V7 said that R7 had only redness from the brace when he was admitted to the facility. A Nurse's Note dated 12/16/2020 documents that there are 2 small open areas to his bottom noted on right buttock that measure 1 cm x 1/2 cm and 1/2 cm by 1/2 cm. The note also documents that an older bruise, at the point of back brace, in the left lower quad that measured 1. 5 cm by 2 cm. The note also documents a red area to left hip measuring 8 cm x 2 cm. Nurse's Note on 12/16/2020 documents that V10 (Medical Doctor) was notified of wounds and new orders were received. A wound flow sheet document dated 12/31/2020 documents a stage 3 pressure ulcer to the spine [MEDICATION NAME] area at the 9th vertebrae measuring 7cm by 2 cm and the right axilla measuring 5cm by 3 cm. There are no other wounds documented on that date. A wound flow sheet dated 2/7/2021 documents the following wounds: a stage 3 pressure ulcer to the lower back measuring 7cm by 3.5 cm with a 2cm depth, a stage 2 pressure ulcer to the left buttocks measuring 3cm by 2.5cm, a stage 2 pressure ulcer to the right buttocks measuring 4cm by 2cm, a stage 2 pressure ulcer to the left heel measuring 1.5cm by 1 cm, and a stage 2 pressure ulcer to the right arm pit measuring 3cm by 1cm. On 2/10/2021 at 11:24 am and 12:30 PM, dressing changes and treatment completed by V7 (Registered Nurse) and V11 (Licensed Practical Nurse) was observed to the wounds on the lower back, right and left buttocks, and right axilla. There are no orders noted on the TAR (Treatment Administration Record) or POS (Prescription Order Sheets) for the wounds to left heel or left axilla. The wound bed to the wound on the back has tunneling with white edges at the perimeter of the open area and appeared to be 8cm x 5cm and 1 cm deep. The wound to the buttocks area is approximately 7cm x 5cm and 1cm deep to the left side and 10cm x 5cm and 1cm deep to the right side. The skin surrounding the wound to the buttocks area appears purple. There is some black tissue noted to the edge of the wound on the right and a small amount of bleeding noted to the wound on the left. The left axilla has an area of redness approximately 4cm x 2cm. There is approximately a 1cm linear opening noted to the center of the wound. A Nurse's Note by V7 dated 12/15/2020 documents an order was received from V13 (Nurse Practitioner) to contact the orthopedic clinic of skin issues related to the TLSO brace. V7 documents that the orthopedic clinic would be contacted in the morning when the clinic was open. A Nurse's Note dated 12/16/2020 at 1:30 PM documents that an attempt was made to contact the Orthopedic Clinic to obtain information about the brace. There are no notes documenting that the orthopedic clinic was contacted about the skin issues related to the brace as ordered per V13 on 12/15/2020. A Nurse's Note dated 12/16/2020 documents that an order was received to refer R7 to a different orthopedic clinic related to the family's request. A Nurse's Note dated 1/4/2021 documents that R7 was transferred via ambulance for an appointment at a local orthopedic clinic. The Nurse's Note form 1/4/2021, POS entry dated 1/4/21, and the January 2021 TAR document an order to only wear the TLSO brace when R7 is doing physical therapy, R7 should not wear the brace in bed, and wash R7's back and axilla areas daily with [MEDICATION NAME] solution, dry, apply antifungal powder and cover with white t-shirt. R7's care plan (dated 1/27/2021), lists a problem of wounds related to the back brace to right armpit, buttocks, and midback. The goal listed is for R7 is to demonstrate healing of the wounds. There are no care plan entries upon admission on 12/8/2020 to identify R7's risk for skin breakdown or documented measures to prevent skin breakdown. There are no care plan entries prior to 1/27/2021 identifying wounds with interventions for prevention or treatment of [REDACTED]. A form titled Braden Scale for Predicting Pressure Ulcer Risk was completed on 12/8/2020. R7 received a score of 12 indicating that R7 is at high risk for skin breakdown. A Skin Treatment Review was completed on 12/8/2020, 12/26/2020, and 12/31/2020. The Skin Treatment Review documents N, or NO, for turning and positioning program and the use of elbow/ heel protectors. On 2/10/2021, V7 states that R7 is completely dependent for bed mobility and transfers. MDS (Minimum Data Set) assessments dated 12/15/2020, 12/21/2020, and 1/2/2021 document that R7 requires total dependence with full staff performance for bed mobility and transfers. On 2/9/2021 at 1:23 PM, R7 is observed lying in bed with heels resting on the bed. R7 was not wearing heel protectors. The heel protectors were noted sitting in a chair in R7's room. On 2/10/2021 at 11:24 AM and 12:30 PM, R7 was observed not wearing heel protectors while lying in bed.

Based on observation, interview and record review, the facility failed to follow the proper personal protective equipment protocols for residents on transmission based precautions. This failure has the potential to affect all 16 residents living in the facility. Findings include: On 2/8/21 at 9:40 AM, V4 (Certified Nurse's Aide) and V5 (Certified Nurse's Aide) went into R67's room to assist her with using her bedside commode. R67 did not have a sign on her door to indicate she was in isolation. V4 and V5 had on an N95 mask, face shield and gloves. V4 and V5 were not wearing a gown. On 2/8/21 at 11:45 AM, V4 took R67's meal tray into her room and V4 didn't put on a gown or gloves. There was a plastic chest of drawers outside R66 and R67's rooms with some personal protective equipment (PPE) provided, but there were no gowns available. At 2:00 PM on 2/8/21, V8 (Maintenance) went into a locked storage area and retrieved gowns and put them in the plastic drawers. On 2/8/21 at 10:00 AM, V1 (Business Office Manager) stated she didn't know a sign needed to be on the door to indicate someone was in isolation. V1 stated R67 was admitted on [DATE]th, 2021 and would be in isolation until February 28th. V1 also stated they haven't had any Covid-19 positive residents since the pandemic started in 2020. V1 stated the staff should be wearing full PPE before going into an isolation room, even if they didn't have Covid-19. On 2/8/21 at 10:00 AM, V4 and V5 stated they should wear a gown when they go into an isolation room, but there weren't any gowns available in the chest of drawers. The facility's policy, Covid-19 Control Measures dated 10/01/20, documents under; Contact Precautions- Post Signage on Door and under Admissions and Readmissions, Line #3 documents, New admissions and readmissions whose Covid-19 status is unknown should be placed in a private room and all recommended PPE (Personal Protective Equipment) should be worn during care of resident under observation, which includes an N95 respirator, eye protection, gloves and gown. Residents are to remain in a private room under observation for 14 days.

Based on interview, observation, and record review, the facility failed to require staff to follow hand hygiene practices consistent with accepted standards of practice, to implement contact isolation precaution procedures, and maintain resident supplies in a sanitary manner. This failure has the potential to affect all 21 residents residing in the facility. Findings include: 1. The Center for Disease Control and Prevention at http://www.cdc.gov/handhygiene/providers/index.html recommends two methods for hand hygiene for healthcare providers. 1. Alcohol based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting, when hands are not visibly dirty. 2. Soap and water are recommended for cleaning visibly dirty hands. On 04/09/19 at 12:31 PM V5 (Certified Nurse Assistant, CNA) was observed leaving R14's room. V5 was observed applying a substance to hands from the canister labeled Theraworx on the wall. When asked if that is what staff use as hand sanitizer, R14 states Yes, and sometimes staff will keep their own sanitizer in their pocket too. R14 was not observed applying any other other sanitizing substance to her hands. On 04/09/19 at12:32 PM, V6 (Maintenance) states the substance in the canisters on the wall throughout the facility labeled Theraworx, is in fact Theraworx. On 4/9/19 at 1:29 PM, V1 (Administer in Training), verified the canisters mounted on the wall throughout the facility labeled Theraworx are used by facility staff as a hand sanitizing solution. On 04/10/19 at 09:22 AM V7 (Housekeeping / Laundry) was asked if she knew why there were Out of Order signs on all of the Theraworx canisters mounted on the walls throughout the facility today. V7 stated, I'm not real sure, I was just told they weren't up to standard. On 04/10/19 at 12:52 PM, V1 states she acknowledges Theraworx is not an alcohol based sanitizer, and should not be used for hand sanitation purposes. V1 states she was notified on 4/9/19 by a staff member from a sister home that Theraworx cannot be used as a hand sanitizer because the sister home was cited during a survey for using Theraworx as a hand sanitizer also. V1 states as soon as she was notified, alcohol based hand sanitizer was purchased and placed throughout the facility for staff use. V1 states Theraworx was removed from the canisters on walls throughout the facility, and out of order signs were applied. On 4/10/19, V1 provided Theraworx Foam product information which lists Theraworx ingredients as: Aqua (Water), Cocamiclopropyl [MEDICATION NAME], Aloe Barbadensis Leaf Juice, [MEDICATION NAME] Silver, Tocopheryl Acetate, [MEDICATION NAME], Beta-Glucan, Citrus Grandis (Grapefruit) Fruit Extract, [MEDICATION NAME] Glucoside, Tetrasodium EDTA, PEG/PPG - 4/12 Dimethicone, [MEDICATION NAME], Propylparaben, Farfum (Fragrance). A resident census and condition form, dated 4/9/19, documents the facility census is 21. 2. On 4/9/19 at 11:16 AM, V3 (Registered Nurse, RN) was observed performing a glucose check on R6. Upon completion of the glucose check, V3 wiped the glucose monitor with a Sani-Cloth Bleach Germicidal Disposable Wipe with no direct, continuous contact time observed. On 4/9/19 at 11:04 AM, V4 (Licensed Practical Nurse, LPN) was observed performing a glucose check on R10. Upon completion of the glucose check, V4 wiped the glucose monitor with a Sani-Cloth Bleach Germicidal Disposable Wipe. V4 opened a new wipe, wrapping the glucometer with the wipe for a direct, continuous contact time of 15 seconds, then removed and disposed of the wipe. Manufacturer guidelines for Sani-Cloth Bleach Germicidal Disposable Wipe states, To Clean, Disinfect, and deodorize: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visible wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minutes wet contact time. V3 provided a list that states R13, R6, R10, and R19 are the residents who require glucose monitoring. V3 states that staff disinfect the glucose monitor in between resident use, and each resident does not have their own monitor. 3. On 04/10/19 at 9:51 AM V8 (CNA), and V5 were observed providing foley catheter care to R10. Gloves were the only personal protective equipment observed being worn by V8 and V5 during care with their clothing observed as coming in direct contact with R10, and his bed linens. V5 and V8 were asked if R10 was on isolation precautions in which they both responded, Yes. V5 stated He is on contact isolation for ESBL (Extended Spectrum Beta-Lactamase) in his urine, but it is contained since he has a catheter. Isolation bins for linens and trash were observed in R10's room, with isolation equipment outside the resident's door containing equipment of: gown, gloves, mask, and hair cover. In a document titled (Company Name) Contact Precautions, with a revision date of 12/09, this document states, Gown: In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the residents room, or if the resident is incontinent or has diarrhea, an [MEDICAL CONDITION], a [MEDICAL CONDITION], or wound drainage not contained by a dressing. Remove the gown before leaving the resident's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environments. 4. A Urine Culture and Sensitivity for R10 dated 03/26/19 documented, Findings: Escherichia Coli On 04/10/19 at 10:43am, V10, family member of R10, stated that R10 is on isolation due to having a urinary tract infection. V10 stated that staff consistently wear gloves when caring for R10, and that some staff wear gowns while others do not. On 04/10/19 at 12:50pm, V5, Certified Nursing Assistant. was observed emptying R10's catheter. A sign on R10's door read, Before entering room, please stop at the nurses station. V5 donned gloves but did not don a gown. V5 placed a trash bag on the floor and the urine graduate inside the bag. V5 opened the catheter portal and urine spilled off the side of the graduate into the bag. After the procedure was finished, V5 took the graduate and bag to the dirty utility room. V5 lifted the lid of the isolation trash container and saw there was no liner bag in the container. Holding the graduate and bag in one gloved hand, V5 used the other hand to open the door and call for another staff member to bring an isolation bag for the can. The urine in the graduate was noted to slosh up the side of the graduate but it did not spill over. On 04/11/19 at 10:08am, V2, Director of Nurses stated R10 is on contact isolation for ESBL ( Extended Spectrum Beta-Lactamase) in the urine. V2 stated that as such, staff should consistently don gloves before providing care for R10 . V2 stated if staff might be exposed to bodily fluids such as wound drainage they should don a gown before providing care. V2 stated since R10 has a catheter, the organism is contained in the closed system and a gown would not be required. When the surveyor asked about the possibility of staff being exposed to urine while emptying the catheter bag, V2 acknowledged there could be a risk of urine contaminating staff's clothing.

Based on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 2 of 2 residents (R6, R14) reviewed for hospitalization s in a sample of 18. Findings Include: 1. R6's Resident Face Sheet documents R21 was admitted to the facility on [DATE]. This document lists V12 (Family member) is the responsible party for R6. Physician order [REDACTED]. Primary [DIAGNOSES REDACTED]. On 01/9/19, R6's Nursing Home to Hospital Transfer Form documents R6 was sent to the emergency roiagnom on [DATE] due to vomiting and diarrhea. R6's Discharge Summary documents an admitted to the hospital of 01/09/19 with a [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical document. 2. R14's Resident Face Sheet documents R14 was admitted to the facility on [DATE]. This document lists V13 (Family member) is the responsible party for R14. Physician order [REDACTED]. Primary [DIAGNOSES REDACTED]. On 02/7/19, R14's Nursing Home to Hospital Transfer Form documents R14 was sent to the emergency roiagnom on [DATE] due to being lethargic, with increased confusion. R14's History and Physical / Discharge Summary documents an admitted to the hospital of 2/7/19 with a [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical document. On 04/10/19 at 11:37 AM, V1 (Administrator in training) states that if a resident is transferred to the hospital, the facility provides notification by phone of the reason the resident is being transferred. V1 states the facility will then send the resident representative a Notice of Bed Hold Policy in the mail. V1 states the Notice of Bed Hold Policy is the only document provided to residents and/or their representative at the time of resident transfer.