Every finding on record at Parkway Manor

Based on interview and record review the facility failed to develop and implement interventions to prevent future falls for 2 of 6 residents (R106, R38) reviewed for falls in a sample of 45. This failure resulted in R106 having three falls on 2/19/2026 and suffering a non-displaced fracture of the right distal fibula.Findings include:1. R106's Face Sheet documented an admission date of 7/25/2023 with diagnoses of atrial fibrillation, late onset of Alzheimer's disease, mild dementia without behavioral disturbance, psychotic disturbance and anxiety among others.R106's MDS (minimum data set) dated 1/1/2026 documents a BIMS (brief interview for mental status) score of 12 out of 15 total which indicates R106 has moderate cognitive impairment. This same MDS documented R106 has no impairment to upper or lower extremities, needs partial/moderate assistance for toileting, showering, dressing, transferring and bed mobility. R106's Fall Risk Assessment Tool dated 1/6/2026 documented R106 with a fall risk score of 20 which indicates R106 has a high fall risk.An Event Report dated 2/19/2026 at 12:41am and entered by V3 (Registered Nurse/RN) documented (R106) was observed on the floor on her bottom, beside her bed. (R106) actively scooting herself across the floor to get around her bed. When asked what happened, (R106) stated Well I was just trying to get up. Denies pain. Denies hitting head. No injuries observed. Vitals obtained. Neurological checks initiated. (R106) assisted back into the bed by this nurse and CNA (Certified Nursing Assistant). (R106) then states, No I don't want to lay down. I need to go check on the kids, and tries to get back out of the bed. Attempted to reorient resident, but she continues to state she needs to get up to take care of the kids. Asked resident if she would like to sit up in her chair, resident stated she would. Resident then assisted into wheelchair and brought up to the nurse's station to be monitored by staff. POA (Power of Attorney) called and updated, stated she would like for something to be given to help (R106) get some sleep and help with her restlessness. On-call notified, spoke with V4 (Nurse Practitioner), ordered for resident to be given Ativan 1mg (milligram) now one time only. POA called and notified of order. The next section of this same report documented 2/19/2026 at 8:00am Incident Reviewed by IDT (interdisciplinary team): root cause analysis consistent with resident attempting to transfer self independently OOB (out of bed) with resident observed on buttocks beside bed. NP (Nurse Practitioner) to review medications with any new orders.An Event Report dated 2/19/2026 at 12:58am and entered by V3, documented (R106) sitting in her wheelchair up at the nurse's station with this nurse and a CNA. (R106) began to lean forward in her chair. Staff attempted to have her sit back and help guide her to lean back in chair, but resident smacked CNAs hand away and then pushed herself forward and out of her chair. CNA was able to assist resident to her knees and then this nurse and CNA assisted her onto her bottom. Resident did not hit her head and denied any pain when asked. Resident assisted back into her chair. Once back in her chair, resident stated that she thinks she's wet. Resident then taken back to her room so she could be changed, her right ankle was observed to be slightly swollen and starting to have some blue discoloration. Resident denies that her ankle hurts when asked and able to move it without any complaints of pain. When asked, resident stated she wanted to lay back down. Resident assisted into bed. Bed lowered to the lowest point. Call light functional and within reach. Resident reminded to use call light if wanting to get up. POA called and notified. V4 (Nurse Practitioner) notified of incident, hallucinations, swelling and discoloration of right ankle. New order for x-ray to right ankle. POA notified of new order. Under the section titled Interventions-Immediate measures taken: (R106) assisted to the floor and then back into chair with no other interventions marked. The next section of this same report documented on 2/19/2026 at 9:02am, Incident Reviewed by IDT Team: root cause analysis consistent with resident assisted per staff from edge of w/c (wheelchair) seat to knees due to resident leaning self far forward in seat. Obtain labs and treat accordingly.An Event Report dated 2/19/2026 at 2:03am and entered by V3, documented R106 observed on the floor beside her bed, laying on her back on the floor mat with feet propped up on her bed. When asked what happened, resident stated Well I was trying to go get on the porch. No injuries observed. Denies hitting head when asked, and no discoloration or swelling noted to head. Denies any pain, Vitals obtained. Neuro-checks restarted from time of this incident During assessment; resident moves her brief to the side and begins to urinate. Resident then assisted into the bed so she could be changed. Resident insisted that she wants to get back up. Once clean and dry, resident assisted back into her chair. Resident sitting up at nurses' station again with staff sitting with her. POA notified, MD (Medical Doctor) aware. Under the section titled Interventions-Immediate measures taken: vitals obtained, neuro-checks restarted and no other interventions are marked. The next section of this same report documented on 2/19/2026 at 10:03am, Incident Reviewed By IDT Team: root cause analysis consistent with resident attempting to get self OOB (out of bed) to go to porch with resident observed lying on floor mat beside bed. Pharmacist to review medications for interactions.R106's care plan documents a problem area or: (Problem Start Date 7/26/2023) at risk for falls r/t (related to) reduced independent mobility, diagnosis of congestive heart failure, diuretic medication, use of psychotropic medication, asthma, atrial fibrillation, Alzheimer's disease, macular degeneration/vision deficit, hypertension, hyperlipidemia, cerebral infarction, right non-displaced distal fibula fracture and frequent incontinence. Goal of Will have reduced risk for fall during this quarter (target date of 8/17/2026) and one intervention listed with start date of 2/19/2026 of Encourage (R106) to leave bathroom door alarm on. No other interventions are listed for falls occurring on 2/19/26 at 12:41am, 12:58am or 2:03am.On 6/10/2026 at 2:15pm, V3 (RN) said she was the nurse providing care for R106 on the night of 2/18/2026 and provided care for R106 until the next morning 2/19/2026 at 6:00am. V3 said around 11:45pm, R106 was noted to be on the floor and had fallen out of bed. V3 said she assessed R106 and found no observable injuries. V3 said it is common for R106 to have episodes of hallucinations and insomnia during the nightshift especially when R106 does not sleep properly. V3 said she notified R106's POA and V4 (Nurse Practitioner) who ordered R106 to have Ativan 1mg orally one time dose. V3 said she administered the medication to R106 but forgot to chart the medication administration on R106's medication administration record. V3 said she assisted R106 into her wheelchair and took her to the nurse's station for closer observation. V3 said around 12:58am, R106 leaned forward and began to fall out of her wheelchair. V3 said V8 (Certified Nursing Assistant) tried to reach R106 in time to prevent the fall but R106 fell forward and landed on her knees. V3 said R106 fell so quickly, the fall could not be prevented due to the staff (V3 and V8) not being in close proximity to where R106 was located. V3 said after getting (R106) back in her wheelchair, V3 said she noticed R106's right ankle was slightly swollen and had developed bruising. V3 said R106 was returned to bed, but again at 2:03am R106 was noted to be laying on the floor and had again fell out of bed. V3 said this time, R106 was assisted into her wheelchair and taken back to the nurse's station where they could monitor R106. V3 said she does not know which fall caused R106's right ankle injury. V3 said she does not think administering Ativan 1 mg (one time dose) to R106 caused her to fall out of her wheelchair because she had just given the medication to her and it could not have worked that quickly. V3 said other than observation and assessment for injuries, she did not implement any new fall interventions to keep R106 from future falls. V3 said V4 (Nurse Practitioner) said she would review R106's medications in the morning and she thought that was all that needed to be done for R106's falls that night.V8 could not be reached for interview during this survey.R106's Mobile X-Ray report dated 2/19/2026 documented (R38) had swelling, bruising post fall and had a 3 view right ankle x-ray with results of 1. Soft tissue swelling around the ankle, 2. Non-displaced fracture of the distal fibula below the syndesmosis.The facility provided a printed report of receipt for when they reported R106's fractured right ankle to Illinois Department of Public Health dated 2/20/2026. The receipt of report documented under Incident Description the following: Resident (R106) rose independently from bed and fell to floor twisting ankle, resulting in non-displaced fx (fracture) to area. Hospitalization was not required, area splinted, and resident remained in facility. Physician and family were notified at time of incident.On 6/10/2026 at 10:30am, V1 (Administrator) said the facility did not have a fall prevention program or a fall policy.At 10:32am, V2 (Director of Nursing) said even though the facility doesn't have a policy regarding fall prevention it is their expectation for the nursing staff to implement interventions to immediately protect the residents from future falls. V2 said for R106's three falls on 2/19/2026, the facility put the following interventions into place: the Nurse Practitioner (V4) to review R106's medications and the pharmacist to review medication for interactions. V2 was asked how these two interventions would protect R106 from future falls and V2 said they wouldn't, but V3 had increased R106's supervision that night, but then agreed the staff still let R106 fall again two more times in the same night. V2 said she feels the facility could have put additional interventions in place to prevent R106 from future falls.2. R38's Face Sheet documents an admission date of 6/3/2022 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, chronic obstructive pulmonary disease, lack of coordination, weakness and muscle wasting and atrophy among others.R38's MDS dated [DATE] documents R38 with a BIMS score of 12 out of 15 total which indicates R38 has moderate cognitive impairment. This same MDS documented R38 has impairment to both upper and lower extremities, uses a wheelchair for locomotion, needs substantial/maximum assistance for toileting, showering, dressing, bed mobility and transferring.R38's Fall Risk assessment dated [DATE] documented R38 with a score of 11 which indicated R38 has a moderate fall risk level.R38's Care Plan documented a Problem with start date of 6/6/2022, of (R38) is at risk for falls r/t (related to) reduced independent mobility, diagnosis of chronic obstructive pulmonary disease, hypertension, anemia, weakness, hereditary/idiopathic neuropathy, hyperlipidemia, coronary artery disease, use of psychotropic medication, use of narcotic medication, left sided weakness, and incontinence. R38's care plan does not include any planned interventions for fall dates of 3/6/2026 or 2/4/2026.R38's Event Report dated 2/4/2026 at 3:05am and entered by V3 (Registered Nurse) documented (R38) observed on floor on her back beside her bed with her pad (incontinence pad) and blankets under her. When asked what happened, (R38) stated, Well I was trying to get up. Stated she didn't hit her head, but she has a headache that she rates a 4/10. No discoloration or swelling noted to head. Denies neck/back pain. Denies any other pain and denies wanting to go to the hospital. When asked, stated No, I'm fine, just get me up. Vital signs obtained. Neuro-checks initiated. (R38) assisted into the bed. Bed remains in the lowest position. Call light functional and within reach. This same Event Report under section titled Interventions-Immediate measure taken documented analgesics and other-vitals obtained, neuro-checks initiated. No other interventions are marked or indicated. The next section of the Event Report documented the following: 2/4/2026 at 8:24am, Incident reviewed by IDT Team: root cause analysis consistent with resident attempting to get self oob (out of bed) independently, with resident observed in floor beside bed. Await U/A (urinalysis) results and treat accordingly.On 6/10/2026 at 2:15pm, V3 said she was the nurse providing care to R38 on 2/4/2026 at 3:05am when R38 fell out of bed. V3 said staff did not put any new interventions into place at the time R38 fell out of bed. V3 said she thought waiting for urine testing results was intervention enough, but could see how that would not immediately prevent future falls.On 6/10/2026 at 10:32am, V2 was asked, What immediate interventions were put into place to prevent R38 from future falls after R38 fell out of bed on 2/4/2026 at 3:06am? and V2 said the staff did not put any new interventions into place to prevent future falls at the time of R38's fall. V3 said waiting for urinalysis results did not immediately prevent future falls for (R38) and other interventions should have been implemented by staff, but were not.R38's Event Report dated 4/13/2026 at 6:49am documented R38 had a fall. The corresponding Progress Note for this event documented the following: Nurse heard (R38) yelling Help me while administering morning medications in another resident's room. Upon entering (R38's) room this nurse observed resident on the floor with legs stretched in front and back against the bed. Pad (incontinence pad) and drawsheet were partially on floor and between resident's back and bed. I slid out of bed stated resident during assessment. (R38) had no c/o (complaints of) pain and denies hitting head. NO lengthening/shortening and full ROM (range of motion) x4 extremities noted. Bed in lowest position. Resident assisted into wheelchair via (full body lift machine) by this nurse and a CNA d/t (due to) resident's request for breakfast. (R38) tolerated well with no complaints of pain. Neuro-checks initiated. Called POA (power of attorney), no answer, awaiting call backA Progress noted which corresponds with this event documented the following: on 4/13/2026 at 9:12am, IDT (interdisciplinary team) met: root cause analysis consistent with resident sliding out of bed with staff to assess bed mobility program.The same Event Report for this event (dated 4/13/2026 at 6:49am) documented under the section titled Interventions-Immediate measures taken -other-recheck if resident had pain and no other interventions were marked or indicated. Under the section titled Notes is documented: 4/13/2026 at 1:21pm, Attempted to assess bed mobility program with no success. On 6/10/2026 at 10:32am, V2 was asked, What immediate interventions were put into place to prevent R38 from future falls after R38 fell out of bed on 4/13/2026 at 6:49am? and V2 said the staff did not put any new interventions into place to prevent future falls at the time of R38's fall, but they should have.R38's Event Report dated 6/6/2026 at 2:53am and entered by V3 documented the following: (R38) observed on her back in the floor on the left side of her bed with bed observed in lowest position. When asked what happened, resident stated I was trying to get up to take my mom to work and I have to go to work too. Denies hitting head. No complaints of headache, nausea or lightheadedness. Denies pain to extremities. Upper and lower right-side extremities able to move per baseline without pain. Unable to move left leg and arm per resident baseline but denies pain to both. [NAME] any pain to neck/back. Vitals obtained, Neuro-checks initiated. Resident assisted back into bed. Resident reminded of the time and where she was, with resident stating understanding. Call light within reach and functional. Bed remains in lowest position. UA (urinalysis) order processed due to resident showing increased confusion. Under the section titled Interventions-immediate measures taken- vitals obtained, neuro-checks initiated with no other interventions marked or indicated. The next section of this same report documented 6/8/2026 at 9:04am, Incident Reviewed by IDT Team: root cause analysis consistent with resident attempting to transfer self OOB (out of bed) independently, stating she needed to take her mom and self to work. Staff obtain UA (urinalysis) due to increased confusion and treat accordingly.On 6/10/2026 at 10:32am, V2 was asked what immediate interventions were put into place to prevent future falls for R38. V2 said the facility checked R38's urine for infection, but did not put any other interventions into place to prevent future falls for R38. V2 agreed checking urine for infection would not immediately keep R38 for falling and said she feels the facility could have put other interventions into place at the time of R38's fall.

Based on interview, observation, and record review the facility failed to serve and hold food at the designated temperature as directed by the recipes for 11 (R8, R10, R16, R23, R29, R60, R62, R74, R81, R88, and R90) of 14 residents reviewed for dining in a sample of 45. Findings include:The week at a glance dated day 9 lunch documents: honey mustard chicken salad plate/lettuce, caramelized Naan bread, pickled beets, and peach dump cake.The recipe for the honey mustard chicken salad documents: 3. cover, label and date and refrigerate overnight to marinate. Maintain 41 degrees Fahrenheit (F) or below.The recipe for the pureed honey mustard chicken salad documents: maintain 41 degrees F or below.The recipe for the pickled beets documents: maintain holding 41 degrees F or below.The recipe for the pureed pickled beets documents: maintain holding 41 degrees F or below.On 06/08/26 at 11:02 AM the temperatures of the following were taken by V16 (Cook) from the holding table: pureed chicken salad was 73 degrees F, the temperature of the mechanical soft chicken salad was 67.2 degrees F, and the temperature of the regular texture chicken salad was 69.4 degrees F, the temperature of pureed lettuce was 56.1 degrees F, and the temperature of the pickled beets were 63.3 degrees F, all items were served within minutes of the temperatures measured.On 06/08/26 during lunch starting at 11:05 AM R8, R10, R16, R23, R29, R60, R62, R74, R81, R88, and R90 received the honey mustard chicken salad, lettuce and pickled beets.On 06/11/26 at 10:11 AM, R29 who was alert to person, place and time, stated chicken salad should be cold.On 06/11/26 at 10:13 AM, R81 who was alert to person, place and time, stated chicken salad should be cold.On 06/11/26 at 10:23 AM, R60 who was alert to person, place and time, stated they like their chicken salad cold. On 06/11/26 at 10:26 AM, R62 who was alert to person, place and time, stated they like their chicken salad coldOn 06/11/26 at 12:47 PM, V1 (Administrator) stated, the temperature of the chicken salad and beets should be at the temperature the recipe directs.

Based on interview and record review the facility failed to ensure restorative programs were administered for 1 of 3 residents (R56) reviewed for restorative services in the sample of 45.Findings Include:R56's undated Resident Face Sheet documents R56 was admitted to the facility on [DATE] with diagnoses that include dementia, Parkinson's disease, hypertension, and narcolepsy with cataplexy.R56's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 13, indicating R56 is cognitively intact.R56's current Care Plan documents a Problem Start Date of 05/27/2026 for AROM (active range of motion) exercise program with an approach of (.Invite and encourage participation in AROM exercise group. Monitor (name of another resident) closely for any shortness of breath or pain and report to nursing. Encourage with praise and verbal cues. This Care Plan includes the Problem area with a start date of Dressing Program - x(times) 1 to put on his pants. The Approach for this Problem area is, Dressing program- Explain task. With verbal cues encourage him to put on his pants assisting as needed. Assist (R56) to a standing position. Encourage him to pull up his pants with supervision. If this fails x 1 assist. This same Care Plan includes a Problem area with a start date of 4/11/23 of, Transfer program- transfers x 1. This Problem area includes the intervention of, Transfer program- Explain task and use a gait belt. With verbal cues and assistance encourage him to come to a standing position and pivot and sit slowly and with control.On 6/8/26 at 9:43 AM, R56 stated he doesn't get therapy services anymore. R56 stated he was walking with therapy, but they stopped it several weeks ago. R56 stated he could stand for 5 minutes but now he can't.R56's Physical Therapy PT Discharge summary dated [DATE] to 5/28/25 documents under Discharge Recommendations and Status, D/C (discharge) Instructions: RNP (Restorative Nurse Program for bike exercises for BLE (bilateral lower extremities) to maintain current level of function. R56's Physician Orders dated 06/11/2026 do not document orders for restorative programs.On 6/11/26 at 11:06 AM, V14 (Director of Rehabilitation) stated R56's knees are horrible he attempted therapy and wasn't able to complete it because his knees wouldn't tolerate it. V14 stated R56 met his maximum potential and wasn't receiving therapy services at this time. V14 stated R56 wants to but is unable to. V14 stated the therapy discharge recommendations were for an exercise bike for restorative program and she wasn't sure what the facility did with the recommendations.R56's Point of Care History Restorative Nursing, Number of minutes for active range of motion dated 5/29/26 to 6/10/26 documents the program was not performed seven times.R56's Point of Care History Restorative Nursing, Number of minutes transferring dated 5/29/26 to 6/10/26 documents the program was not performed four times.On 06/11/2026 at 12:32 PM, V13 (Certified Nursing Assistant/Restorative Aid) stated R56 was riding the bike after he was discharged from therapy but there wasn't much movement. V13 stated he had arthritis in his knees so instead of doing the bike she started doing sitting wheelchair leg exercises and standing with his walker. When asked if she wrote the restorative orders, V13 stated she talks to therapy, and they give her the restorative programs. When asked where she documented the restoratives she does with him, V13 stated she had papers she can document her stuff on. V13 stated the only restoratives that would be in the electronic medical records system were the active range of motion programs. When asked if she had any documentation of changing R56's restorative program, V13 stated she didn't. V13 stated the only thing she documented in the system is if the person refuses and R56 never refused. When asked about V13 speaking to therapy and getting new restorative programs for R56, V13 stated therapy hadn't given her a new program for R56 since he was discharged from therapy last year (5/28/2025). V13 stated she spoke with therapy and told them R56 wasn't using his legs, and they said to try leg exercises, but they didn't give her an updated restorative sheet. This surveyor reviewed R56's Point of Care History with V13 and asked if she had completed any restorative programs with R56 from 5/29/26 to 6/10/26 and V13 stated, I had to move my schedule around. I have a lot of programs to do, and I don't get to everyone. I try to do them at least twice a week and then try to switch them around so I can do other people as well. On 6/11/26 at 2:40 PM, V2 (Director of Nurses) stated she would expect restorative programs to be completed as recommended by therapy.The facility was unable to provide this surveyor with a policy regarding restorative programs.

Based on interview, observation, and record review the facility failed to provide dining in a manner that exhibits dignity by not cueing or encouraging residents to use utensils for 1 of 1 resident (R88) reviewed for dignity in a sample of 45. Findings include:R88's resident face sheet documents an admission date of 01/28/23 with diagnoses including: metabolic encephalopathy, dementia, sepsis, hemiplegia affecting right side, ulcerative proctitis, hereditary and idiopathic neuropathy, atrial fibrillation, diverticulosis, fibromyalgia, transient cerebral ischemic attack, aphasia, dysphagia following cerebral infarction, muscle weakness, reduced mobility, osteoarthritis, anxiety disorder, anemia, depression, and pain. R88's Minimum Data Set (MDS) dated [DATE] documents a Brief interview of Mental Status of 03 indicating severe cognitive impairment. R88's eating assistance is documented as set up and clean up assistance needed. R88's care plan documents a problem area dated 02/08/23 of eating program-mechanical soft diet due to dysphagia following cerebral infarction with an intervention of eating program: dining room at meals, 90 degrees upright sitting position, mechanical soft diet with thin liquids, small single sips. Set up meal with dycem (rubber mat). Place utensil in R88's hand, single sips, small bites, alternate solids/liquids. R88 requires verbal instruction and tactile cues for attention, size of bites, fluid intake, and utensil use. Encourage R88 to swallow and slow pace. R88 has right side visual neglect, place items on the left side of her. Give verbal cues to repeat swallow. Re-iterate her attention back to meal as needed. Dependent on staff for intakes if she fatigues. Monitor for right side pocketing/oral clearance. Sit upright 30 minutes after eating. On 06/09/26 at 11:44 AM, R88 was in the dining room eating her ground ham with gravy, seasoned green beans and soft Au gratin potatoes with her fingers. R88 finished eating her ground ham with her fingers then started picking up the green beans individually and ate a few then ate some of the Au gratin potatoes with her fingers, then ate a few more green beans with her fingers. R88 continued this until all the food on the plate was gone, then she picked up her bread and ate that. During this time there were no staff encouraging or cueing R88 to use her silverware.On 06/10/26 at 11:46 AM, R88 was in the dining room eating her ground country style ribs with sauce with her fingers, R88 continued until 11:53 AM when she started eating her mashed potatoes and gravy with her fingers, at 11:59 AM R88 finished her mashed potatoes and started eating her bread with butter. During this time, no staff encouraged or cued R88 to used her utensils. On 06/11/26 at 11:34 AM, R88 was in the dining room eating her salad with an orange colored dressing with her fingers, there was a plastic fork sitting approximately 4 inches from the top of the bowl laying sideways, almost perpendicular with her bowl with no movement towards using the fork or any signs of use of the fork. At 11:44 AM R88 was still eating her salad with her fingers with no encouragement from staff to use any utensils. At 11:46 AM, R88 received her lunch and started eating her ham and beans with her fingers. R88 was picking individual beans and individual pieces of ham out of the ham and beans soup, would shake some of the liquid off and then eat the bean or the piece of ham. R88 continued this process until 12:16 PM when V12 (Speech Therapy) stopped by her table and encouraged her to use an utensil. After this R88 picked up her fork and took four bites of her potatoes and diced carrots. At 12:16 PM three CNAs were sitting at the table assisting other residents and V11 (Social Services Assistant) stopped by the table and did not cue or encourage R88.On 06/11/26 at 12:31 PM, V9 (Care Plan Coordinator) stated R88 has had the same interventions listed in her care plan since 2023, R88 does not have any other interventions for her nutrition or eating ability.On 06/11/26 at 12:35 PM, V10 (Minimum Data Set Coordinator) stated based off of the MDS R88's eating ability is set up or clean up assistance. V10 stated, the MDS is based off of the CNAs documentation. V10 stated, if R88 was eating with her fingers for the last three days, that could be her preference. V10 stated, R88's BIMS is a 03.On 06/11/26 at 12:47 PM, V1 (Administrator) stated, if someone was eating with their fingers she would expect a staff member would assist the resident or cue the resident to use her silverware.

Based on interview and record review the facility failed to properly store medications by pre-pouring medications and administering more than one residents medications at a time. This has the potential to affect all 103 residents currently residing at the facility. Findings Include: The facility Daily Census Report dated 4/21/2025 documents 103 residents currently reside at the facility. The untitled letter from V22 (Family Member) to V1 (Administrator) dated 4/13/25 documents in part, Improper Medication Handling and Storage: Medication cups containing loose, pre-poured pills labeled for different patients were repeatedly observed stacked on top of medication carts by multiple nurses (V9/Licensed Practical Nurse, V6 (LPN), and others), most recently on 04/13/2025. This practice violates CMS (Central Management Services) medication safety regulations (F760 and F761), which require that medications be administered to one patient at a time and securely stored until use. Leaving multiple patients' medications exposed and unattended creates a high risk for cross-contamination, medication errors, and misadministration, and reflects a systemic failure in clinical oversight. On 4/21/25 at 12:34 PM, V22 (Family Member) stated she was at the facility visiting R1 and saw V6 (LPN/Licensed Practical Nurse) and another unknown nurse preparing medications for multiple residents at one time by placing the medications in small clear medication cups, labeling the cup with the resident name, and leaving the cups sitting unattended on top of the medication carts. On 4/22/25 at 10:14 AM, V11 (Certified Nursing Assistant) stated she had seen unknown nurse's prepare medications in advance using little medication cups. V11 stated they sometimes set them up in cups, wrote the residents name on them, and then dispensed a couple at a time. On 4/22/25 at 10:35 AM, when asked if he prepared medications in advance of administration, V6 (LPN/Licensed Practical Nurse) stated if he had multiple residents sitting at a table he would prepare all of their medications in medication cups and write their names on them. V6 stated then he would take all of the medication cups to the residents sitting at the table at the same time. On 4/22/25 at 11:50 PM, V2 (Director of Nurses) stated nursing staff are not supposed to pop the medications out of the pharmacy cards prior to administration. V2 stated they should take each resident their medication prior to preparing the next resident's medications. V2 stated they should prepare a resident's medications, administer the medication, sign the medication administration record indicating it was administered, then move to the next resident. The facility policy Medication Administration using eMAR (electronic medication administration record) dated 11/11 documents, Objective: 1. To provide the resident with those medications deemed necessary by the physician 11. Documentation of meds (medications) given will be done in a consistent manner by the nurse documenting preparation and administration of the medicine on the eMAR .Documentation on the eMAR will be done at the time of administration of the medication. The National Coordinating Council for Medication Error Reporting and Prevention website found at https://www.nccmerp.org/recommendations-health-care-organizations-reduce-medication-errors-associated-related-devices documents under, Recommendations for Healthcare Organizations to Reduce Medication Errors Associated with the Label, Labeling, and Packaging of Pharmaceutical (Drug) Products and Related Devices documents These recommendations apply to healthcare systems, hospital systems, individual hospitals, long-term care facilities, and other organized health care settings. The Council recommends the following: Healthcare organizations should develop processes to ensure that all medications are labeled prior to administration to a patient per USP (United States Pharmacopeial Convention) General Chapter 7 Labeling, the term 'labeling' includes all labels and other written, printed, or graphic matter on a medication ' s immediate container or on, or in, any package or wrapper in which it is enclosed, except any outer shipping container.The term 'label' is that part of the labeling on the immediate container. All clinician-prepared medications or solutions should be labeled, unless the medication or solution is prepared at the patient ' s bedside and is immediately administered to the patient without any break in the process. In accordance with State/Federal Laws and Regulations, healthcare organizations should employ machine-readable systems (e.g., bar coding) in the management of the medication use process. Healthcare organizations should utilize industry standards to ensure machine-readable validity meets industry quality standards. Healthcare organizations should have procedures in place to address gaps and failure modes in the use of machine-readable systems. Healthcare organizations should have policies and procedures developed for repackaging of medications that will clarify labeling and include a bar code to help prevent errors. Systematic approaches, including Healthcare Failure Mode and Effects Analysis (HFMEA) and root cause analysis (RCA), should be implemented within the healthcare organization to identify and evaluate actual and potential causes of errors related to labeling and packaging (e.g., failure to use bar code scanning, barcodes that don ' t scan, and situations where patient armbands cannot be applied). These systematic approaches should be accompanied with guidance related to monitoring, auditing, and quality improvement initiatives (e.g., PDSA-Plan-Do-Study-Act) to ensure changes improve the labeling of medications to reduce medication errors. Healthcare organizations should develop and implement (or provide access to) education and training programs for healthcare professionals, technical support personnel, patients, and families/caregivers that address methods for reducing and preventing medication errors associated with the information provided on an organization ' s medication labeling .

Based on observation, interview, and record review the facility failed to ensure call lights were within reach for 8 of 12 (R1-R5, R8, R10, and R11) residents reviewed for call lights in the sample of 12. Findings Include: 1. R1's Resident Face Sheet with a print date of 4/22/25 documents R1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that include aftercare following a joint replacement of left total knee, heart failure, diarrhea, depression, and weakness. R1's Care Plan documents a Problem area with a start date of 4/9/25 of, Ambulation Program- x (times) 1 assist using walker. This same Care Plan documents a Problem area with a start date of 4/8/25 of (R1) is at risk for falls r/t (related to) reduced independent mobility, recent L (left) total knee done, use of psychotropic medication, use of diuretic medication, DX (diagnosis) of osteoarthritis . This Problem area includes the intervention dated 4/8/25 of, Instruct (R1) to call for assist before getting out of bed or transferring. Encourage her to stand slowly. On 4/21/25 at 12:34 PM, V22 (Family Member) stated when she (V22) went to visit R1 at the facility her call light and personal cell phone were out of her reach. V22 stated she moved them where R1 could reach them and after leaving the facility attempted to call R1 on her personal cell phone. V22 stated R1 didn't answer but called back later that evening and told her when she called R1's phone was where she couldn't reach it. 2. R2's Resident Face Sheet with a print date of 4/22/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, diabetes, acute kidney failure, anxiety, reduced mobility, muscle weakness, insomnia, and pain. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has a memory problem and has modified independence in cognitive skills. R2's current Care Plan documents a Problem area with a start date of 7/12/19, Transfer Program- Assist of two utilizing a stand aide. This same Care Plan documents a Problem area with a start date of 7/12/19 of, (R2) is at risk for falls r/t reduced independent mobility, Dx of weakness, dementia .incontinence, non-ambulatory. This Problem Area includes the intervention with a start date of 7/2/19 of, Encourage (R2) to call for assistance with transfers. On 4/21/25 at 9:06 AM, R2 was observed sitting in a wheelchair in her room, facing the foot of her bed. R2's call light was looped on the headboard of the bed, out of R2's reach. On 4/21/25 at 9:16 AM, this surveyor entered R2's room with V1 (Administrator) present. R2 remained in her wheelchair at her bedside. R2's call light remained on the headboard of R2's bed. When asked if R2 could reach her call light, V1 (Administrator) stated, Maybe. R2 did not respond to this surveyors questions regarding her call light. 3. R3's Resident Face Sheet with a print date of 4/22/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include displaced fracture of right femur, Alzheimer's disease, and muscle weakness. R3's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 10, which indicates a moderate cognitive deficit. R3's current Care Plan documents a Problem area with a start date of 2/24/25 of, (R3) is at risk for falls r/t reduced independent mobility, DX of Alzheimer's disease, osteoporosis .incontinence .fall prior to admission . This Problem area documents an intervention with a start date of 2/24/25 of, Instruct (R3) to call for assist before getting out of bed or transferring. Encourage her to stand slowly. On 4/21/25 at 9:13 AM, R3 was sitting in a wheelchair in her room with her feet resting on her bed. She was sitting approximately mid way down the bed with the bedside table between her and the nightstand that was sitting at the head of the bed. R3's call light was wrapped around the head board of the bed out of R3's reach. R3 was able to move her legs off the bed but would have had to move the night stand to be able to reach the call light. On 4/21/25 at 9:23 AM, this surveyor entered R3's room with V1 (Administrator) present. R3 remained in the same position with her call light still wrapped around the head board of her bed. V1 (Administrator) stated R3 may be able to reach her call light. 4. R4's Resident Face Sheet with a print date of 4/22/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include diabetes, pain, difficulty walking, and muscle weakness. R4's MDS dated [DATE] documents a BIMS of 12, indicating R4 has a moderate cognitive impairment. R4's current Care Plan documents a Problem area with a start date of 11/11/2020 of, (R4) is at risk for falls r/t reduced independent mobility .She is hard of hearing and has a communication board. (R4) transfers self at times putting her at risk for a fall .This Problem area includes an intervention with a start date of 11/16/21 of, Encourage (R4) to use a call light for supervision with transfers and needed assistance. On 4/21/25 at 9:11 AM, R4 was laying in bed with her call light looped around the head of her bed. R4 does not appear to be able to reach her call light. On 4/21/25 at 9:17 AM, this surveyor entered R4's room with V1 (Administrator) present. R4 remained in bed sleeping with call light still looped around the head of her bed. V1 (Administrator) stated R4 could probably reach her call light. On 4/21/25 at 4:30 PM, R4 was laying in bed with call light hanging down from the wall on the opposite side of the night stand and draped from the opposite side of the night stand to the top with the button laying facing the bed. At 4:34 PM, V8 (CNA/Certified Nursing Assistant in training) entered R4's room. V8 stated maybe R4 threw her call light onto the table. When asked if R4 would be able to reach her headboard, V8 assisted R4's arm above her head and R4's arm did not reach the head board. 5. R5's Resident Face Sheet with a print date of 4/22/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include pain, unsteadiness on feet, muscle weakness, and hypertension. R5's MDS dated [DATE] documents a BIMS score of 06, indicating R5 has a severe cognitive deficit. R5's current Care Plan documents a Problem area with a start date of 8/23/23 of, (R5) is at risk for falls r/t reduced independent mobility . This Problem area includes an intervention of Instruct (R5) to call for assist before getting out of bed or transferring . On 4/21/25 at 9:20 AM, R5 was sitting in a wheelchair with a table between her and the bed. R5's call light was looped around the head of the bed. When asked how she got assistance if she needed it, R5 stated the little red button. R5 started looking for the call light and was not able to locate it. R5 was not able to locate it without this surveyors assistance. R5 attempted to reach her call light and was unable to. V1 (Administrator) was present during this observation and asked R5 if she could go get assistance if she needed it. R5 stated yes she could go find someone if she needed assistance. 6. R8's Resident Face Sheet with a print date of 4/22/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, weakness, lack of coordination, anxiety, dementia, and polyneuropathy. R8's MDS dated [DATE] documents a BIMS score of 02, indicating R8 has a severe cognitive deficit. R8's current Care Plan documents a Problem area dated 10/17/22 of, (R8) is at risk for falls r/t reduced independent mobility This Problem area includes the intervention dated 10/17/22 of, Instruct (R8) to call for assist before getting out of bed or transferring . On 4/21/25 at 9:11 AM, R8 was sitting in a wheelchair near her bed. R8's call light appeared to be running from the wall under the blankets on R8's bed. This surveyor was not able to locate the call light. On 4/21/25 at 9:18 AM, this surveyor entered R8's room with V1 (Administrator) present and asked where R8's call light was. V1 pulled R8's call light out from under the blankets on her bed near the head of R8's bed. R8 was sitting in a wheelchair with a table between her and the bed. When asked if R8 would have been able to reach the call light, V1 (Administrator) stated, Maybe. On 4/22/25 at 9:05 AM, V17 (RN/Registered Nurse) stated R2 doesn't use her call light. V17 stated R2 doesn't provide her own care she just prefers to call out for assistance. V17 stated R3 uses her call light. V17 stated R4 is able to use her call light but usually provides her own care with little assistance. V17 stated R5 does everything on her own and doesn't use her call light for anything. When asked if the call light was only to be used to get assistance for care or if it was also there in case of an emergency, V17 stated yes it can be used if there is an emergency. V17 stated R8 could use her call light but likes to stay in bed until staff get her for meals or care. When asked if she would have expected all of the residents call lights to be within their reach, V17 stated, Yes, they should have been. 7. R10's Resident Face Sheet with a print date of 4/22/25 documents R10 was admitted to the facility on [DATE] with diagnoses that include lack of coordination, asthma, diabetes, repeated falls, incontinence, and heart failure. R10's current Care Plan documents a Problem area with a start date of 4/21/25 of, (R10) is at risk for falls r/t reduced independent mobility . This Problem area includes an intervention dated 4/21/25 of, Instruct (R10) to call for assist before getting out of bed or transferring On 4/21/25 at 3:54 PM, R10 was sitting in a wheelchair next to her bed. R10's call light was in the bed under [NAME] the bed pad on the opposite side of the bed. V5 (LPN/Licensed Practical Nurse) got the call light, moved the bedside table that was between R10 and the bed, and pushed R10 closer to the bed so she could reach the call light. R10 stated she could self propel her wheelchair but she was not able to reach the call light where it had been. 8. R11's Resident Face Sheet with a print date of 4/22/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include heart disease, chronic kidney disease, depression, and malignant neoplasm of breast. R11's current Care Plan documents a Problem area dated 4/16/25 of, (R11) is at risk for falls r/t reduced independent mobility . This Problem area includes an intervention dated 4/16/24 of, Instruct (R11) to call for assist before getting out of bed or transferring . On 4/21/25 at 3:59 PM, R11 was sitting in her room in a wheelchair near the window. R11's call light was on the opposite side of the bed. V5 (LPN) got R11's call light and place it near R11. On 4/22/25 at 10:14 AM, V11 (CNA/Certified Nursing Assistant) stated both R10 and R11 are physically able to use their call lights. V11 stated as a CNA she would expect the call lights to be within reach of residents. The facility Call Light policy dated 01/04 documents, Objectives: 1. To respond to resident's request and needs 6. Offer further services before leaving resident's room. Can I do anything for you? Be sure call light is within reach before leaving room.

Based on observation, interview, and record review, the facility failed to provide pain medications per physician's orders for 1 (R251) of 2 residents reviewed for pain management in the sample of 40. This failure resulted in R251 becoming tearful and experiencing increased pain. Findings Included: R251's Resident Face Sheet documented an admitted [DATE]. This same document listed diagnoses including other specified disorders of bone density and structure, other site, osteopenia of spine, rheumatoid arthritis, unspecified, unilateral primary osteoarthritis, right knee, bilateral primary osteoarthritis of hip, and primary osteoarthritis, right shoulder. R251's Care Plan documented a focus area of Problem: Dx (diagnoses) of Rheumatoid arthritis, osteoarthritis/right knee, and osteoarthritis/right shoulder puts her at risk for pain with a start date of 03/25/2025. Interventions documented included administer pain medications as ordered. Monitor for side effects with start date of 3/25/2025. R251's April 2025 Physicians Order Report documented orders for hydrocodone-acetaminophen 7.5-325 mg (milligrams). One tablet by mouth every 4 hours for pain-prn (as needed) with a start date of 3/24/2025. R251's Medication Administration History report dated 3/24/25 to 4/3/2025 documented hydrocodone-acetaminophen 7.5-325 mg. One tablet by mouth given on 4/3/25 at 1:42 AM. The same report documents R251's pain was rated at an 8 out of 10 on the pain scale before the pain medication and 0 out of 10 on the pain scale after the pain medication. On 04/03/25 08:28 AM, V2 (Infection Preventionist) and V3 (Registered Nurse/RN) were observed entering R251's room to administer AM medications. R251 was observed notifying V2 that she had asked for her hydrocodone-acetaminophen 2.5 hours ago. V2 and V3 both stated to R251 that she is scheduled for this medicine every 12 hours at 7:00 AM, she does not have an order for every 4 hours and apologized that her medication was late. R251 stated that she does have an order that she can take this pain medication every 4 hours for pain, and she last took it at 2:00 AM this morning. R251 stated to V2 and V3 that she hurts all over and rated her pain at a 7 on a 1 to 10 pain scale. R251 was observed crying when talking to V2 and V3 and while taking her medications. R251 was observed to be alert and oriented to person, place, and time. On 4/3/2025 at 8:35 AM, V3 (RN) stated R251 does not have an order for hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed. On 4/3/2025 at 9:06 AM, V2 stated R251 did have an order for hydrocodone-acetaminophen 7.5-325MG every 4 hours as needed and there was a communication breakdown between staff. On 4/3/2025 at 9:17 AM, R251 is alert and oriented to person, place, and time. R251 stated she did notify staff members at 6:00 AM this morning that she had been in pain and wanted her pain medication. R251 stated, upon waking up she is a 5 out of 10 on the pain scale is her normal and she tries to stay ahead of hurting more. R251 stated she does get her hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed and the last time she had it was around 2:00 AM this morning. On 4/3/2025 at 9:52 AM, V4 (Certified Nurse Assistant/CNA) stated R251 did report to her at 6:00 AM that she wanted her pain medication. V4 stated she notified V3 (RN) while she was in report that R251 was requesting her pain medication. V4 stated that V3 did respond back to her by saying ok'. On 4/4/2025 at 8:33 AM, V7 (Nurse Practitioner) stated her expectations are for the nursing staff to administer medications based on physician's order. V7 stated that R251 did have a physician's order for hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed and scheduled every 12 hours. V7 stated that 2.5 hours after R251 requested her pain medication was not an appropriate time frame to administer the medication. The facility policy titled Pain Management (revised 3/03/22) documented under Policy: The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms.

Based on observation, interview, and record review the facility failed to develop and implement interventions for a resident at risk for altered nutritional status for 1 (R83) of 3 residents reviewed for nutrition in a sample of 40. Findings include: R83's Resident Face Sheet documented an admitted [DATE] with diagnoses including: Primary osteoarthritis, unspecified hand, unspecified dementia, moderate protein calorie malnutrition, multiple fractures of ribs bilateral, pain, and tremor, unspecified-hx (history). R83's 3/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R83 was cognitively intact. R83's 3/5/25 MDS Section GG documented R83 required Partial/ Moderate assistance with eating, indicating helper does less than half the effort. Section S- Care Area Assessment Summary, under Care Area 12. Nutritional Status, the boxes for Column A, Care Area Triggered, and Column B, Care Planning Decision, are both marked. R83's Care Plan documented under Problem Resident Care Information with a problem start date of 2/27/25. Documented approach includes Regular diet. Set up. Plate guard and weighted utensils with an approach start date of 3/19/25. R83's Care Plan did not document R83 was at risk for weight loss or nutrition concerns. R83's 2/27/25 Occupational Therapy (OT) Evaluation and Plan of Treatment documented in part .New Goal . (R83) will improve ability to safely and efficiently perform eating tasks with Setup and Clean-up Assistance including but not limited to use of built-up utensils . and plate guard to facilitate ability to live in environment with least amount supervision and assistance and to ensure adequate nutrition and hydration . Patient Referral and History . Medical Factors . hand deformity from arthritic changes . Hand Dominance = patient is right-handed . Functional Skills Assessment . Eating . increasing arthritic changes in R (right) hand . R83's Dietitian/Admit Assessment note dated 2/27/2025 at 10:08 AM documents [AGE] year old female admitted (2/26) per progress note on a Regular Diet. Assisted at meals due to fracture. Intakes 50-75%. Weight: (2/27): 114.6 . On Vitamin C Supplement. Estimated Needs: 1560 calories (30 kilo-calories per kg (killigram)), 1560 cc fluids (1 cc (cubic centimeter) per kilo-calories), and 52-62 gram protein (1.0-1.2 injury factor). Plan: Add Diet to orders. R83's Weight Variance Report documented the following weights: 2/27/25 114.6 lbs. (pounds) 3/2/25 112 lbs., indicating a 2.6 lb. weight loss or 2.3% weight loss in 3 days 3/8/25 110 lbs., indicating a 4.6 lb. weight loss or 4% weight loss in 9 days 3/15/25 108 lbs., indicating a 6.6 lb. weight loss or 5.75% weight loss in 16 days 3/22/25 104 lbs., indicating a 10.6 lb weight loss or 9.25% weight loss in 23 days 4/3/25 107 lbs., indicating a 7.6 lb. weight loss or 6.63% weight loss in 35 days An unsigned weekly weight note with a date documented of 3/19 documents that R83 has a current weight of 108 lbs on 3/15 and documents that R83 has a 5.8% or 6.6 lb weight loss in 16 days. This document further states not a significant change yet, but trending with an approach of Added adapted equipment a few days ago. Monitor. Another unsigned weekly weight note dated 3/26 documents a current weight of 104 lbs and documents last weeks approach of New adaptive equipment, monitor and documents an approach of ask for HCHPS (high calorie high protein supplement). R83's Physician Order Report dated 3/2/25 to 4/2/25 documents an order dated 3/28/25 for High Calorie/ High Protein Supplement ordered by V7 (Nurse Practitioner). On 4/1/25 the following observations were made: 12:39 PM: R83's noontime meal tray was delivered to R83's room. R83's weighted silverware was wrapped in a paper napkin and placed on the far side of her plate. R83 had regular silverware placed beside her plate. R83's plate did not have a plate guard. R83 picked up the regular fork and started eating with difficulty holding the fork. 12:44 PM: R83 was observed feeding herself with difficulty holding the regular fork between her index and middle finger. R83's thumb joint was noted to be deformed. While trying to get food onto the fork, R83's hand would slide down the fork to the area where the fork widened, and the tines began. R83 was observed dropping a lot of the food from the fork onto her clothing protector. 12:50 PM:R83 sat her regular fork on her plate to take a bite of bread. R83 attempted 7 times at picking the regular fork back up. 12:52 PM: R83 attempted to cut a piece of brownie with regular fork and the fork kept slipping out of R83's hand. R83 picked up the regular spoon and was able to cut a piece of the brownie but dropped the piece before getting it to her mouth. R83 then piled up the plates in front of her and started licking food from her hands and the food dropped on the table. On 4/2/25 the following observations were made: 11:43 AM: R83's noontime meal was delivered with a weighted spoon and no weighted fork, a plate guard, and regular silverware. 12:00 PM: R83 was eating with a regular fork with difficulty dropping food on the table and on herself. On 4/4/25 at 9:42 AM, R83's breakfast was sitting in front of her in her room on the bedside table. R83's breakfast plate did not have a plate guard and no weighted utensils were present. R83 said sometimes staff would bring her the weighted utensils and plate guard sometimes they didn't, it just depended on the meal. On 4/3/25 at 10:58 AM, V8 (Occupational Therapist) said she would order weighted utensil for a resident if they had tremors or difficulty grasping a regular utensil and would order a plate guard to have more control with the plate to get food onto the utensil and to increase independence. V8 said R83 had trialed the weighted utensils at a facility prior to being admitted due to some tremors and hand weakness. V8 said she expected staff to provide all ordered assistive devices. R83's Progress Notes documents an entry on 4/4/25 at 8:20 AM for a late entry for 4/3/25 at 12:10 PM documenting During the lunch meal, (R83) was served weighted utensils and a plate guard. CNA (Certified Nursing Assistant) returned shortly afterwards saying that (R83) requested a regular set of silverware. (R83) had weighted utensils, plate guard, and regular silverware per her request. On 4/4/25 at 9:47 AM, V7 (Nurse Practitioner) said if a resident is not eating with adaptive equipment they could have weight loss. V7 said if therapy ordered adaptive equipment for a resident, it should be provided. V7 said that she was not aware of R83's weight loss. On 4/4/25 at 12:23 PM, V1 (Administrator) said the facility did not have a policy pertaining to assistive devices. The facility's Weight Monitoring policy with a revision date of 9/6/24 documented in part . 2. Residents are weighted weekly for the first 4 weeks following admission .5. Licensed staff will notify the physician of the following: A. 5% or more gain or loss in a 30-day period .7. Notification to the physician must be documented, and also whether or not new orders were received for either significant weight losses or gains .9. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to RD (Registered Dietitian) as needed .

Based on interview and record review the facility failed to timely transmit a Minimum Data Set assessment (MDS) for 1 of 19 residents (R78) reviewed for MDS assessments in a sample of 40. The findings include: R78's face sheet documents an admitted as 10/14/2024 and includes the following diagnoses: Parkinson's Disease, dementia, Diabetes Mellitus type two, and anxiety. This face sheet documents the last qualifying hospital stay was 10/8/2024-10/14/2024. On 4/2/25 at 2:00 PM, V5 (MDS Coordinator) and surveyor reviewed most recent MDS (Minimum Data Set) and V5 confirmed that it was showing it was open and started on 10/14/24 but not closed and transmitted. V5 stated that she would look into why R78's MDS was showing an overdue status. On 4/3/25 at 9:30 AM, V5 (MDS Coordinator) stated that she found that when R78 left for the hospital she got the MDS started as a discharge with return anticipated but never transmitted it. V5 stated that she transmitted the discharge assessment on 4/2/25, but that is was considered late. Review of the final validation report on 4/3/25, documents that R78's discharge assessment target date was 10/30/2024, but was not transmitted as complete until 4/2/25.

Based on interview and record review, the facility failed to investigate an abuse allegation of misappropriation of property for 1 (R4) of 3 residents reviewed for abuse in a sample of 41. Findings include: 1. R4's face sheet documented an admitted [DATE] with diagnoses including: hypertension, pulmonary hypertension, chronic kidney disease stage 3, and difficulty in walking. R4's Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 1/9/24 at 9:39 AM, R4 said she had $100 dollars taken out of her purse. R4 said she thought another resident had taken it. R4 said she had reported it to the facility and the facility had replaced it. R4's progress note dated 12/4/23 at 10:19 am by V1 (Administrator) documents in part .Resident reported another resident had removed her money from her room. Said the other resident was confused and went thru her things and didn't mean harm but she was aggravated that the money was lost because it was Christmas money to give her grandkids when they came in, Search conducted in room and belongings of resident accused. Resident accused stated she didn't take it, it was her friend. She then stated she put it up for her so she wouldn't lose it but couldn't find it. Staff will continue to search . R4's progress note dated 12/12/23 at 10:24 am by V1 documented Facility replaced money resident reported missing, possibly taken by resident. On 1/12/24 at 11:08 AM, V1 said when R4 had reported she had money missing and thought another resident had taken it, V1 had went to search the alleged resident's room. V1 said the alleged resident did not recall taking any money or where she had placed any money. V1 said R4's money was not found in the facility. V1 said a day or two later she spoke with R4's daughter to verify R4 had $100. V1 said R4's daughter verified R4 did have $100 and was planning on giving money to R4's grandchildren for Christmas. V1 said R4's money had been reimbursed to R4 from the facility. V1 said she had not completed a formal investigation because she thought R4's money would be found and returned to R4. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documents the following under the section titled Policy: 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 resident's symptoms. The same policy documents the following under the section titled Investigation: 1. Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation. 4. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health. 5. The Administrator shall be responsible for resident's protection from retaliation during and after the investigation.

Based on observation, interview, and record review, the facility failed to implement interventions to mitigate falls for 1 (R71) of 7 residents reviewed for accidents in a sample of 41. Findings include: 1. R71's face sheet documented an admitted [DATE] and diagnoses including: dementia, hypertension, weakness, dysphagia, cognitive communication deficit. R71's 10/10/23 Minimum Data Set (MDS) documented a Brief interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. R71's 10/10/23 Fall Risk Assessment Tool documented a score of 23, indicating R71 is a high fall risk. The facility's 8/10/23 through 1/10/23 Fall Log documented R71 had an unwitnessed fall in his room on 11/5/23 while trying to self-transfer from his wheelchair to his bed. R71's care plan (review date 11/4/23) documented in part . is at risk for falls r/t (related to) reduced independent mobility . and documents an intervention dated 5/16/23 of dysom (sic) (non slip padding) in wheelchair and an intervention dated 1/31/21 of anti-rollbacks to wheelchair. On 1/9/24 at 10:43 AM, R71 was observed sitting in his wheelchair in the dining room completing an activity. R71's wheelchair had an anti-rollback attached to the back of his wheelchair with one arm missing and the other arm bent at an angle unable to make contact with the wheelchair wheel. On 1/10/24 at 11:34 AM R71, was observed sitting in his wheelchair in the dining room. R71's wheelchair did not have a dycem cushion in the seat of his wheelchair. On 1/12/24 at 12:20 PM, V6 (Director of Memory Care) said on 1/11/24 R71 did not have a dycem cushion in his wheelchair when the facility checked. V6 said R71 would sometimes take the dycem cushion (non slip pad) out of his wheelchair when R71 went to use the bathroom. V6 said R71 was known to throw the dycem cushion away. On 1/11/24 at 11:01 AM, V2 (Director of Nursing/ DON) said she expected R71 to have anti-rollbacks on his wheelchair and the dycem cushion in his wheelchair as care planned. V2 said she expected any staff to complete a work order if they see any wheelchair parts not in working order. On 1/11/24 at 1:00 PM, V1 said the facility did not have a fall policy. V1 provided a revised 4/3/18 Emergencies policy documenting the procedure to care for a resident after a fall.

Based on interview and record review, the facility failed to implement the facility policy and procedure for Pneumococcal Vaccinations for 1 out of 5 residents (R69) reviewed for immunizations in a sample of 41. Findings include: R69's face sheet documents that R69 was admitted to the facility on [DATE] with diagnoses including encephalopathy, heart failure, peripheral vascular disease, and cardiomegaly. R69's Face Sheet documents a date of birth indicating that R69 is [AGE] years old. R69's Minimum Data Set (MDS) dated for 10/31/2023 documents a Brief Interview for Mental Status (BIMS) score of 12, indicating R69 has moderate cognitive impairment. RF69's Vaccination Records in the Electronic Medical Records (EMR) documents that R69 declined Pneumococcal vaccination on 8/16/2023, 8/23/2022 and 2/17/2022. This documentation was noted on Pneumococcal Vaccine Immunization Assessment/Consent forms. The Risk Assessment and Assessment for Contraindications to the Pneumococcal Vaccination sections of R69's Pneumococcal Vaccine Immunization Assessment/ Consent forms dated 8/16/2023, 8/23/2022 and 2/17/2022 are left blank including the assessment question of Is the resident currently up to date on pneumonia vaccination per CDC (Centers for Disease Control) guidelines? R69's Pneumococcal Vaccine Immunization Assessment/Consent form dated at time of admission on 2/17/2022, had written at the bottom that resident received P23 @ (at) primary with no date of administration documented on the form. The same consent for documents: I have been educated as to the risk and benefits of pneumococcal vaccination and DO NOT want to be vaccinated. This statement is marked with an x along with R69's signature on the signature line. The Pneumococcal vaccine assessment/consent form does not distinguish if the declination was for the Pneumococcal polysaccharide vaccine (PPSV23), Pneumococcal Conjugate Vaccine (PCV) 13, PCV15, or PCV20. On 1/12/2024 at 11:30am, R69 was asked if he remembered when he had his Pneumonia vaccine before admission to the facility and R69 stated No, I don't remember. R69 stated that he takes the flu shot and would be willing to take the needed pneumonia shots. R69 was asked if he had been educated on the different types of pneumonia vaccines and R69 stated, No, I was not aware. R69 was alert to person, place, and time at the time of the interview. On 1/11/2024 at 2:20pm, V2 (Director of Nursing) stated that she does not have a vaccination log or binder, and that all the vaccination records are in the resident's Electronic Medical Record (EMR). On 1/12/2024 at 8:10am, V2 said she could not produce the dates of the pneumonia vaccination for R69 for the vaccines received prior to his admission on 2/17/22. V2 said that the consents do not specify which pneumococcal vaccine was consented to or declined. V2 again said that they do not have a log documenting resident's vaccines administered and dates. The facility policy and procedure titled Pneumococcal Vaccination (Revision date 8/11/22), policy # 3.34B documents It is the policy of the facility to provide immunizations in accordance with CDC (Centers for Disease Control) recommendations. The facility policy documents under Procedure that All residents aged [AGE] years or more and those residents that are determined to be at high risk (those with chronic illness such as lung, heart, or kidney disease, sickle cell anemia, diabetes, recovering from illness, those in congregate living environments, with a weakened immune system, etc.) will be offered the pneumococcal vaccine as recommended by the CDC. Procedure step 1 documents: All residents will have their immunization status assessed at the time of admission and annually thereafter. Any vaccinations that have been received prior to admission will be recorded in the electronic health record. Procedure step 2 documents: Each resident and/or resident representative will receive education regarding the pneumococcal vaccine appropriate for them via the vaccine information sheet provided by the CDC, regarding the benefits and potential side effects of the vaccine. The CDC Immunization Schedule (https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received only PPSV23: 1 dose PVC15 or 1 dose PVC20. Administer either PCV15 or PVC 20 at least 1 year after PPSV23 dose.

Based on interview and record review, the facility failed to implement abuse policies by not reporting abuse and theft allegations within the designated time frame for 2 (R4,and R30) of 3 residents reviewed for abuse in a sample of 41. Findings include: 1. R4's face sheet documented an admitted [DATE] with diagnoses including: hypertension, pulmonary hypertension, chronic kidney disease stage 3, difficulty in walking. R4's Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 1/9/24 at 9:39 AM, R4 said she had $100 dollars taken out of her purse. R4 said she thought another resident had taken it. R4 said she had reported it to the facility and the facility had replaced it. R4's 12/4/23 progress note documented in part .Resident reported another resident had removed her money from her room. Said the other resident was confused and went thru her things and didn't mean harm but she was aggravated that the money was lost because it was Christmas money to give to her grandkids when they came in. Search conducted in room and belongings of resident accused. Resident accused stated she didn't take it, it was her friend. She then stated she put it up for her so she wouldn't lose it but couldn't find it. Staff will continue to search . R4's 12/12/23 progress note documented Facility replaced money resident reported missing, possibly taken by resident. On 1/12/23 at 11:08 AM, V1 (Administrator) said R4 had reported the missing money. V1 said she had not reported the missing money to Illinois Department of Public Health (IDPH) because she did not think R4's money had been stolen and was going to be found. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documents the following under the section titled Misappropriation of Resident Property: 1. No person shall misappropriate or steal any resident property. Any person who becomes aware of any alleged misappropriation or theft of resident property shall report the incident to the Administrator immediately. 2. The Administrator or designee shall investigate the alleged misappropriation or theft of resident property. 3. The Administrator or designee shall be responsible for supervising the investigation and reporting the results of the investigations to IDPH. 40666 2. R30's face sheet documents she was admitted to the facility on [DATE]. The same document lists some of R30's diagnoses as dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type 2 diabetes mellitus without complications, paranoid personality disorder, and hallucinations, unspecified. R30's MDS (Minimum Data Set) dated 12/5/23 document that R30 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R30 is cognitively intact. A document titled Occurrence Report, (Facility Name), Initial/ Final Report, with no date or time, documents R30's name at the top of the report and states Police were onsite looking for resident, stated she had called the department and a nurse had been mean to her and not given her correct blood thinning medication. The report also said that the resident reported while at the (medication) cart the nurse told her that the resident was distracting her and she needed to step back from cart and allow her to review the medication correctly. Resident stated then that the nurse took her arm and pushed her away from the cart to the wall. Resident stated that she called the police because the administrator would not do anything about it. A Progress Note in R30's Electronic Medical Record (EMR) dated 12/11/23 at 1:30pm by V1 (Administrator) documents two police officers onsite looking for a resident in suite A, stating she claimed to have been abused by nurse. After some research, they identified that it was (R30). Officers interviewed resident in room, came out and stated that she had said the night nurse had shoved her up against a wall. She did not report the incident to the facility staff because the facility staff wouldn't address it . A Fax Confirmation Sheet documents that a fax was sent to IDPH (Illinois Department of Public Health) on 12/11/23 at 16:13 (4:13 PM). On 1/12/23 at 10:00am, V1 (Administrator) said she was not aware of any abuse allegations until the police arrived. V1 also said she believed she had 24 hours to report it since was unfounded. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documents the following under the section titled Initial steps and reports of alleged abuse or neglect - documents the following in step 2: If the matter involves alleged abuse or results in serious bodily injury, the Administrator, or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more than 2 hours after the matter becomes known or no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury.

Based on observation, interview and record review, the facility failed to assess the individual food preferences for 2 (R13 and R74) of two residents reviewed for food preferences in the sample of 42. Findings include: 1. R13's Face Sheet documented an admitted [DATE]. R13's November 2022 Physician Order Sheet documented an order for regular diet with regular consistency and thin liquids. R13's Dietician Progress Notes for 09/29/22, 11/03/22, and 11/10/22 documented weight loss with interventions to address weight loss, however contained no documentation as to R13's food preferences. There was no documentation in any of R13's dietary notes about R13's food preferences. On 11/14/22 at 12:16pm, R13 was alert and oriented to person and place. R13 got the month and year right but the date wrong. R13 stated R13 hates the food the facility serves R13. R13 stated R13 eats the same thing, a grilled cheese sandwich and/or chicken noodle soup, every day for lunch and dinner. R13 stated R13 always eats in R13's room. There was an untouched dish of beets on R13's tray. R13 stated, I don't know why they keep sending me this crap I don't like. R13 stated staff have never asked R13 what kinds of foods R13 likes. R13 stated staff has not explained to R13 what foods are always available. On 11/14/22 at 12:45pm, V4 (Certified Nursing Assistant/CNA) stated R13 is a picky eater who will only eat grilled cheese and chicken noodle soup. On 11/15/22 at 9:30am, V3 (Dietary Manager) stated it is her responsibility to interview residents about their food preferences and to document them within the Dietary Progress Notes. V3 stated she has not yet had an opportunity to assess or discuss food preferences with R13. V3 stated she does know R13 requests chicken noodle soup and grilled cheese daily. On 11/15/22 at 12:08pm, R13 was eating lunch in R13's room. R13 was eating two bowls of chicken noodle soup, without a grilled cheese. R13 stated R13 was not in the mood for grilled cheese today. R13 stated R13 always orders biscuits and gravy for breakfast. R13 stated R13 likes bacon and would eat it if served to R13, but it is not served very often and R13 is not sure if R13 can request it. R13 stated R13 likes fried eggs but the facility only serves poached or scrambled eggs. R13 stated nobody has ever asked R13 how R13 prefers R13's eggs. 2. R74's Face Sheet documented an admitted [DATE]. R74's November 2022 Physicians Order Sheet documented an order for regular diet, regular consistency, and thin liquids. R74's Dietician Assessments dated 09/22/22, 10/13/22 and 11/10/22 documented weight loss with interventions to address weight loss, however contained no documentation as to R74's food preferences. There was no documentation in any of R74's dietary notes about R74's food preferences. On 11/14/22 at 11:57am, R74 was observed in her room with V5 (Family Member). R74 was alert and oriented to person and place but not time. R74 was eating a restaurant catfish meal brought in for her by V5. R74 stated she does not really like foods the facility serves her. R74 stated today she asked staff to not bring in a tray as she did not like any of the foods offered today. On 11/15/22 at 9:38am, V3 stated she has not had an opportunity to speak with R74 about her food preferences, but that V5 had called V3, concerned about R74's intakes and her weight. V3 stated she recalls V5 stated R74 likes fish and pasta. On 11/15/22 at 11:50am, R74 was in her room with V5, eating a restaurant fried chicken meal V5 brought her. V5 stated R74 did not like the foods the facility served her so V5 decided to start bringing food in for R74. V5 stated he called V3 to tell V3 about R74's food preferences, for example, R74 absolutely will not eat cheese. V5 stated he has noted R74 is frequently served foods containing cheese even after this conversation. R74 stated for breakfast this morning, she was served a cheese omelet. R74 stated she did not eat it and did not request a substitute, but would have eaten plain scrambled eggs had they been offered to her. R74 stated the lunch meal today was Some kind of casserole-I told them not to bother to bring it in here. R74 stated she did not recall hearing anything about some foods always being available. An undated Always Available Menu Policy documented, The Food Service Supervisor (Dietary Manager) is to work with the residents family/friends/DPOA (Designated Power of Attorney) as well as (to) utilize direct meal observations and meal intakes to discern usual beverage, bread, and other specific meal preferences. The Always Available Menu items on this document included: Hamburger on Bun, Cheeseburger on Bun, Meat Salad Sandwich, Deli Meat and Cheese Sandwich, Fried Egg Sandwich, Grilled Cheese Sandwich, Peanut Butter and Jelly Sandwich, and Chef Salad with 2 ounces of Meat and Cheese and 1 Hard Boiled Egg.

Based on observation, record review and interview, the facility failed to follow safe food handling practices for storage, preparation, and service. This has the potential to affect all 106 residents living in the facility. Findings include: 1. The Resident Census and Conditions of Residents form, dated 01/13/2020, documents a census of 106 residents residing at the facility. 2. On 01/13/2020 at 9:45 AM, the following items were observed in the facility's kitchen area: - the walk in refrigerator fan and nearby ceiling area was heavily soiled with a dark colored, moist dust. - a 5 gallon paper ice cream container was damaged, and the carton was torn with ice cream on the outside of the container. - the floor beneath the large steam table and food preparation area, located in the middle of the kitchen, was blackened with layered dirt and had not been cleaned. - the wall area behind the stoves and ovens had peeling beige paint. - a minimal to moderate layer of grease was noted in the vents of the hood above the stoves, and on the glass doors of the steam ovens. 3. On 01/13/2020 at 10:00 AM, multiple servings of dessert items, identified by V14 (Head Cook) as Pumpkin Crunch Cake, were stored in the walk in refrigerator on a multiple tiered cart of trays with a quilted cover. At this time, V3 (Food Service Supervisor) and V14 each said that the quilted cover was laundered, yet there was no documentation or schedule presented to show how often the quilted cover was being laundered. The same, quilted cover was observed in use on 01/14/2020 and 01/15/2020 during lunch preparation. The quilted cover had a dried white substance noted on the outside on 01/15/2020. 4. On 01/13/2020 at 10:00 AM, an unlabeled covered bin, identified by V14 as containing dried cocoa powder, was located beneath the milk machine and there was a large scoop inside the bin. The scoop was also observed inside the bin on 1/14/2020 at 10:35 AM and on 1/15/2020 at 9:30 AM. When asked, V14 confirmed that the bin was dry cocoa powder used for hot chocolate. The facility's Food Service policy, revised 09/10, page 2, section B, 7. reads: Food not subject to further washing or cooking before being served shall be stored in a way that protects it against contamination. 8. Unless its identity is unmistakable, bulk food not stored in the original labeled container or package in which it was obtained shall be stored in a container labeled to identify the food by common name. 5. On 01/16/2020 at 10:45 AM, V3 stated that the quilted tray cover had been thrown away and replaced with plastic covers. V3 said that the quilt cover could not be properly laundered. V3 said that she placed a scoop holder beside the cocoa powder to avoid staff placing the scoop inside the bin. V3 also said that the wall behind the stove and ovens were cleaned and painted, the process to clean beneath the steam table preparation area had been initiated, and the dirty walk in refrigerator fan and ceiling were cleaned.

Based on interview, observation, and record review the facility failed to ensure residents and/or resident representatives were provided the facility's bed hold policy at the time of transfer for 4 of 4 residents reviewed for hospitalization (R17, R24, R52, R92) in a sample of 30. The findings include: 1. R17's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15, which indicates R17 is cognitively intact. On 3/19/19 at 10:12 AM, R17 said she was hospitalized for [REDACTED]. A progress note dated 3/8/19 documents R17 was transferred to the hospital due to a critical lab. The note did not contain any information regarding bed hold information being provided to R17 or to her representative. R17's medical record did not document if she was provided with written notification of the facility bed hold policy, and more specifically notification of the duration of the bed hold. On 03/20/19 at 10:20 AM, copies were requested of the Bedhold and Readmission Policy Acknowledgement (Form #NH-370; Adopted: 10/5/18) for R17's hospital admission on 3/8/19. On 03/20/19 at 11:00 AM, V1 (Administrator) brought copies of the Admit/Discharge Report that is sent to the Ombudsman, and stated they send these monthly. V1 also provided a copy of the hospital transfer notification (Form NH#259, Adopted: 10/5/18) that was mailed to R17's family, but could not provide documentation that R17 or her representative were provided written notification of the Bedhold and Readmission Policy Acknowledgement form. 2. R92's Admission MDS dated [DATE] documents an admission date of [DATE]. R92's MDS dated [DATE] documents a BIMS score of 10, indicating moderate cognitive impairment. R92's medical record documents a letter (a hospital transfer notification - Form NH#259, Adopted: 10/5/18) that states R92 was transferred to a local hospital on [DATE] due to a change in condition. R92's record did not document if he or his representative were provided with written notification of the facility bed hold policy, and more specifically notification of the duration of the bed hold. On 03/20/19 at 10:00 AM, copies were requested of the Bedhold and Readmission Policy Acknowledgement (Form #NH-370; Adopted: 10/5/18) for R92's hospital admission for 2/26/19. On 03/20/19 at 11:00 AM, V1 (Administrator) brought copies of the Admit/Discharge Report that is sent to the Ombudsman, and stated they send these monthly. V1 also provided a copy of the hospital transfer notification (Form NH#259, Adopted: 10/5/18) that was mailed to R92's family, but could not provide documentation that R92 or his representative were provided written notification of the Bedhold and Readmission Policy Acknowledgement form. 3. R52's MDS dated [DATE] documents an admission date of [DATE] and a BIMS score of 99, indicating R52 was unable to complete the interview. R52's medical record documents a letter (a hospital transfer notification - Form NH#259, Adopted: 10/5/18) that states R52 was transferred to a local hospital on [DATE]. R52's record did not document if he or his representative were provided with written notification of the facility bed hold policy, and more specifically notification of the duration of the bed hold. On 03/20/19 at 10:20 AM, copies were requested of the Bedhold and Readmission Policy Acknowledgement (Form #NH-370; Adopted: 10/5/18) for R52's hospital admission for 1/28//19. On 03/20/19 at 11:00 AM, V1 (Administrator) brought copies of the Admit/Discharge Report that is sent to the Ombudsman, and stated they send these monthly. V1 also provided a copy of the hospital transfer notification (Form NH#259, Adopted: 10/5/18) that was mailed to R52's family, but could not provide documentation that R52's representative was provided written notification of the Bedhold and Readmission Policy Acknowledgement form. 4) R24's Minimum Data Set ((MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 15, which indicates R24 is cognitively intact. R24's record documents a letter (a hospital transfer notification - Form NH#259, Adopted: 10/5/18) that states R24 was transferred to a local hospital on [DATE] due to a change in condition. R24's Progress Note dated 2/18/19 at 9:00 AM documents, Lifeline in facility at this time to transport res. (resident) copy of CCD (continuity of care document), face sheet, POLST (physician's orders [REDACTED]. On 3/21/19 at 9:30 AM, V2 (Director of Nursing/DON) stated the facility sends the bedhold and readmission policy acknowledgement to the hospital with the resident when they are transferred. When asked if the bedhold acknowledgement form is given to the resident representative, V2 (DON) stated, No. V2 stated the facility puts the bedhold acknowledgement form in a manila envelope with the other paperwork being sent to the hospital with the EMT's. When asked if there was any documentation to show if the residents (R17, R52, R92, and R24) received the bedhold acknowledgement form V2 (DON) stated, No.

Based on record review and interview, the facility failed to formulate and communicate a resident's advanced directive wishes for one of one (R92) resident reviewed for advanced directives in a sample of 30. Findings include: R92's Admission Minimum Data Set ((MDS) dated [DATE] documents an admission date of [DATE]. R92's MDS dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R92's (MONTH) 2019 Physicians Order sheet documents R92 as a Full Code. R92's medical record had an Illinois Statutory Short Form Power of Attorney for Health Care document that was signed by R92 and his Son/POA (Power of Attorney) dated 2/22/19. This document has a section with R92's initials that shows his choice of the following: I do not wish my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my agent believes the burdens of the treatment outweigh the expected benefits . On 03/20/19 at 10:57 AM, V1 (Administrator) was asked for documentation of R92's Advanced Directive. V1 stated they did not have a POLST (Physicians Order for Life Sustaining Treatment) for R92. V1 then stated that R92 requested to be a full code on admission. On 3/20/19 at 1:30 PM, R92 was asked about his wishes regarding advanced directives, such as if his heart stopped beating, would he want to be resuscitated, and R92 replied No, when it quits, it quits.

Based on interview, observation and record review the facility failed to provide ongoing assessment of respiratory status and response to oxygen therapy, and failed to have a physicians order/indication for use of oxygen therapy for 1 of 1 resident (R90) reviewed for oxygen therapy in the sample of 30. Findings include: On 03/19/19 at 9:51 AM, an oxygen concentrator was noted beside R90's bed, with the oxygen tubing in a bag hanging on the side of the concentrator that had a date of (MONTH) 20, 2019 written on the outside of the bag. On 03/21/19 at 12:56 PM, an oxygen concentrator was again noted in R90's room beside the bed, with the oxygen tubing in a bag hanging on the side of the concentrator that had a date of (MONTH) 20, 2019 written on the outside of the bag. On this same date and time, R90 stated that she only uses the oxygen at night when needed, and doesn't use it every night. R90's Care Plan with a last care conference date of (MONTH) 18, 2019 documents an admission date of [DATE], and lists no problems, goals or approaches related to oxygen therapy for R90. On 03/21/19 at 01:07 PM, V10 (Registered Nurse/RN) said the oxygen tubing is changed on the 5th day, and the humidifier is changed out at the same time. V10 stated they place a bag on the oxygen tank or concentrator to store the tubing and face masks or cannulas, and the date written on the bag is dated 5 days in advance. V10 stated I wrote a note on admission saying R90 received oxygen at 2 liters a minute only at night and notified her physician. V10 further stated however that when R90 admitted , they checked her O2 (Oxygen) sats (saturation) BID (twice a day), and since they were within normal limits, the oxygen for R90 was discontinued. R90's progress note dated (MONTH) 26, 2019 documents Reviewed medications with resident and no discrepancies. Resident did state that she wears 2L (liters) of oxygen at bedtime only. Messaged V11 (Nurse Practitioner) for order for Oxygen. Resident notified. Review of R90's medical record revealed no physicians orders could be located for oxygen therapy, nor for the discontinuation of oxygen therapy. Throughout the duration of the survey, the facility was unable to produce any physicans orders for R90's use of oxygen or any evidence of ongoing assessment of oxygen therapy.

Based on interview, observation, and record review the facility failed to follow their policy regarding the disposal of medication for 1 (R403) of 1 resident reviewed for pharmacy services in a sample of 30. Findings Include: On [DATE] at 4:00 PM, the medication room located behind the nurses station on ,[DATE] wing was observed. Inside the medication room next to the hand wash sink was a blue 13 gallon trash can with a clear liner. Inside the trash can, among used paper towels, discarded paperwork, and food wrappers were ten (10) partially dispensed 30-pill medication punch cards labeled with R403's information. R403's medication cards included the following: 1) [MEDICATION NAME] 12.5 mg (milligram) - 28 pills remaining; 2) [MEDICATION NAME] 20 mg - 5 pills remaining; 3) [MEDICATION NAME] 300 mg - 5 pills remaining; 4) Atorvastatin 20 mg - 4 pills remaining; 5) [MEDICATION NAME] 50 mg - 10 pills remaining; 6) [MEDICATION NAME] ER 30 mg - 5 pills remaining; 7) Potassium Chloride ER 20 meq (milliequivalent) - 5 pills remaining; 8) Pantaprazole 40 mg - 8 pills remaining; 9) [MEDICATION NAME] 20 mg - 8 pills remaining; 10) Eliquis 5 mg - 9 pills remaining. On [DATE] at 4:10 PM, V2 (Director of Nursing/DON) stated she did not know how R403's medication ended up in the trash can. V2 stated resident medications should not be in the medication room trash can or any other trash can in the facility. V2 further stated this is not facility protocol or how licensed staff have been trained to dispose of resident medication. V2 stated the medication rooms are equipped with bottles of a liquid chemical called Drug Buster Drug Disposal System that are to be used for the safe disposal of medications. R403's Resident Face Sheet documents she is a current resident with an admission date of [DATE]. The facility document titled, 8.2 Disposal/Destruction of Expired or Discontinued Medications documents the following: Applicability: This Policy 8.2 sets forth procedures relating to medication disposal and destruction. Procedure: 11.1 - Facility should destroy discontinued or outdated non-controlled medications by one of three (3) methods: 11.1 - Prior to destruction, an authorized Facility staff member should remove medications, including pills, capsules, liquids, creams, etc., from their dispensing containers and pour the medications into a container or plastic bag . 11.2 - An authorized facility staff member should place the medication containers in a container or box. Facility staff member should then seal the box with strong tape and label the box as MEDICATION FOR DESTRUCTION 11.3 - Facility-approved commercially available drug disposal kits.

Based on observation, interview and record review the facility failed to recognize and evaluate the risk factors associated with a method of transportation for a follow-up appointment for 2 of 4 residents (R1, R3) evaluated for physician follow-up appointments in a sample of 4. This failure resulted in R3, a resident experiencing anxiety, crying episodes, increased pain, being terrified, being fearful, having sleeplessness and the inability to progress with therapy. The findings include: 1. According to R3's Electronic Health Record (EHR) R3 is [AGE] years old, admitted to the facility on (MONTH) 22, (YEAR) from a local hospital's Cardiac Care Unit, after receiving a Transcather Aortic Valve Replacement, Balloon Aortic Valvuloplasty, Temporary Pacemaker Placement, Possible Percutaneous Coronary and Peripheral Intervention Transesophagel Echocardiogram (Bilateral). R3's [DIAGNOSES REDACTED]. Arthritis. According to R3's MDS (Minimum Data Set) assessment dated (MONTH) 5, (YEAR) R3 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R3 is cognitively intact, and needs extensive assistance with one person physical assistance with the following activities of daily living: locomotion off unit, and transfers. According to this same MDS, R3 needs extensive assistance with two persons physical assist with toilet use and is at risk for getting a pressure ulcer. R3's Medication Administration Record [REDACTED]. R3's physician's orders [REDACTED]. R3's Insulin Administration History report dated (MONTH) 22, (YEAR) through (MONTH) 26, (YEAR) documents R3's blood sugars were checked three times a day before breakfast, after lunch, and at bedtime. This report further documents R3's blood sugar results were greater than 200 (5) times, greater than 300 (10) times, indicating R3's blood sugar being unstable. R3's Physical Therapy evaluation dated (MONTH) 23, (YEAR) which documents a run date through (MONTH) 6, (YEAR) states the reason for referral as recent hospitalization due to chronic diastolic heart failure and aortic valve replacement. Pt (patient) reports a significant decline in functional mobility and strength over the past few weeks. Pt now presents with impairment in gait, balance, safety and LE (lower extremity) strength that limit independence level. R3's Occupational Therapy evaluation dated (MONTH) 23, (YEAR) which document with a run date through (MONTH) 6, (YEAR) states the reason for referral as presenting following a transcatheter aortic valve replacement balloon aortiv valvuloplasty and temporary pacemaker placement and spending approximately 1 week in ICU (intensive care unit). Pt (patient) continues to c/o (complain of) weakness, decreased strength and balance and some confusion requiring increased assistance with all care. On (MONTH) 1, (YEAR) at 3:40 PM during a tearful interview R3 stated a nurse came into her room on (MONTH) 29, (YEAR) at around 7:00 AM to tell her she needed to be ready to leave for an appointment. R3 then stated I told her I didn't have transportation and she said we have a bus coming. R3 further said I got ready and left the faciity on a bus thinking I was going to my appointment. R3 stated when she got on the bus at the facility she was the only person on the bus. R3 then stated the bus driver drove me to (nearby town) and turned into a mall back door J.C. Penny parking lot. I said what are you doing, you can't leave me here and the bus driver replied, Oh yes I can another bus will be here in 40 to 45 minutes. R3 then said she waited 30 minutes, and checked her watch and it was around 8:00 AM and R3 stated No one was around, no stores open, no cell phone, no nothing! R3 continued and said she went to the appointment and the receptionist at the doctors office asked me what I was doing as the two doctors were not in the office that day. R3 told them she had no one to pick her up. R3 then stated I was to the point all I could do was cry. R3 said the receptionist said she would call the facility and let them know, she did not have another doctors appointment and this same receptionist told her on three different occasions it would be about 15 minutes before someone would be here to pick her up. R3 stated someone at the doctors office asked her (R3) if there was a family member they could call and R3 had them call her son. R3 verified she left the facility at around 7:30 in the morning and got back to the facility around 1:30 PM that afternoon by ambulance. R3 stated I was terrified and so upset by the time I got back .I couldn't do therapy for 2 days. I have [MEDICAL CONDITION] and I went to therapy and tried but I couldn't do it. R3 said the same girl that came in that morning and told her about the appointment told her she could get an extra pain pill if she needed and R3 told her yes she needed one. R3 stated I cried all night long from fear, I was petrified and hurting. It was a nightmare, I could hardly stand from the [MEDICAL CONDITION], I was done for. R3 was crying and and trembling during the conversation and further stated I felt everyone was staring at me when I got back and they were saying in a low voice There she is, and that happened to her. R3 then stated after about the third day I started getting good enough to participate in the therapy again. When questioned about a nurse (V6) coming in and discussing the doctors appointments with her and being provided with information about being dropped off and picked up R3 stated I did not know anything about a doctors appointment until 7:00 AM the morning of the appointment. During this interview R3 was crying, wiping tears with her hands, wringing her hands, and running her hands through her hair intermittently. R3's Physical Therapy daily treatment notes for (MONTH) 27, (YEAR) through (MONTH) 2, (YEAR) indicates a decline in predication of physical therapy on (MONTH) 29, (YEAR) and (MONTH) 30, (YEAR) with the following statements for (MONTH) 29, (YEAR) as Treatment withheld patient ill and (MONTH) 30, (YEAR) as .Patient still very emotional/crying over bus ride with (community transportation provider) yesterday. She c/o feeling weak, dizzy, with slight nausea. R3's Occupational Therapy (OT) participation notes specifies R3's participation in OT decreased on (MONTH) 29, (YEAR) with the following note Res (resident) unavailable after a very long and detrimentally challenge day with doctor appointment, elevated stress and sugar level, withheld due to sickness. On (MONTH) 30, (YEAR) Occupational therapy participation was decreased and a note stating pt (patient) very emotional on this date still regarding yesterday episode. Pt (patient) c/o dizziness and fatigue. Speech Therapy daily treatment note dated (MONTH) 29, (YEAR) states Validation tech and distraction tech utilized to decrease anxiety from recent doctors office trip where she rode public transportation .Continued validation of feelings which decreased tearfulness and calmed patient. On (MONTH) 5, (YEAR) at 10:00 AM, R3 stated I'm getting better, I woke up night before last and couldn't go back to sleep for thinking about the whole ordeal, but I'm getting better. On (MONTH) 6, (YEAR) 12:00 PM, R3 stated I'm doing better, I still think about it and everyone here has told me they are sorry it happened. A document entitled After Visit Summary from a local hospital, page 4 of 9, dated (MONTH) 22, (YEAR) lists a follow up appointment with (V17, physician) at the Valve Clinic at 9:00 AM on (MONTH) 29, (YEAR) and another follow up appointment with (V18, [MEDICATION NAME] Surgery physician) on (MONTH) 29, (YEAR) at 10:40 AM both located in the same building. Progress notes as follows for R3: 5/22/2018 at 1:21 PM states [AGE] year old female admitted . accompanied by Family member (V16). Another progress note dated 5/22/18 at 1:57 PM notes two follow up appointments with V17 and V18 in the same office at a nearby town one at 9:00 AM and the other at 10:40 AM. The note further documents, Family aware and provided a copy of scheduled appointments. R3's Progress note dated (MONTH) 25, (YEAR) at 4:11 PM states Spoke with res (resident) regarding f/u (follow-up) appointment on 05/29/18 at the (a local physician office) in (local nearby town). Res has requested (local community transportation provider) to transport. Called et (and) spoke with . at (local community transportation provider); res will be picked up from facility at 7:35 AM et (and) taken to (major department store) in (local town); res will change buses at 8:35 AM then be taken to appointment. After 2nd (second) appointment is concluded; res will be picked up from (physician office) at 12:15 PM and taken to (major department store) bus stop and change buses at 12:45 PM; res will then be transported back to facility et should arrive back at approximately 1:30 PM .Resident notified et verbalized understanding. This note was signed by V6, Licensed Practical Nurse (LPN). According to www.google.com/maps the physician's office where R3 had the follow-up appointment on (MONTH) 29, (YEAR) was 13 miles from the facility and takes 17 minutes to get to the drop off point if there are no other stops. R3's Progress note for (MONTH) 29, (YEAR) at 7:47 AM states Res (R3) OOF (out of facility) at this time via (local community transportation provider) to f/u appointment with V17 and V18. Another note dated (MONTH) 29, (YEAR) at 10:38 AM states V18 called the facility and notified this nurse res did not have appointment with V18 today. res cardio f/u is scheduled with V19, physician on 6/4/13 (18) @ (at) 3:00 PM. V6, Licensed Practical Nurse (LPN) notified (local community transportation provider) to p/u (pick up) res from V18's office. R3's Progress note for (MONTH) 29, (YEAR) at 11:12 AM, states (local community transportation provider) unable to p/u res and transport back to facility, V2, Director of Nursing (DON) instructed this nurse to notify (local ambulance service) to p/u res . R3's Progress note for (MONTH) 29, (YEAR) at 1:30 PM, states Res returned to facility at this time via (local ambulance service). Res A/O x 3 (alert and oriented to person place and time), res upset, crying and tired, son here in facility to see res, res stated she has never been through such an ordeal. Res stated she was never seen by MD. This nurse notified V17's office r/t appointment Son requested copy of discharge order w/ (with) scheduled apts (appointments) and (local community transportation provider) phone number. R3's Progress note for (MONTH) 29, (YEAR) at 3:12 PM Called and spoke with (V4) she stated res was seen at V17's office for a nurse only visit and included a symptom site check and EKG (electrocardiography). On (MONTH) 6, (YEAR) at 8:41 AM, V16, R3's family member states he received a document with the follow up appointments on it when R3 was admitted into the facility, however he did not know she was going to be dropped off at a mall parking lot to wait on a bus and states She (R3) was very upset and further states She was picked up at the facility at 7:30 AM and I can't imagine a bus driver driving off and leaving her there alone. On (MONTH) 6, (YEAR) at 10:59 AM, V20, Licensed Practical Nurse (LPN) states when R3 returned to the facility she was upset and crying. V20 stated she completed an assessment on R3, all her vital signs were within normal range for her, assisted her to bed, gave her a pain pill, ordered her a meal tray and held her hand. V20 stated she told R3 she was extremely sorry and the supervisors were aware of the situation and they were checking into it. V20 then stated an hour later she (R3) wasn't crying and seemed calmer. On (MONTH) 1, (YEAR) at 4:30 PM, V7, family of R3 said R3 went without necessities for 6 hours from the time she left the facility at 7:30 AM to 1:30 PM, and further said V4 , the Practice Manager called him and said (R3) did not get lunch. V7 stated R3 is Diabetic and takes insulin and eating on a schedule is important. V7 stated that during a phone call with R3 after her return to the facility R3 told him,she was so emotional she was beside herself. V7 stated,I feel it was neglectful that she was left outside in the elements to fend for herself. V7 also stated R3 was out of her normal routine, not knowing if or when she would be picked up and by who, plus having dementia and only being in that facility for 7 days after a surgical procedure on her heart. V7 further stated I believe it was extremely traumatic for her. V7 said what he got from R3's communication that evening was that there was no one around in that parking lot familiar to her, she was sitting in a wheelchair without a cell phone and nothing familiar, that would be upsetting to anyone. On (MONTH) 1, (YEAR) at 2:45 PM, V3, Registrar at physician office says R3's appointment was at 9:00 AM with a nurse and that took about 45 minutes to an hour. V3 stated R3 told her she had another appointment with another physician in the same building but was told that doctor was not in that day. V3 then stated she told the receptionist at the other physician's office to call the facility and tell them R3 needed to be picked up. V3 stated she left for lunch and returned around noon and R3 was still sitting in the waiting room. V3 then stated she called the facility and talked with someone I believe it was the Director of Nursing (DON) and told them R3 needed to be picked up. I called a second time and was told the DON was working on it. V3 stated she helped R3 to the bathroom a couple of times while she was waiting and stated I sat with her, gave her something to drink, snacks when she told me she was diabetic she was visibly upset and trembling. On (MONTH) 1, (YEAR) at 1:50 PM, V5, family member of R3 said she met with the (V2, Director of Nursing) today and was told R3's bus was suppose to be a bus to bus transfer and that R3 was not suppose to be alone in that parking lot. V5 stated V2 admitted R3 was crying and upset and the nurses were trying to comfort her. V5 said even her room mate said she (R3) cried and cried when she returned to the facility. On (MONTH) 5, (YEAR) at 12:34 PM, V6 (LPN), verified R3 was provided with the information regarding the follow-up appointments for (MONTH) 29, (YEAR) on (MONTH) 25, (YEAR) and documented it in the progress note section of R3's EHR. V6 stated staff of the transportation provider said R3 was supposed to get off one bus and get on another. V6 did not specify if the bus driver was to wait the 30 to 45 minutes for the other bus to get there. V6 then stated I don't blame her for being upset. I did not tell her she would be dropped off and have to wait in a parking lot for another bus. On 6/5/18 at 1:30 PM, V13 (local transportation bus driver) stated she typically drove that bus and she made trips to nearby town with that bus route. V13 stated she did not transport to different locations in the nearby town, that she only dropped people off at five central locations and the nearby town bus would pick them up at those locations and take them where they needed to go in the nearby town. When asked if there was a wait between her dropping them off and the nearby town bus picking them up V13 stated, Yes, 15-30 minutes. On 6/5/18 at 3:54 PM, V14 (local transportation bus driver) stated he did at times drive the bus to the nearby town and would drop the individuals from the facility off at the bus stop. When asked if the nearby town bus was waiting for them when he would drop the residents off V14 stated, Not always. Sometimes they have to wait for the next bus, but if they want special transportation so they don't have to wait for the bus they just have to call our office and schedule it. On (MONTH) 6, (YEAR) at 10:23 AM, V2, Director of Nursing (DON) said V20, LPN told her the doctors office had called concerned because R3 was telling them she had sat in a parking lot for 45 minutes waiting on a bus. V2 stated she called V21, Director of Operations at the community transportation facility and left a message. V2 stated between 10:00 AM and 10:38 AM an employee from the physician office called and said they were done with R3 and and could not get a-hold of the community transportation company to pick her up. V2 then stated she told the employee, R3 had another appointment with another physician at their same building V2 stated that later on V20 told her that R3 did not have a second appointment with V18 and the physician's office staff could not get in touch with the community transportation system to pick R3 up. V2 further said V20 was instructed to call the community transportation provider and was told it would be a while. V2 then told V20 to call the local ambulance company to pick R3 up at the doctors office and bring her back. V2 said when V21 (Director or Operations with the local community transportation provider) was informed what had happened with R3 being dropped off in the parking lot to wait on a bus to pick her up V21 stated to V2, Oh I'm so appalled, that is not suppose to ever happen with your residents. V2 then stated that V21 would start an investigation and get back with us with the results. When questioned about the progress note by V6 stating R3 was being picked up at 7:35 AM and changing buses at 8:35 AM and the parking lot where R3 was to change buses was 13 miles away from the facility on (MONTH) 6, (YEAR) at 3:30 PM, V2 stated they make other stops along the way, we did not know they were going to leave her in the parking lot. On (MONTH) 5, (YEAR) at 2:30 PM, V1 (Administrator) stated she had a verbal agreement with the local transportation service to pick up the resident's at the facility and complete a bus to bus transfer or they would take them directly to the door of their appointment. V1 stated that leaving a resident waiting for another bus was not suppose to happen. V1 said she had called V21 and was told she would find out what happened with R3 and was told it was a driver error and that V21 knew that resident's at that facility were to be taken directly to there destination and not dropped off somewhere waiting for another bus to pick them up. V1 then stated I told her I could not trust that service anymore and that I would authorize an ambulance transport if necessary before I would use them to go out of town anymore. A letter dated (MONTH) 6, (YEAR) from the community transportation provider states In our assessment of what occurred the customer (R3) was scheduled on the wrong route. To compound the situation the driver broke protocol and didn't call the office. The driver gave the customer the option to stay on the bus or be dropped off at the (major department store) stop under the canopy. This is not normal operating procedure for (formal name of facility) customers. We have a para transit bus without transfers that she should be scheduled on. 2) R1's care plan snapshot dated 5/25/18 documents R1 is a [AGE] year old male whose [DIAGNOSES REDACTED]. R3's care plan also documents R1 requires extensive assistance of two staff to transfer and is at risk for falls. On 6/1/18 at 10:30 AM, R1, who is alert and oriented to person, place and time stated he had knee replacement surgery and was at the facility for rehabilitation. R1 stated he had not had any appointments outside of the facility since arriving but he did have one scheduled for Tuesday 6/5/18. On 6/1/18 at 11:10 AM, V9 (Certified Nursing Assistant-CNA) stated staff did not accompany residents to appointments. V9 stated if a resident was not able to go by themselves family went with them or the physician came to the facility. On 6/6/18 at 10:09 AM V2 (Director of Nursing) stated the facility assists residents with scheduling transportation based on the residents choice. Residents can be transported by a local transportation company, a cab, or family. If a resident goes by a local transportation company or a cab the nursing staff gather pertinent medical information for the resident to take with them. They inform the resident of the appointment and what time they need to be ready for the appointment. The nurse lets the CNA- certified nursing assistant know the resident has an appointment. Staff give the resident their medical records and either takes the resident to the front entrance or the 600 hall entrance or the resident propels themselves to the appropriate entrance to wait for transportation. Upon return to the facility the transportation company will drop them off inside the front entrance or the 600 hall entrance. On 6/5/18 beginning at 1:15 PM, R1 was in the 600 hall dining room. R1 stated he was not sure what time his bus would pick him up or where he was supposed to get on the bus. R1 stated he was concerned he was going to miss his appointment and it was very difficult to get an appointment with his physician. R1 went to the nurses station located between the 300 and 400 hall at 1:20 PM and spoke with the nurse (not identified) she stated she would have to call to find out where he was supposed to be. After the nurse made a phone call, R1 left the nurses station and went towards the 600 hall. A CNA (V11) followed R1 down the 400 hallway and asked him if she could take his wheelchair to the wheelchair clinic. R1 told V11 she could not take his wheelchair since he had an appointment. V11 followed R1 to the exit door located next to the therapy department and obtained R1's pulse prior to putting the code in for R1 to exit. R1 exited the building to wait for the bus, V11 stayed inside the building. A local transportation bus pulled to the curb and lowered the ramp. R1 began to cross the ramp to get onto the bus. The bus driver (V13) stated to R1 she was there to pick up someone else and his bus would be here shortly. R1 was then picked up by a wheelchair accessible bus. On 6/5/18 at 4:51 PM, V11 (Certified Nursing Assistant) stated she was R1's CNA today (6/5/18) from 5:30 AM until 2:00 PM. V11 stated she was not aware R1 had a medical appointment until he told her in the hallway at approximately 1:30 PM. When asked if it was typical for her to not be aware of a residents appointment V11 stated the nurses usually tell her or they have wrote it down somewhere. When asked how she would know when a resident returned from an appointment V11 stated if they are dropped off up front the staff will call and let their CNA know they are back. If the resident is returned to the back entrance (by the therapy department) the bus driver brings the residents to their hall. On 6/5/18 at 3:54 PM the local transportation company bus returned to the facility. The bus driver assisted R1 off the bus using the wheelchair lift. The bus driver (V14) asked R1 if he needed assistance into the building. R1 told V14 he did not need assistance. There were no staff present outside at this time. R1 attempted to push the button that would open the doors into the building. This button did not open the doors. R1 was unable to hold the door open and self propel his wheelchair into the building unassisted. On 6/5/18 at 4:41 PM, V12 (CNA) stated he was assigned to R1 after 2 PM on 6/5/18. When asked if he had seen R1, V12 stated, No, not yet. He is at a doctor's appointment. His family took him and they will sign him back in when he gets back. When asked how he would know when to expect him back V12 stated, I haven't got word yet.

Based on interview and record review the facility failed to provide supervision during toileting for 1 of 4 residents (R3) reviewed for falls in the sample of 5. This failure resulted in R3 sustaining multiple skin tears to the right forearm and thigh, a laceration to the left side of the head and a Periprosthetic Fracture of the right femur that required surgical repair (Opertive Report, History and Physical and/or emergency room Physician Documentation all dated 9-22-17.) Findings include: R3's Physician order [REDACTED]. R3's Admission History and Physical from the local hospital dated 9-16-17, prior to admission to this facility, lists [DIAGNOSES REDACTED]. R3's 5 day Minimum Data Set Assessment with an entry date of 9-21-17 lists the following information: - In part, under section I additional active [DIAGNOSES REDACTED]. - Birthdate of 3-29-32 ([AGE] years old) - Section GO300 D is coded a (2) for moving on and off the toilet, meaning not steady, only able to stabalize with staff assistance. - Section GG130 C Toileting Hygiene for admission performance is coded a (1) meaning Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. - Section GG0170 under admission performance for toilet transfer: The ability to safely get on and off a toilet or commode is coded a (1) meaning Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. R3 has a physician's orders [REDACTED]. On 10/02/17 at 1:10 PM, E3 (Certified Nurse Aide/ CNA) said, early in the morning on 09/22/17 she and E6 (CNA) assisted R3 from her bed into a wheel chair. E3 said they took R3 to the bathroom that is located in R3's room and helped R3 out of the wheelchair and onto the toilet. E3 said E6 walked out of the bathroom and began removing the sheets from R3's bed. E3 said she stepped out of the bathroom and told E6 she was going to get a trash bag. E3 said she was gone for approximately 45 seconds and when she returned R3 was sitting on the floor next to the toilet. E3 said R3's arm and head were bleeding. E3 said R3 was saying my arm, my arm. E3 said she immediately alerted E4(Registered Nurse) and E 5 (Licenses Practical Nurse/Treatment Nurse). E3 said that was the first time she had ever dealt with R3. On 10/02/17 at 1:25 PM, E4 said she entered R3's bathroom around 7:00 AM on 09/22/17. E4 said R3 was sitting in the floor with her back against the wall . E4 said she noticed blood on R3's head. E4 said she asked R3 if she hit her head and R3 did not answer her appropriately. E4 said she called an ambulance because R3 had a wound on her head and did not respond appropriately to her questions. On 10/03/17 at 11:30 AM, E6 said she helped E3 take R3 to the bathroom. E6 said that R3 was confused when they put her in the wheelchair. E6 said she was outside of the bathroom removing the sheets from R3's bed. E6 said E3 told her she was leaving R3 in the bathroom. E6 said before E3 returned she heard a loud noise in the bathroom. E6 said when she went into the bathroom R3 was sitting on the floor with her back against the wall . E6 said R3 indicated that her leg hurt. E6 said R3 must have pulled her pants up before she fell . On 10/02/17 at 3:30 PM, R5 said R3 was her roommate for one night. R5 said one evening last week R3 moved in to the bed next to hers. R5 said R3 was very restless most of the night. R5 said in the morning when the day shift staff arrived two staff members helped R3 to a wheel chair and took her into the bathroom in their room. R5 said one CNA , E6 stepped out of the bathroom and was removing linens from R3's bed. R5 said she heard E3 say sit here and I will be right back, I knew that wasn't good. R5 said E3 walked out of the bathroom. R5 said R3 fell just moments after R3 walked out of the bathroom. R5 said E3 called the nurse. R5 said E5 stayed with R3 until the ambulance arrived. R5 said she did not hear R3 cry or complain of pain. R5 said she could not see the guys from the ambulance move R3 but they did put R3 on a cart and take her away. On 10/03/17 at 8:44 AM, Z2 (Technician/ Ambulance) , said on 09/22/17 they responded to a call regarding a fall involving R3. Z2 said when they arrived R3 was sitting on the floor in the bathroom . Z2 said he and his partner got beside R3, and took hold of her arms. Z2 said they helped R3 to stand. Z2 said R3 took a couple of steps to the cot and they laid her down. Z2 said R3 said I am fine, I am fine. Z2 said R3 did not cry in pain and her vital signs were good. An Admission History and Physical note from the hospital dated 09/22/17 states that R3 's Chief Complaint is a Post Fall Injury. An X-Ray dated 09/22/17 at 8:15 AM, indicates R3 sustained a Periprostetic Fracture of the right distal femur. On 10/03/17 at 8:08 AM, Z1 (Surgeon) said R3's fracture was clearly a new injury, caused from trauma. R3's History and Physical (H&P) note dated 09/22/17, dictated by Z1, notes R3 had been in the hospital a week ago 09/16/17 to repair a fracture of the right distal femur, that occurred at home. This same H&P notes that on 09/21/17 R3 was discharged from the hospital and sent to a rehab facility. The History and Physical dated 09/22/17, signed by Z1, states R3 was admitted through the emergency roiagnom on [DATE] following a ground level fall at a rehab center. Z1 notes R3 sustained a new fracture of the right distal femur, starting above the interlocking screw distally and extends down distally below it. A History and Physical note dated 09/23/17 notes R3 had a surgical procedure using a plate and wires to repair the fracture of her distal femur. The 09/22/17 emergency room Record also noted R3 was treated for [REDACTED].

Based on observation, interview and record review, the facility failed to ensure timely assessment and follow-up of resident bruising, failed to provide prompt follow-up of radiograph testing results, and failed to provide timely treatment for [REDACTED]. This failure resulted in a 7 day delay in medical / surgical intervention, as well as documented increased pain and lessened cognition during this timeframe. The findings include: R2's computerized medical record documents that R2 is [AGE] years old and was admitted to the facility on [DATE]. R2's [DIAGNOSES REDACTED]. Section C of the Minimum Data Set ((MDS) dated [DATE] documents R2 has a Brief Interview of Mental Status score of 14, indicating R2 is cognitively intact. Section B of the MDS further documents that R2 has no deficits in hearing, speech, or the ability to express or understand others. R2 was coded with no acute changes in mental status in the MDS Section C, [MEDICAL CONDITION]. On 8/7/17 at approximately 1:00pm, R2 was noted to be wearing a brace to the right leg. R2 was asked about her leg fracture and she stated that it had been painful. R2 further stated that she had no recollection of any trauma around the time of the bruising and fracture. R2's progress note dated 6/3/17 at 1:58am documents a weekly skin assessment with no skin issues. R2's progress note dated 6/9/17 at 6:00am documents a 7 centimeter (cm) by 7.5 cm bruise to the left knee, tender to touch, Z1 (Physician) and Power of Attorney (POA) were notified and R2 was given pain medication. A subsequent progress note dated 6/9/17 at 9:39 am documents R2 has a large purple bruise to the back of the right knee Resident calling out in pain. Bruise warm to touch, resident still stating she is having pain to both legs, despite having a pain pill. BLE (Bilateral Lateral Extremities) remain swollen as well. A computerized nursing progress note dated 6/9/17 at 9:43am states Z1 (Physician) was notified of R2's bilateral lower extremities (BLE) bruises and notes the Nurse Practitioner was to be in the facility to assess the resident. R2's medical record was reviewed and found no documentation of an assessment visit being completed by Z1 or the Z3 (Nurse Practitioner). On 8/22/17 at 5:13pm, Z3 confirmed that no record of an assessment or visit for R2 was documented/completed. An event report in R2's medical record dated 6/9/17 identifies the Posterior right bruise was measured 24cm by 13cm. R2's Medication Administration Record (MAR) documents that R2 received as needed (PRN) [MEDICATION NAME] 5-325 at 5:56am on 6/9/17, coded pain 6 out of 10 before and after the medication, and the medication was noted as not effective. R2's progress note dated 6/10/17 at 1:44am states that R2's bruising is painful to touch and pain medication at bedtime (HS) was effective. The note continues, oriented to person only. R2's progress note dated 6/11/17 at 1:18pm states resident continues to complain of pain / tenderness during assessment of BLE. Resident complains of pain when staff reposition her. PRN medication gives some relief. R2's MAR for 6/11/17 documents that PRN [MEDICATION NAME] was given at 7:43am, with pain noted before at an 8 out of 10 and a 4 after. Noted Semi-effective. There were no further notes entered in R2's medical record for the next 11 hours and 41 minutes. R2's progress note dated 6/12/17 at 12:59am states resident continues to yell when lower extremities are touched. Lower extremities continue to be [MEDICAL CONDITION]. Bruising remains. PRN [MEDICATION NAME] for pain. However, R2's MAR shows no record of any pain medication being administered on 6/12/17. No administration of [MEDICATION NAME] is documented on the MAR in relation to this progress note. On 6/13/17 at 3:26 pm, R2's progress notes document that Z1 was notified about the resident's continued pain and bruising. New order for X-rays of the bilateral femurs, bilateral tibia and fibula and the pelvis were ordered by Z1. The 6/14/17 12:18am progress note states that the X-rays were taken at 7:30pm on 6/13/17, and they are awaiting results. X-ray findings dated 6/13/17 titled Patient Report document the following impressions: Late subacute or older [MEDICATION NAME] fractures, proximal left tibia and fibular head. Probable [MEDICAL CONDITION]. Acute appearing displaced angulated fracture, distal right femur, and indeterminate ovoid dense structures in the soft tissues medial to the right knee. On 8/7/17 at noon, E3, ADON (Assistant Director of Nursing) stated that the computerized medical record system documents that the 6/13/17 X-ray results for R2 were added to the computerized medical record keeping system and available on 6/14/17 at 12:17am. The time frame from the X-rays being completed, read, and the report being sent to the facility on the evening of 6/13/17 to being available in the computerized system was 4 hours and 47 minutes. R2's progress note dated 6/14/17 at 12:18am states bruising remains at top left knee and posterior right knee, area remains swollen, areas painful to touch. PRN meds effective at HS. X-ray 6/13/17 at 7:30pm. R2's progress note dated 6/15/17 at 12:52 am documents Oriented to person only bruising remains, area remains swollen, area painful to touch, pain with Range of Motion (ROM), pain pill at HS effective. R2's nursing progress notes on 6/16/17 at 3:22am state that Z1 was made aware of the 6/13/17 X-ray results. Z1 ordered that R2 be sent to the emergency room (ER) at that time. A 50 hour and 5 minute delay in treatment for [REDACTED]. On 8/9/17 at 10:10am, Z1 stated that he was not aware of R2's 6/13/17 X-ray results until being contacted on 6/16/17 at 3:22am by E4 (Licensed Practical Nurse). Z1 stated no delay in care is desirable, and his expectation would include being notified timely. Z1 stated that R2's results took longer to be communicated than they should have. On 8/10/17 at 10:35am, E4, LPN (Licensed Practical Nurse) stated that she had been off work for a few days and on 6-16-17 when reporting for work, she checked a computerized message board while logging in. E4 indicated that the message board directs the nurses to tasks for review, such as Laboratory reports and X-rays. E4 stated that the X-ray results for R2 from 6/13/17 were on the message board awaiting action. E4 indicated that she could not find that Z1 had been notified in R2's record, and since she could not find notification, she was obligated to report the X-ray findings to Z1. E4 stated that she notified Z1 through the Mediprocity system (secure data transfer) and Z1 immediately responded to send R2 to the emergency room . E4 was questioned about the 50 hour delay in notifying Z1, and she responded that usually the staff immediately address notifying the physician of X-ray results. E4 indicated it is not the usual practice to wait. Computerized nursing progress notes from 6/20/17 at 12:22pm and 3:35pm indicate that R2 was returning from the hospital. R2 was post operative surgery of a right fractured femur. The 3:35pm note states, Resident alert to name, aware of surroundings and where she is. Resident states that she, is glad to be home. A 6/23/17 Physician's progress note states that R2 had recently suffered a non-traumatic / pathologic right femur.

Based on record review and interview the facility staff failed to prevent a resident from falling out of bed, while soiled bed linens were being changed, for 1 of 5 residents (R3) reviewed for falls in the sample of 7. This failure resulted in R3 falling from the bed and sustaining significant complex lacerations to the nose and left brow that required extensive surgery. Findings include: 1. R3's Admission Record notes she was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. R3's Care Plan dated 05/10/17 notes the following: a) R3 requires two staff to assist with transfers. b) R3 can bear weight as tolerated on the left leg . c) R3 wears a boot on the left leg. R3's Minimum (MDS) data set [DATE], section G notes R3 requires 3/3+ assistance to transfer in bed (meaning extensive assistance(weight bearing supprt) of two+ persons to physically assist the resident.) Section C, notes R3 scores 13 of 15 for cognitive status, meaning R3 is cognitively intact. R3's Nurses Note dated 06/03/17 at 8:09 PM, states CNA reported R3 rolled out of bed. R3 prone position in the floor next to the bed. Moderate amount of bright red bleeding controlled with pressure. Laceration to the left side of face and nose. No difficulty breathing. Moving extremities per self. Answering questions appropriately. Resident remains in floor. Ambulance notified. On 06/20/17 at 2:31 PM, E4 ( Certified Nurse Aide/ CNA) stated the night R3 fell from bed, R3's entire bed needed to be changed. E4 said sometime between 6:00 PM and 7:00 PM on 06/03/17, she asked E5 (CNA) and E6 (CNA) to help her change R3. E4 said E5 and E6 told her she could change R3 by herself. E4 said she had never changed R3 by herself. E4 said she went into R3's room alone, and loosened the soiled sheets. E4 said I was trying to roll her over. I told her to stop and she continued to roll out of bed onto the floor. E4 said she rolled R3 away from her. E4 said R3 is usually coherent and will follow commands. E4 said the bed was in the lowest positon and there was no side rail in place. At 1:51 PM on 06/21/17, E5 (Certified Nurse Aide) stated that she arrived at work at approximately 1:50 PM the day that R3 fell out of bed. E5 further stated that E4 did ask her for help with R3, but she was assisting E6 with another resident. E5 said she told E4 she had been helping R3 all day. R3 was rolling by herself very well. E5 could not remember if R3 was wearing a boot on her leg at the time of the fall. A History and Physical report from a local hospital dated 06/04/17 notes R3 had suffered a significant laceration to her nose, from the bridge to the tip, that was bleeding quite significantly, requiring vasoconstrictors and a nose clamp. R3 was hypoxic and mouth breathing due to the nasal injury. The report further states there is no evidence of orbital or nasal or facial fractures. Z1 (Doctor) evaluated and plans to take R3 to surgery. A Preoperative [DIAGNOSES REDACTED]. The Postoperative [DIAGNOSES REDACTED]. The History notes state there was a lot of bleeding, maceration and damage to the skin. Severe swelling of the periobital area. Several areas were cauterized. A 3 centimeter area was through and through into the right nasal cavity. It started off more superficially in the mid nose and then traveled completely transecting (cutting across ) the nostril. Through the case R3 had quite a bit of issues with blood pressure running low. No significant bleeding. R3 was intubated during the procedure. On 6-15-17 at 9:15 a.m., Z3 (family of R3) said that R3 was discharged from the hospital to another long term care facility.

Based on observation, interview and record review the facility failed to follow standard and contact isolation precautions/protocols when caring for residents with infections, failed to adequately clean and thoroughly disinfect shared medical equipment, and failed to use proper infection control practices for cleaning of isolation rooms to prevent transmission of Clostridium Difficile (C-Diff) between residents. This failure resulted in an Immediate Jeopardy with the potential to affect all 110 residents. While the Immediate Jeopardy was removed on 02/02/16, the facility remained out of compliance at a severity level 2 as the facility continues to educate staff and evaluate the effectiveness of the Infection Control policies and procedures. Findings Include: On 2/3/16 at 9:10 PM, E2 stated that infection control policies are based on CDC (Centers for Disease Control) guidelines so if something is not in the facility policy, CDC guidelines are used. According to the CDC (Center for Disease Control) information titled CDC 24/7: Saving Lives. Protecting People-Frequently Asked Questions about Clostridium difficile for Healthcare Providers shows[DIAGNOSES REDACTED] (Clostridium Difficile) is a spore forming toxin. Disease resulting from[DIAGNOSES REDACTED] infections: PCM (pseudomembranous colitis), toxic mega colon, perforations of the colon, sepsis and death. Clinical symptoms: watery diarrhea, fever, loss of appetite, nausea, abdominal pain. Patients at increased risk for[DIAGNOSES REDACTED]: antibiotic exposure, gastrointestinal surgery/manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising condition, advanced age.[DIAGNOSES REDACTED] infections: patient exhibits clinical symptoms, patient test positive for[DIAGNOSES REDACTED] organism/or its toxin. How is[DIAGNOSES REDACTED] transmitted:[DIAGNOSES REDACTED] is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the[DIAGNOSES REDACTED] spores.[DIAGNOSES REDACTED] spores are transferred to patients mainly via hands of healthcare personal who have touched a contaminated surface or item. How can[DIAGNOSES REDACTED] infections be prevented in hospitals and or other healthcare settings: Use Contact Precautions: for patients with known or suspected[DIAGNOSES REDACTED] infections- Place these patients in private rooms, if no private room available, patients can be placed in rooms (cohorted) with other patients with[DIAGNOSES REDACTED] infections, use gloves when entering patients ' rooms and during patient care, perform hand hygiene after removing gloves (because alcohol does not kill[DIAGNOSES REDACTED] spores, use of soap and water is more efficacious than alcohol based hand rubs, preventing contamination of the hands via glove use remains the cornerstone for preventing[DIAGNOSES REDACTED] transmission via the hands of healthcare workers. Use gowns when entering patients rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases (because[DIAGNOSES REDACTED] infected patients continue to shed organism for number of days following cessation of diarrhea). Implementation and environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using EPA (Environmental Protection Agency)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. Follow the manufacturer's instructions for disinfections of endoscopes and other devices. Recommended infection control practices in long term care and home health settings are similar to those taken in traditional health care settings. According to the CDC document titled Infection Prevention During Blood Glucose Monitoring and Insulin Administration shows The CDC has become increasingly concerned about the risks for transmitting of hepatitis B virus (HBV) and other infectious disease during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirement: Finger stick devices should never be used for more than one person, whenever possible blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Insulin pens and other medication cartridges and syringes are for single-patient-use only and should never be used for more than one person. Best practices for Assisted Blood Glucose Monitoring and Insulin Administration: If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacture does not specify how the device should be cleaned and disinfected then it should not be used. If shared, blood glucose meters should be cleaned and disinfected after every use. Insulin vials: if the vials must be used for more than one person it should be stored and prepared in a dedicated medication preparation area outside of the patient care environment and away from potentially contaminated equipment. Blood Glucose Meters: Whenever possible, blood glucose meters should be assigned to an individual person and not shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. General: Unused supplies and medication should be maintained in clean areas separate from used supplies and equipment (e.g. glucose meters) does not carry supplies and medications in pockets The facilities policy and procedure titled Nursing: Categories of Transmission-based Precautions with revision date 8/09 documents in part It is the policy of the facility to follow established transmission-based (isolation) precaution. The objective is to prevent the spread of infection in the facility. The staffs responsible are nursing staff, housekeeping staff and any and all staff having direct contact with the resident. Contact precautions must be implemented, in addition to Standard Precautions for resident known to be infected or colonized with organisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring Contact Precautions include, but not limited to: Clostridium Difficile. Gloves and hand hygiene: wear gloves upon entering the room if contact with resident or potentially contaminated surfaces is possible, during the course of caring for resident, change gloves and perform hand hygiene (wash hands if dealing with[DIAGNOSES REDACTED]) after having contact with infective material, remove gloves before leaving the room and perform hand hygiene (wash hands if dealing with[DIAGNOSES REDACTED]), after glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident ' s rooms. Wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room; if the resident is incontinent; or if the resident has diarrhea. Resident care equipment: When possible, dedicate that use of noncritical resident care equipment items such as stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single resident to avoid sharing between residents; if use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. The facilities policy and procedure titled Housekeeping Isolation Procedure with revision on 01/03 documents in part It is the policy of the facility to ensure that contagious disease are not transmitted to other residents and the purpose is to enforce the procedure to keep contagious disease to a minimum. The staff responsible: Administration, Director of Nursing, Food Services Supervisor, Food Service Staff, Nursing Personnel, Housekeeping Supervisor, Housekeeping Staff. The procedure: Housekeeping shall receive written notice from nursing staff that a resident is in isolation. The notice should include resident's name, room number and date of isolation onset. The same daily cleaning procedures used in other resident rooms should be used to clean rooms and bathrooms of residents in isolation. Cleaning equipment used in rooms of residents requiring isolation should be disinfected before being used in other resident rooms. Dirty water discarded, wiping cloths and mop heads should be laundered and dried and buckets disinfected before re-use. When cleaning a room, use the same precautions as other staff members (gowns, gloves). All horizontal surfaces of furniture, mattresses, etc. should be cleaned with disinfectant solution. All floors, including bathrooms should be mopped with disinfectant solutions. Wash walls with disinfectant solutions, thoroughly scrubbing exposed areas. According to the facilities policy and procedure titled Policy no: 1.11 (IL) Area: Admiration Subject: Infection Control with revised date 08/09 documents Infection Control Policy: All residents with known or suspected infectious conditions will be cared for using the most appropriate nursing care determined for the benefit and safety of the resident concerns, the other residents in the facility, and the safety of the employees. Standard Precautions: Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions should be applied to the care of all residents regardless of the suspected or confirmed presence of an infectious agent. Standard Precautions include but are not limited to: Hand Hygiene, Safe injection practices, Proper use of PPE (Personal Protective Equipment) (gloves, gowns, mask, etc.), resident placement within the facility, care of the environment, textiles, and laundry, handling equipment, disposal of waste. Hand washing is the foundation of controlling infectious disease. Personnel must wash their hands when coming on duty; when they are visibly soiled; when they are between residents; after they handle dressings, urinals, bedpans, needles, or syringes; after toilet use; and when they complete duty. Unless hand washing is specifically required, antimicrobial agents such as Alcohol based rubs are appropriate for cleaning hands and can be used for direct resident care. Gowns are worn by all personnel coming in direct contact with residents who require contact (if necessary) precautions. Gloves, disposable in nature, will be worn unless sterile gloves are necessary. Gloves will be changed after direct contact with resident's secretion or excretions, even if care of resident has not been completed. Environmental control will consist of dusting with damp cloth and wet mopping room after all other rooms have been cleaned. Employee traffic to and through the room will be limited to that which is necessary. Terminal cleaning upon termination of isolation includes cleaning and bagging equipment for disinfections or sterilization; washing furniture and mattress covers; washing grossly soiled areas on walls; and wet mopping floors by means of double bucket technique. The facility identified germicidal bleach wipe (Environmental Protection Agency Register Number: -1- 49) noted to have a blue label on 1/26/16 at 4:00 PM used to clean the blood glucose monitoring machine includes the following directions a 3 minute contact time is required to kill Clostridium difficile spores and reapply as necessary to ensure that the surface remains wet for the entire contact time. Allow surface to air dry. According to directions on the disinfection cleaning product used by housekeeping (Environmental Protection Acency Regulation Number: 5741-28) noted to have red label on 1/28/15 at 10:45 AM, shows on the label when cleaning residents rooms for residents identified in isolation for[DIAGNOSES REDACTED], the following instructions are specified on the label when cleaning for[DIAGNOSES REDACTED] a 8 minute contact time is necessary for cleaning the spore, and fecal matter/waste must be thoroughly cleaned from surfaces/objects before disinfection by application with a clean cloth, mop, and/or sponge saturated with the disinfectant product. Cleaning is to include vigorous wiping and/or scrubbing, until all visible soil is removed. Special attention is needed for high touch surfaces. Surfaces in patient rooms are to be cleaned in an appropriate manner. Restrooms are to be cleaned last. According to directions on the germicidal wipe product noted to have a purple lable on 1/26/16 at 4:00 PM (Environmental Protection Acency Number: -2- ) shows no indicated use for[DIAGNOSES REDACTED]. Product label shows it is an alcohol wipes for and under directions for use: This product is not to be used as a terminal sterilant/high level disinfectant. Under cleaning: use one or more wipes, as necessary, to wet surface sufficiently and to thorougly clean the surface. Disinfectant: Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed o this label. Allow surface to air dry. Contact time: Allow surface to remain wet for 1 full minute. On 1/27/16 at 9:05 AM, E2 DON stated these are used for regular cleaning of items(container with purple container). E2 stated the container with the blue label is and bleach base and for[DIAGNOSES REDACTED] and the purple label is an alcohol base and is not effective with[DIAGNOSES REDACTED] so staff should not be using if resident is on isolation for[DIAGNOSES REDACTED] to clean items on or in the medications carts. E2 stated the one (purple label) can be used to clean the Blood Glucose Monitoring Machine unless the resident has[DIAGNOSES REDACTED] because it will kill most orgainisms as long as staff follow the directions. According to the informational document provided by the facility regarding their bleach solution, documents kills[DIAGNOSES REDACTED] spores in one step in three minutes but, contact time for disinfectant is the amount of time a surface must remain wet with the product to achieve disinfectant. According to the facility policy titled Glucose Monitoring with a revision date of 01/15 shows to please follow instructions listed in the designated Blood Glucose Monitoring System User's Guide to performing a test. How to Clean/Disinfect the designated Blood Glucose Monitoring System: The machine should be disinfected between uses, using a validated disinfecting agent. According to the facility designated Blood Glucose Monitoring Operator's Manual with no date shows: Materials Needed: A valid disinfecting wipe. Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The following products are validated for disinfecting the Blood Glucose Meter: Disinfectant towels or wipes with - (EPA(Environmental Protection Agency) Number: -1; -8; -10- ; -12). Important: Users need to adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting Blood-borne pathogen between patients and healthcare professionals. A new pair of clean gloves should be worn by the user before testing each patient. Wipe all external areas of the meter including both front and back until surface visibly clean. Allow the surface of the meter to remain wet at room temperature for the contact time on the wipes's direction for use. Wipe meter dry or allow to air dry. The Center for Disease Control, CDC, guidelines under 11/1 Environmental Measures Certain Pathogens (e.g. [DIAGNOSES REDACTED]icile) may be resistant to some routinely used hospital disinfectants. Also, since[DIAGNOSES REDACTED]icile may display increased level of spore production when exposed to non-chlorine based cleaning agents, and spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of 1:10 dilution of 5/25% .hypochlorite (household bleach) and water for routine environmental disinfection of rooms and with patients with [DIAGNOSES REDACTED]icile when there is continued transmission. According to the facilities updated Infection Control Log provided on 2/2/16 for November 2015, December 2015 and January 2016 through the morning of 2/2/16, the following is documented for R11: Hallway 400; admitted [DATE]; onset date-1/27/16; site-stool; symptom-frequency; culture-yes; organism-C-diff; isolation-yes; nosocomial-yes; resolved-blank On 1/27/16 at 7:25 PM, E39 RN(Regisered Nurse) entered R11's room to give him his evening medications and was not wearing gloves. R11 had isolation signs posted on his doorway. At that time E2, DON (Director of Nursing) was questioned as to why R11 was on isolation and she stated R11 had been diagnosed with [REDACTED]. According to R11's face sheet, R11 was admitted on [DATE] at 4:33 PM, and according to a progress note from the referring local hospital dated January 22, 2016, R11 has the following impressions: Increased size of a pleural based, speculated nodular lesion in the left upper lobe; Mild new midiastinal lymphadenopathy; right pleural effusion, suspicious for pneumonia; Similar marked emphysematous disease; and Cholelithiasis. In addition, according to a Esophagogastroduodenoscopy (EGD) report dated January 22, 2016 a post-operative [DIAGNOSES REDACTED]. R11's nursing note dated January 26, 2016 at 8:20 AM states Res (resident) c (with) c/o (complaints of) loose stools et (and) stomach cramps last NOC (night). Abd (abdomen) soft et non tender. Occasional c/o stomach cramping. Bowel sounds active x (times) 4 quad. (quadrant). Z5 (R11's physician) notified. Awaiting call back from (Z5's) nurse for further orders. R11's nursing note dated January 26, 2016 at 1:08 PM states Received a new order from (Z5) to check stool for cdiff et start [MEDICATION NAME] 250 mg (milligram) 1 tab (tablet) PO (orally) TID (three times a day) x 10 days and the following nursing notes for R11 on January 27, 2016 at 10:43 AM .reports resident positive for[DIAGNOSES REDACTED], MD notified January 27, 2016 at 11:02 AM (Z5) notified of stool specimen results. Res continues on [MEDICATION NAME] as previously ordered r/t (related to) loose stools. Awaiting MD (medical doctor) response. Another note dated January 27, 2016 at 2:17 PM Received new order from (Z5) to increase [MEDICATION NAME] to 500 mg 1 tab PO TID x 4 days. A lab report from a local hospital laboratory dated January 27, 2016 states the lab specimen was collected on January 26, 2016 at 10:31 AM as: C.Difficile PCR Positive C#, a positive result indicates the detection of toxigenic C.Difficile DNA. The Care Plan for R11 lists a problem start date of January 27, 2016 for Dx (diagnosis) of[DIAGNOSES REDACTED], with approaches on the same date of Encourage resident to wash hands after defecation, encourage resident to wash hands before meals and Follow principles of infection control and universal/standard precautions for[DIAGNOSES REDACTED], which was more than 24 hours after R11 first reported symptoms. According to the facilities updated Infection Control Log provided on 2/2/16 for November 2015, December 2015 and January 2016 through the morning of 2/2/16, the following is documented for R14: Hallway 100; admitted [DATE]; onset date-1/15/16; site-stool; symptoms-odor; culture-yes 1/15/16; organism-C-Diff; isolation-yes; nosocomial-yes; resolved 1/22/16 Hallway 100; admitted [DATE]; onset date 1/25/16; site-stool; symptoms-foul odor; culture-no; organism-C-Diff; isolation-yes; nosocomial-yes; resolved-blank R14's nursing note dated 1/10/16 at 12:44 PM by E21 LPN shows Resident complains of having diarrhea at least twice a week. Residents Power of Attorney requesting doctor be notified. Resident denies any pain or discomfort. Resident states It ' s been going on for a while now. I can't remember how long Doctor notified along with current medication list. R14's nursing note on 1/12/15 shows a doctors order to check stool for[DIAGNOSES REDACTED]. R14's nursing note on 1/15/16 has resident positive for[DIAGNOSES REDACTED]. R14's Plan of Care shows problem start date of 1/15/16, R14 has [DIAGNOSES REDACTED]. R14's Nursing note dated 1/25/16 at 5:05 PM shows new orders received to discontinue stool for[DIAGNOSES REDACTED], Give [MEDICATION NAME] for a total of 21 days. R14's nursing note dated 1/26/16 at 1:14 AM shows resident continues on Vancomcin related to[DIAGNOSES REDACTED]. No adverse reactions noted. Isolation precautions continue. R14's nursing note dated 1/26/16 at 9:27 AM, shows [MEDICATION NAME] treatment continues related to[DIAGNOSES REDACTED]. On 1/26/15 during initial tour at 9:45 AM, R14's room was observed and had no signs posted in room or on door to indicate she was on isolation precautions. On 1/26/15 at 9:55 AM, E24 LPN (Licensed Practical Nurse) stated R14 was on isolaiton and R14's room should be identified as a resident on isolation. E24 stated R14 just now went on isolation. E24 stated he was setting up the isolation now. On 1/26/16 at 4:00 PM, E6 LPN (Licensed Practical Nurse) monitored R14 blood glucose. E6 stated I can't take the strip bottle in the room because R14 is on isolation. E6 performed glucose test but the machine did not register R14's result and E6 placed the used lancet into the trash can. E6 took lancet out of the trash can, wrapped the lancet and monitor strip in a glove, placed the blood glucose meter on the counter top and washed hands. E6 then put gloves on, picked up contaminated glove with gloved hand and exited the isolation room. E6 placed wrapped glove in sharps container. E6 then removed gloves and cleaned her hands with alcohol cleanser only. E6 then touched top of medication cart and blood glucose strip container, obtained another strip, applied cleaned gloves and re-entered isolation room. When E6 finished the procedure she took the blood glucose machine out of the isolation room and used germicidal bleach wipe to clean the blood glucose monitoring machine. She wiped over the surface of the blood glucose meter once for less than ten seconds and placed it on top of the germicidal wipe that was on top of the 100 hallway medication cart. E6 then waited three minutes and placed the blood glucose machine inside the top drawer of the 100 hallway medication cart without any protective covering and on top of another blood glucose monitoring machine. The medication cart contained another blood glucose monitoring machine, eye drops, nasal sprays, insulin pens and oral medications. On 1/27/16 at 9:00 AM, E6 LPN stated R14 had been on isolation for a while and R14 was originally put on isolation on 1/15/16 after a positive stool for[DIAGNOSES REDACTED] and then came back off after she was on [MEDICATION NAME] for 7 days. E6 stated that R14 had more loose stool and the doctor had originally ordered to get another stool to check for C- diff but then just gave an order not to get the stool culture and put R14 on liquid [MEDICATION NAME] for three more weeks. E6 stated she thought R14 went back on isolation on 1/25/16 but wasn't positive. E6 stated the way she cleaned blood glucose monitor was to wipe it down and then let it sit for three minutes. E6 did not verbalize knowledge of manufacturer's guidelines regarding use of germicidal cleaner used for blood glucose monitoring for Clostridium Difficle. On 1/27/16 at 9:35 AM, R14 stated staff had been helping her after she went to the bathroom. R14 stated staff had to help her because she was having problems getting herself completely cleaned because she was having diarrhea and loose stools. R14 stated this (staff helping) was before her son had spoken with nursing about his concern about her having so many stools. R14 stated she thought the problem with the diarrhea and loose stools was going on for a week or two before her son had spoken to the nurse about his concerns about her having the diarrhea. R14 stated that after her son spoke to nursing and relayed his concerns to them about her loose stools and diarrhea, nursing then spoke to the physician about these symptoms. R14 stated she had been told just to make sure she washed her hands really good. R14 stated she has been and continues to go to the main dining room for meals and goes to activities and wheels herself around the facility. R14 stated that she keeps her own journal to write down when she has showers and when she has bowel movements so she can keep track of her care. R14's journal showed bowel movements noted every day from 1/19/16 to 1/27/16. R14's Brief Mental Assessment was done on 1/5/16 and shows a score of 12, indicating she is able to answer questions appropriately. On 1/27/16 at 9:45 AM, E2 DON stated R14 was on isolation starting on 1/15/16 but came off for a couple days and went back on 1/25/16. On 1/27/16 at 10:15 AM, E11 CNA (Certified Nursing Assistant) stated she had given R14 a shower last Tuesday (1/20/16). E11 stated R14 was on isolation at that time. E11 stated she gave R14 the shower in the community bathroom on 100 hallways. E11 stated when she was done with R14's shower; she wiped everything in the common bathroom down with the bleach wipes. E11 was not able verbalize how to clean according to the bleach wipe manufactures guideline. E11 did not indicate if or how the shower room was mopped or deep cleaned or if this was done. On 1/28/16 at 11:10 AM, E20 LPN (Licensed Practical Nurse) entered R14's identified[DIAGNOSES REDACTED] isolation room to administer insulin. E20 took R14's insulin pen into the room and injected R14 in the abdomen. E20 placed the insulin pen on the sink and was half on a barrier and half on the countertop. E20 washed her hands and applied new gloves and picked up insulin pen and placed it on clean barrier next to the blood glucose monitoring machine. E20 picked up insulin pen and exited room. E20 wiped over R14's insulin pen with the facility designated bleach disinfectant for less than 10 seconds and placed it in top of medication cart drawer with other insulin pens. When questioned E20 stated she should have cleaned the insulin pen longer before she placed it in the medication cart. At no time did E20 re-clean the identified contaminated insulin pen. When E20 was questioned, she stated she was just starting her noon medication pass and would be giving more medications and insulin. On 1/29/16 at 8:45, the DON stated if resident is symptomatic for[DIAGNOSES REDACTED] will go ahead and put in isolation. On 1/29/16 at 9:45 AM, E22 (Housekeeper) stated R14's room was on the 100 hallway. E22 stated she normally cleaned R14's room, and even prior to her being placed on isolation resident was having explosive, foul smelling stool and she was pretty sure it was[DIAGNOSES REDACTED]. E22 stated that when she had asked a nursing assistant what was going on with R14, they were aware she was having loose stool and E22 figured the nurses knew too. E22 stated even before R14 was on isolation R14 had loose stools and R14 had stool all over the bathroom and across her room to her closet. E22 stated that R14 would try to clean up the feces herself but didn't do a very good job. E22 stated R14 trying to clean up after problems with loose stools had occurred more than once. E22 stated she had been sweeping R14's room with a broom and bringing it out and putting it on the housekeeping cart as well as the dustpan. E22 stated she probably should have not done this and used the dust mop. E22 stated she never used a gown when cleaning R14's room. E22 stated when she cleans a room for[DIAGNOSES REDACTED] she cleans the bathroom in the middle of the cleaning process, not last. E22 stated she used the same housekeeping cart to clean hallway 100 and 200. E22 stated she was the regular housekeeper on these units and her assignment for each day was to take care of both 100 hallway and 200 hallway. On 2/2/16 at 3:25 PM, Z3 (Power of Attorney) for R14 stated that he was the one that made the facility nurse aware of R14 having issues with loose stools. Z3 stated R14 had so much loose stool in her adult brief that it was saturated and coming apart. Z3 stated R14 had told him and the nurse, who was a Registered Nurse, that she had been having the loose stools for a while and she had been needing help making sure she was getting herself clean. Z3 stated R14 had been keeping a journal of her bowel movements and showers since her admission and the staff was aware of it as far as he knew. Z3 stated that a while back, around the beginning of 2015, R14 had issues with[DIAGNOSES REDACTED] and the facility had treated it totally different. Z3 stated they had been much more strict with the isolation precautions and were cleaning all the time. Z3 stated this is why he was so concerned this time because the facility didn't seem to be doing any precautions. Z3 stated the only way he had been made aware of what the bug was is because he had family in the medical field and they had explained how serious it could be. Z3 stated the facility did not do any education with him or R14 except put R14 on isolation and tell them to make sure to wash their hands with soap and water because alcohol wouldn't work. Z3 stated that approximately 10 days ago he was at the facility visiting R14 and the nurse had done R14's blood glucose monitor and gave R14 her insulin in the common area across from the dining room. Z3 stated the nurse did not have the cart with her but made two trips up the hallway once with the blood glucose machine and once with R14's insulin. On 2/2/16 at 4:05 PM, Z2 (Medical Director/Primary Care Physician) stated he was the Medical Director for the facility and was the Primary Care Physician for R14 and R16. Z2 stated that if a resident was having any signs and symptoms of an infectious disease and specifically[DIAGNOSES REDACTED] such as loose stool, then he would expect the facility to put them on the appropriate isolation as soon as the symptoms were present. Z2 stated he would expect the facility to notify the primary care physician for further direction with regard to culture or care of the issue. Z2 stated the resident and resident ' s Power of Attorney need to be made aware as necessary. Z2 stated[DIAGNOSES REDACTED] is a spore and therefore was not cleaned in the same manner as some other organisms. Z2 stated he would expect the facility to clean according to what the direction or guidelines of the product said, or according to the facility policies. Z2 stated all staff should be communicating to nursing if they are seeing signs of[DIAGNOSES REDACTED] such as the loose stool. Z2 indicated if a housekeeper or certified nursing assistant is aware of someone having loose stools or any signs of infections they should be communicating this to the nursing staff. According to the facilities updated Infection Control Log provided on 2/2/16 for November 2015, December 2015 and January 2016 through the morning of 2/2/16, the following is documented for R16: Hallway 600; admitted -12/15/15; onset date-1/4/16; site-stool; symptom