Every finding on record at Scott County Nursing Center

Based on observation, interview and record review the facility failed to follow physician's orders for weight loss supplements to prevent weight loss for 1 (R5) of 2 residents reviewed for weight loss in the sample of 24. This failure resulted in R5 losing 12 pounds which is 10.34% of weight in less than 30 days.Findings include:R5's Undated Face Sheet documents she was initially admitted to the facility on [DATE]. R5's admission Minimum Data Set (MDS) dated [DATE] documents R5 is severely cognitively impaired. Independent with eating. Height 63 inches and 113 pounds. No or unknown weight loss of 5% or more in the last month or 10% or more in the last 6 months.R5's Care Plan dated 12/1/2025 documents resident has a regular diet with thin liquids, (supplemental ice cream) BID (twice a day.)R5's Registered Dietitian Note, dated 11/19/2025 documents, resident recently admitted r/t (related to) L (left) Femur Fx (fracture.) Hx (history) of UTI (urinary tract infection) and weakness. Regular diet remains adequate for nutrition needs, weight at 113# (pounds), w/n IBW (ideal body weight) Range. Alert and independent at meals. (Supplemental ice cream) started 2x/day for weight support, continue to monitor, Refer PRN (when needed.) Est (estimated) Needs: 1275 cal (calories)/day, 52 g (grams) Pro (protein)/day and 1500 ml (milters)/day not documented what this is related to. R5's Physician's Order Sheet (POS) dated 11/16/2025 documents (supplemental ice cream) BID (twice a day.)R5's Medical Record (electronic and paper chart) dated 11/2025, 12/2025 and 1/2026 no documentation R5 received (supplemental ice cream) BID per physician's orders. R5's Electronic Medical Record, dated 1/5/2026 R5's weight was documented 116.0 pounds and on 1/30/2026 R5's weight was documented 104.0 pounds. R5 lost 12 pounds in less than 30 days, which is 10.34% weight loss. On 4/21/2026 at 12:15 PM R5 was sitting up in wheelchair in dining room. R5 ate 75% of meal including Swedish potatoes with noodles. No (supplemental ice cream) was on her lunch tray.On 4/22/2026 at 9:22 AM V7 (Licensed Practical Nurse/LPN) stated she doesn't administer (supplemental ice cream) to residents because that is a frozen health supplement similar to ice cream that is served to the residents during meal, and the kitchen staff administer them to the residents. V7 stated she doesn't document R5 ate the (supplemental ice cream) because it is administered by kitchen staff and she doesn't know if the resident ate it and she doesn't administer it. On 4/22/2026 at 11:00 AM V5 (Dietary Supervisor) went to the shed and looked in the freezer and stated they do not have any (supplemental ice cream), and they only have one resident that takes it which is (R5) and she will order some today and give R5 extra protein until the (supplemental ice cream) is ordered. V5 stated she wasn't aware the facility didn't have (supplemental ice cream) in stock and didn't know how long it has been since (R5) received a (supplemental ice cream). V5 stated she didn't report to any staff that the facility doesn't have any (supplemental ice cream), and she didn't notify the registered dietician either. On 4/22/2026 at 12:15 PM V11(Registered Dietitian/RD) stated she expects the facility to follow facility policy on implementing RD recommendations and stated she expects her recommendations to be implemented within a week after she documents the recommendations. V11 stated she expects the facility to document health supplements including (supplemental ice cream) to for weight support to be documented as administered and to be available for the resident at the facility as ordered. If any of the health supplements she ordered weren't available, she expects the facility to call and let her know so she can order a different health supplement, so the resident doesn't experience avoidable weight loss. V11 stated she wasn't aware the facility didn't have (supplemental ice cream) available at the facility. On 4/22/2026 at 12:30 PM V1 (Administrator) stated she expects the facility to follow all physician's orders including health supplements to prevent weight loss. V1 stated kitchen staff put (supplemental ice cream) on resident's meal trays because it is meant to be served cold and nurses do not have a way to serve cold items. V1 stated kitchen staff document the (supplemental ice cream) was served. V1 was not aware that the facility didn't have any (supplemental ice cream) in stock and stated they should have them if it's a physician's order. On 4/22/2026 at 2:04 PM V1 stated the kitchen staff are not documenting the (supplemental ice cream) are being administered and no one to her knowledge notified the RD that the facility didn't have any (supplemental ice cream). V1 stated she wasn't aware the kitchen staff weren't documenting they were administering the (supplemental ice cream) or if the resident was eating the (supplemental ice cream). V1 stated if the resident is prescribed a (supplemental ice cream) for weight loss and doesn't receive it or doesn't eat it then that intervention isn't working and she expects the dietary staff to notify her or the Director of Nurses (DON) so they can notify the RD, so the resident doesn't experience weight loss. V1 stated she couldn't find any invoices that (supplemental ice cream) were ordered and/or delivered to the facility. The Facility's Nutritional Replacement Policy, dated 1/19/2012, documents all residents exhibiting weight loss or weigh below their ideal body weight average consecutively (with consideration to their weight history) may be place upon a program of Nutritional Replacement and administered as physician orders. Purpose: to prevent weight loss which is frequently observed in elderly residents. Special instructions: The Nutritional Replacements will be given as per physician's orders. A consulting dietician will be in the facility on a monthly basis. As per the dietician's recommendations, nutritional replacements may be recommended to be altered per the resident's physician. The dietary service will provide these replacements.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident for 1 of 2 residents (R41) reviewed for abuse in the sample of 24. This failure resulted in R41 feeling scared and threatened.Findings Include:On 4/22/26 at 9:20 AM, R41 stated she was in the dining room talking with some of the other ladies, when R22 propelled himself in his wheelchair over to her and ran into her with his foot pedals, backed up, and did it two more times. R41 stated R22 then said to her get out, she wasn't needed, and he was going to go out and get a corn stalk out of the field and wrap it around her neck. R41 stated she was scared, felt threated, and reported it to the nurse and V1 (Administrator). R41 stated she was so scared that she had the nurse watch her to make sure she made it to her room and R22 wasn't following her. R41 stated she had one other incident with R22, she was in the dining room, moving chairs over to a table for her and some other residents to play dominos, when R22 wheeled over to her and told her to get out of there, she wasn't wanted there. R41 stated she didn't say anything back to R22 and tries to avoid him. R41 stated she understands R22 had a stroke and has dementia, which has caused him to be like that, but he still scares her. R41 stated they moved R22 and to another hall, so she isn't near him.R41's Face Sheet, undated, documents R14 has a primary diagnosis of Disorders of the Muscle.R41's MDS (Minimum Data Set), dated 2/2/26, documents R41 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R41 is cognitively intact.On 4/22/26 at 10:45 AM, R22 denied any concerns with abuse or any past conflicts with other residents.R22's Face Sheet, undated, documents R22 has a primary diagnosis of TIA (Trans ischemic Attack).R22's MDS, dated [DATE], documents R22 has a BIMS score of 13, indicating R22 is cognitively intact.R22's Care Plan, dated 1/23/25, documents resident recently had a verbal altercation with another resident. This resident has requested to be moved away from other resident at mealtimes where altercation took place. Staff is to monitor and makes sure this resident and the other resident are not in contact at any time. Resident continues to have behaviors of yelling and stating false accusations towards staff. He also becomes verbally aggressive with staff during care with his wife.The Facility Abuse Investigations Final Report, dated 7/7/25, documents on 7/7/25 at 4:30 PM, there was an allegation of a resident-to-resident altercation involving R22 and R41. R41 came to administrator to report that she thinks R22 has went nuts. R41 stated R22's eyes were bulging out of his head like an alien. R41 thinks R22 made a threat at her, but she cannot remember exactly what R22 said. R41 stated she thinks it was something about wrapping corn around her neck but is unsure. R41 stated she was not even talking to R22 when he stated this statement to her. R41 immediately left the area of R22. Staff were not present during this time and did not hear any threats being made. R41 stated she is going to stay away from R22 from now on. Administrator spoke with R22 and he stated there was a fight because he feels R44 is being rude to his wife. R22 denied threatening R41. R22 doesn't sound upset about the incident and stated he is going to stay away from R41. The Facility Abuse Investigation Final Report, dated 9/28/25, documents on 9/25/25 at 1:30 PM, there was an alleged resident to resident altercation involving R41 and R22. Administrator followed up on the incident. Administrator spoke to staff member that was present and states R22 raised his voice at R41 and stated, get your a** out of here, you cannot play this game. R41 did not reply but immediately left the area. Staff member confirmed that residents did not physically touch each other and the incident was quickly over. Administrator spoke with R41 who says R22 is not like he was when she worked with him, he is very different. Residents do know each other from outside this setting. R22 does not want R41 to play dominos as she has mentioned in front of several residents before that the game is dumb. Administrator explained everyone is allowed to play the games here if they wish. Administrator encouraged to start two games at separate tables so everyone can play. No further incidents occurred. On 4/22/26 at 11:05 AM, V1 (Administrator) stated when the incident on 7/7/25 occurred, the staff immediately separated the residents and discussed the incident with both residents. V1 stated they reviewed and updated their care plans to keep away from each other. R22 claimed he did not threaten R41. When the incident on 9/25/25 occurred, R41 was going to play dominos with other residents and R22 told R41 to get out of there, she couldn't play. V1 stated at that time the residents would play dominos at one big table together and after that, they divided it into 2 separate games and different tables with staff present. V1 stated there haven't been any further incidents since then. On 4/23/26 at 10:23 AM, V13 (Medical Director) stated he is not aware of any current or past behaviors with R22 or R41 and he would expect the facility to follow their Abuse Policy. The Abuse Prevention Program Policy, with a revision date of 1/26/24, documents this facility advocates for the prevention of, reporting of, and immediate investigation of allegations of resident abuse, neglect, mistreatment, and misappropriation of resident funds or property.

Based on interview and record review, the facility failed to follow their abuse policy by not reporting an allegation of abuse and for not preventing abuse for 2 of 2 residents (R22, R41) reviewed for abuse in the sample of 24.Findings Include:On 4/22/26 at 9:20 AM, R41 stated there was an incident that happened last year with R22. R41 stated she was in the dining room talking with some of the other ladies, when R22 propelled himself in his wheelchair over to her and ran into her with his foot pedals, backed up, and did it two more times. R41 stated R22 then said to her get out, she wasn't needed, and he was going to go out and get a corn stalk out of the field and wrap it around her neck. R41 stated she was scared, felt threatened, and reported it to the nurse and V1 (Administrator). R41 stated she was so scared that she had the nurse watch her to make sure she made it to her room and R22 wasn't following her. R41 stated she had one other incident with R22, she was in the dining room, moving chairs over to a table for her and some other residents to play dominos, when R22 wheeled over to her and told her to get out of there, she wasn't wanted there. R41 stated she didn't say anything back to R22 and tries to avoid him. R41 stated she understands R41 had a stroke and has dementia, which has caused him to be like that, but he still scares her. R41 stated they moved R22 to another hall, so she isn't near him.R41's Face Sheet, undated, documents R14 has a primary diagnosis of Disorders of the Muscle.R41's MDS (Minimum Data Set), dated 2/2/26, documents R41 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R41 is cognitively intact.R41's Progress Note, dated 7/04/25 at 8:48 PM, documents the following: Reported to this nurse from another resident (R41) that during supper time, R41 told R22 that he does not know how to be a husband and doesn't do anything right. R41 reported to other nurse, R22 told her to shut up with big mean eyes. Did not give a reasoning as to why he had told her to shut up.R22's Face Sheet, undated, documents R22 has a primary diagnosis of TIA (Trans ischemic Attack).R22's MDS, dated [DATE], documents R22 has a BIMS score of 13, indicating R22 is cognitively intact.R22's Care Plan, dated 1/23/25, documents resident recently had a verbal altercation with another resident. This resident has requested to be moved away from other resident at mealtimes where altercation took place. Staff is to monitor and makes sure this resident and the other resident are not in contact at any time. Resident continues to have behaviors of yelling and stating false accusations towards staff. He also becomes verbally aggressive with staff during care with his wife.R22's Progress Note, dated 7/04/25 at 8:45 PM, documents the following: Resident summoned writer to room and stated that he needs to talk to me. R22 stated that during supper time, another resident (R41), told him that he does not know how to be a husband and does nothing right. Res informed me that he did yell at her and told her Shut up! You know everybody's' business and if you don't know it you, are trying to find out! Resident is requesting for him and his wife to sit together away from R41 during mealtimes.The Facility Abuse Investigations Final Report, dated 7/7/25, documents on 7/7/25 at 4:30 PM, there was an allegation of a resident-to-resident altercation involving R22 and R41. R41 came to administrator to report that she thinks R22 has went nuts. R41 stated R22's eyes were bulging out of his head like an alien. R41 thinks R22 made a threat at her, but she cannot remember exactly what R22 said. R41 stated she thinks it was something about wrapping corn around her neck but is unsure. R41 stated she was not even talking to R22 when he stated this statement to her. R41 immediately left the area of R22. Staff were not present during this time and did not hear any threats being made. R41 stated she is going to stay away from R22 from now on. Administrator spoke with R22 and he stated there was a fight because he feels R41 is being rude to his wife. R22 denied threatening R41. R22 doesn't sound upset about the incident and stated he is going to stay away from R41. The Facility Abuse Investigation Final Report, dated 9/28/25, documents on 9/25/25 at 1:30 PM, there was an alleged resident to resident altercation involving R41 and R22. Administrator followed up on the incident. Administrator spoke to staff member that was present and states R22 raised his voice at R41 and stated, get your a** out of here, you cannot play this game. R41 did not reply but immediately left the area. Staff member confirmed that residents did not physically touch each other and the incident was quickly over. Administrator spoke with R41 who says R22 is not like he was when she worked with him, he is very different. Residents do know each other from outside this setting. R22 does not want R41 to play dominos as she has mentioned in front of several residents before that the game is dumb. Administrator explained everyone is allowed to play the games here if they wish. Administrator encouraged to start two games at separate tables so everyone can play. No further incidents occurred. On 4/22/26 at 11:05 AM, V1 (Administrator) stated when the incident on 7/7/25 occurred, the staff immediately separated the residents and discussed the incident with both residents. V1 stated they reviewed and updated their care plans to keep away from each other. R22 claimed he did not threaten R41. When the incident on 9/25/25 occurred, R22 and R41 were going to play dominos with other residents and R22 told R41 to get out of there, she couldn't play. V1 stated at that time the residents would play dominos at one big table together and after that, they divided it into 2 separate games and different tables with staff present. V1 stated there haven't been any further incidents since then. On 4/22/26 at 2:30PM, V1 (Administrator) stated she does not have an allegation of abuse for 7/4/25, only the one for 7/7/25. V1 stated she would expect the staff to follow their abuse policy.The Abuse Prevention Program Policy, with a revision date of 1/26/24, documents this facility advocates for the prevention of, reporting of, and immediate investigation of allegations of resident abuse, neglect, mistreatment, and misappropriation of resident funds or property.

Based on interview and record review, the facility failed to report an allegation of a verbal resident to resident altercation in 2 of 2 residents (R22, R41) reviewed for reporting of alleged abuse violations in the sample of 24.Findings Include:R41's Face Sheet, undated, documents R14 has a primary diagnosis of Disorders of the Muscle.R41's MDS (Minimum Data Set), dated 2/2/26, documents R41 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R41 is cognitively intact.R41's Progress Note, dated 7/04/25 at 8:48 PM, documents the following: Reported to this nurse from another resident (R41) that during supper time, R41 told R22 that he does not know how to be a husband and doesn't do anything right. R41 reported to other nurse, R22 told her to shut up with big mean eyes. Did not give a reasoning as to why he had told her to shut up.R22's Face Sheet, undated, documents R22 has a primary diagnosis of TIA (Trans ischemic Attack).R22's MDS, dated [DATE], documents R22 has a BIMS score of 13, indicating R22 is cognitively intact.R22's Progress Note, dated 7/04/25 at 8:45 PM, documents the following: Resident summoned writer to room and stated that he needs to talk to me. R22 stated that during supper time, another resident (R41), told him that he does not know how to be a husband and does nothing right. Res informed me that he did yell at her and told her Shut up! You know everybody's' business and if you don't know it you, are trying to find out! Resident is requesting for him and his wife to sit together away from R41 during mealtimes.There was not a Facility Abuse Investigation for the alleged verbal resident to resident altercation on 7/4/25.On 4/22/26 at 2:30PM, V1 (Administrator) stated she does not have an allegation of abuse for 7/4/25, only the one for 7/7/25.The Abuse Prevention Program Policy, with a revision date of 1/26/24, documents this facility advocates for the prevention of, reporting of, and immediate investigation of allegations of resident abuse, neglect, mistreatment, and misappropriation of resident funds or property.

Based on record review and interview the facility failed to assess and notify the physician after R2 experienced choking incident on 9/13/2025 for 1 of 3 residents reviewed for choking (R2) in the sample of 4. This failure resulted in R2 developing pneumonia which required antibiotic treatment and experiencing an additional choking episode on 9/18/2025 with R2 requiring Heimlich maneuver both times.Findings Include: R2's video swallow study dated 9/5/2025 at 13:23 documents multiple consistencies of food and liquids mixed with barium were fed to R2 by the speech pathologist and the swallowing mechanism was observed under fluoroscopy. The study documents penetration with spontaneous clearing of thin and mildly thick liquids. R2's Progress notes dated 9/13/2025 at 12:55PM documents B/P 144/62, P-54, R-18, SP02 90% room air. R2's notes document during lunch R2 was eating a pulled pork sandwich, and began to choke, Certified Nursing Assistant (CNA) performed Heimlich maneuver on R2. Notes documents food became dislodged and R2 able to speak. R2's notes document R2 took drinks of water and continued to eat lunch. Notes document R2 states she is fine now. Will continue to monitor.R2's Progress notes dated 9/17/2025 at 11:59AM documents R2 complained of productive cough with yellowish sputum, and occasional hemoptysis. Documents R2 reports the blood is bright red. R2's notes document the cough has been ongoing for a few days; the hemoptysis onset is today. R2's progress notes document R2 also complaining of a sore throat and ear pain. Afebrile. Lung sounds clear throughout. R2's progress notes document reached out to Primary care physician, recommend cetirizine for rhinitis and congestion and asking for chest x-ray due to hemoptysis.R2's chest x ray report dated 9/17/2025 documents impression: moderate hiatal hernia, bilateral multifocal infiltrates in both lungs, low lung volumes, follow up imaging recommended after treatment to document resolution.R2's progress notes dated 9/18/2025 10:45am documents Physician Assistant (PA) here for follow up post chest X-ray done yesterday. Notes document new orders received for antibiotic therapy for pneumonia, follow up chest Xray 2 weeks (10/2.)R2's progress notes dated 9/18/2025 at 7:00PM documents writer called to the dining room with reports resident is having difficulty. Notes document writer enters to witness other nurse on duty post Heimlich maneuver. R2's progress notes document it is reported to writer that table mates alerted staff in the dining room that R2 was choking, other nurse approached and performed the Heimlich maneuver and R2 able to speak with raspy voice. Notes document when writer arrived R2 was breathing, skin was pink, no signs/symptoms of distress at that time. Notes document R2 consumed all her chicken and dumplings and a bite of her biscuit. Vital signs post event T98.2, P55, R20 B/P 176/88 sp02 90%. Notes document R2 informed writer she does not feel as if there is any remaining blockage in her airway and her airway is visually clear. Notes document R2 declines further evaluation outside the facility. Notes document R2 is able to drink thin liquids without difficulty or episode. Notes document R2 does not want any more to eat this evening. Notes document episode reported to administrator and primary care physician (PCP), R2's progress notes document new order received for speech therapy to evaluate and treat and to be on pureed diet until that time. R2's Physician Order (PO) date 9/19/2025 documents Azithromycin 250mg 2 tabs today then 1-tab daily days 2-5. F/u chest x-ray 2 weeks.On 9/24/2025 at 10:39AM V5 (Licensed practical Nurse/LPN) stated she was on duty on 9/18 when R2 choked. R2 stated when she got to the dining room V3 (Registered Nurse/RN) was standing behind R2 and had performed the Heimlich on R2. V5 stated one of the CNAs had checked R2's mouth. V5 stated R2 was talking. V5 stated she had not known R2 to have difficulties with swallowing but eating problems were more related to her arthritis. V5 stated on 9/18 after her choking incident she notified the physician an order received for pureed diet and speech therapy evaluation. V5 stated R2 returned to the facility on 9/6 from a hospital stay in which R2 had a stroke. V5 stated she had a swallowing study while at the hospital and R2 returned to the facility on a regular diet with honey consistency liquids. V5 stated that had been upgraded to thin liquids by therapy.R2's Minimum Data Sheet (MDS) dated [DATE] documents R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14. R2's care plan dated 6/26/2025, documents R2 has a regular diet with thin liquids, k-cups with straws. Height 61 weight 134. Ideal Body Weight (IBW) rang 95-115#. Body Mass Index (BMI)I 25.3, weight trends July 132#, [DATE]# and [DATE]#. R2 has no known food allergies. Monthly weight. Diagnosis, major depression, anxiety insomnia, GERD, Alert and orientated able to voice her wants/needs, feeds/hydrates herself in the large dining room. Places her own order for all meals. not a very picky eater and likes most foods. Has her own teeth in good condition, her intake/appetite is good for most meals. Care plan documents the following interventions dated 6/26/2025 monitor monthly weight and intake, serve foods of choice, serve diet as ordered, notify physician of weight loss/gain of 5% in 30 days 7.5% in 90 days, 10% in 180 days, assist with tray set up and placement of clothing protector as needed, monitor for signs and symptoms of edema, diet-regular, thin liquids, k-cups with straw encourage intake at all meals. R2's care plan documents 9/18/2025 R2 had an incident in the dining room. R2 had trouble swallowing and Heimlich was performed. R2 had order for Speech Therapy to evaluate, and resident will be monitored by staff during all meals. On 9/24/2025 at 1:24PM R2 in recliner in area across from the nurse's station. R2 stated she did choke 2 times, and her diet has now been changed to pureed diet. R2 stated does not like the diet. R2 stated the meats are not good. R2 stated she did eat pureed carrots, potatoes and gravy and pureed apple crisp at lunch. R2 stated when she gets choked the food goes down but then feels like it gets stuck. R2 stated the second time she choked it was worse than the first time.On 9/24/2025 at 2:43PM, V1 (Administrator) stated she did not become aware of R2's choking incident on 9/13 until the choking episode on 9/18. V1 stated R2 remained on the same diet of regular diet with thin liquids after choking on 9/13 until choking episode on 9/18 and after that R2 was placed on pureed diet and thin liquids until could be evaluated by speech. V1 stated the physician should have been notified of choking incident on 9/13.R2's physician progress notes dated 9/24/2025 at 4:00PM. Progress notes R2 being seen due to 2 events of choking. 1 on 9/13 and 1 on 9/18. Documents Heimlich maneuver was performed during both episodes. Review of systems documents R2 is alert. Assessment and plan documents choking initial encounter, poor historian; please obtain speech eval, please downgrade to pureed diet, please monitor for further choking episodes and perform Heimlich maneuver if further choking episodes is witnessed manifested by signs of sever obstruction like weak or unable to cough, inability to speak, inability to breathe, of if the patient is witnessed clutching the throat, cyanosis is seen. Please do not perform the Heimlich maneuver if the patient is coughing forcibly, breathing or talking to avoid intervening with abdominal thrusts. Also order for Floroscopic Esophagram double contrast, Reason: swallowing problems, choking.On 9/25/2025 at 8:32AM, V10 (Speech Language Pathologist/SLP) stated she was not aware of R2's choking incident on 9/13/2025. V10 stated she became aware when the evaluation order came for the choking episode 9/18. V10 stated received order for evaluation on 9/19 and did come in and do on the 19th. V10 stated when R2 returned to the facility R2 was on a regular diet with moderate thick liquids. V10 stated she recommended change to thin liquids on 9/9. V10 stated R2 had no signs or symptoms of aspiration. V10 stated when looking at video swallow R2 had on 9/5 while in the hospital it documented penetration which means the food goes down to the level of the trachea and spontaneously comes back out. V10 stated she seen R2 on 9/9, 9/11 and 9/16. V10 stated she was seeing R2 to evaluate her liquids and discharged her on 9/16. V10 stated R2 was on a regular diet with thin liquids from 9/9-9/18 and diet changed after choking on 9/18. V10 asked surveyor if she had seen chest Xray results, V10 stated recent chest x-ray showed a moderate hiatal hernia which could lead to esophageal dysphagia which could be causing her problem. Surveyor referred V10 back to Xray regarding bilateral infiltrates in lungs with diagnosis of pneumonia and V10 agreed R2 could have possibly aspirated. V10 stated she should have been notified of choking incident on 9/13. V10 stated interview with R2's table mates they said R2 was still talking. V10 stated R2 reported she would swallow her food and then pointed to chest area below throat and stated feels like food is there. V10 stated would make sense if esophagus involved. V10 stated she had talked with R2 about a Barium swallow as last test on 9/5 was a modified Barium swallow. V10 stated the physician was at the facility last evening and did not know at this time if any new orders.On 9/25/2026 at 10:50AM R2 stated when she chokes, she is still getting air and can breathe. R2 stated she can talk and ask for help. R2 consistently points at chest below throat and states feel like food just sits there. R2 stated when staff intervene it is sure a relief because feels like food won't go down. R2 stated staff had spoken to her about another swallow study and she would not be against that. On 9/25/2025 at11:00AM V2 (Director of Nursing/DON) stated she was not aware of the first choking incident until after the second incident. V2 stated that she followed up to ensure there was a speech eval after the second episode. V2 stated staff are to be close by when R2 is eating. V2 stated would question if true choking episode as no documentation of any food being expelled and R2 can still talk. On 9/25/20025 at 11:15AM V10 (SLP) stated based on her evaluation on 9/19/2025 she will analyze diet, liquids, signs and symptoms of aspiration and choking, and different diet textures. V10 stated right now looking at minced and moist consistency. V10 stated R2 did well with a banana today. V10 stated she will be working with R2 twice a week. V10 did state she had spoken with R2 and the physician in regard to barium swallow. V10 stated will not increase diet consistency too much until a barium swallow. V10 stated would question if true choking incident because R2 can call for help. On 9/25/2025 at 11:15AM V11 (LPN) per phone interview stated on 9/13/2025 she was not in the dining room when R2 choked. V11 stated she was coming up the hall from passing medications and was told R2 got choked and CNA did Heimlich. V11 stated R2 was eating again when she seen her. V11 stated that R2 stated the pulled pork was stringy. V11 stated she did not do a lung assessment on R2 or notify the physician of a change in condition. On 9/25/2025 at 1:02PM per phone interview V12 (Physician), V12 stated he had been notified of both choking incidents on 9/18/2025. V12 stated R2 had remained on the same diet after choking on 9/13 and diet changed on 9/18 after informed of choking incidents. V12 stated he was at the facility last night to see R2. V12 stated may not be a true choking as speech stated R2 can clear food. V12 stated in regard to use of Heimlich maneuver if not really choking? V12 stated better safe than sorry. V12 stated the plan is to refer R2 to GI and have speech therapy continue to work with R2. On 9/25/2025 at 1:43PM per phone interview with V12 (Physician). V12 stated if he had been notified of choking incident on 9/13/2025 at that time V12 stated he would have downgraded R2's diet and ordered a speech eval. V12 stated the Heimlich maneuver irritation to the ribs. V12 stated performing Heimlich maneuver if not true choking, the benefits outweigh the risks. V12 stated the Heimlich maneuver can cause aspiration pneumonia if the resident vomits. On 9/25/2025 at 1:52 PM V3 (RN) stated she performed the Heimlich on R2 on 9/18/2025. V3 stated she did x2. V3 stated she was not nurse assigned to R2, but V3 stated she was pushing her med cart from dining room and said a resident told her R2 was choking. V3 stated R2 was not talking and had been eating chicken and noodles and after doing Heimlich was able to clear food. V3 stated R2 was drinking liquids when she left dining room. On 9/25/2025 at 2:25PM V1 (Administrator) stated the Heimlich maneuver should not be used if resident not actually choking. V1stated the Heimlich can cause rib fractures and choking.On 9/25/2025 at 3:01PM V8 (CNA) stated on 9/13 when R2 choking in dining room R2 was coughing, and table mate yelled and pointed to R2. V8 stated R2 was gasping when V8 did Heimlich.The facility policy Resident Condition Change/Policy on Contacting a Physician dated, revised 8/14/2018 documents when a change in condition (depending on severity) occurs in a resident, the resident's personal physician or the on-call physician will be contacted. The policy documents change may exist if the resident is beyond usual baseline/predicted or obvious acute changes in health.

Based on interview, observation, and record review the facility failed to perform hand hygiene, change gloves when needed, and have signage indicating the need for Enhanced Barrier Precaution, for 5 of 16 residents (R12, R13, R21,R25, R27) to prevent cross contamination reviewed for infection control in the sample of 29. Findings include: 1. On 12/11/24 at 9:24 AM, V15, Certified Nurses Aide, (CNA) and V8 CNA both donned gloves without hand hygiene. V8 and V15 transferred R25 from her reclining geriatric chair to her bed using a full mechanical lift. Once in bed, R25's pants and incontinent pad were removed. V8's groin, labia, and meatus was cleaned with premoistened peri-wash cloths with the same gloves. V8 touched R25's leg and shoulder to assist with rolling over onto R25's side. V8 with pre-moistened peri-wash cloths cleansed the rectal area and buttocks. V8 placed a new incontinent pad, straightened R25's night gown, pillow, covers, and removed her gloves but did not wash her hands. V8 using the bed control lowered the bed, removed the trash bag from the can, inserted a new bag, left room, went up the hall, placed the trash in the soiled utility room, and went and got R13 in her geriatric reclining wheelchair and pushed her to her room with no hand hygiene. R25's Face Sheet, print date of 12/11/24, documents that R25 was admitted on [DATE]. On 12/11/24 at 3:50 PM, V15 CNA stated that she just forgot to wash her hands before putting on gloves and taking them off. On 12/11/24 at 4:00 PM, V1, Administrator, stated that she expects staff to perform hand hygiene before putting on gloves, after removing gloves and whenever they need it. 2. On 12/11/24 at 9:38 AM, V8 pushed R13 into her room to transfer R13 to bed. V15 was present to assist. V8 and V15 transferred R13 to bed using a full mechanical lift. V8 and V15 both donned gloves with no hand hygiene. R13's Face Sheet, print date of 12/11/24, documents that R13 was admitted on [DATE]. 44967 3. R21's Face Sheet, undated, documents R21 was originally admitted to the facility on [DATE] with diagnosis of Hemiplegia/Hemiparesis and Dysphasia following Cerebral Infarction, Metabolic Encephalopathy, Dementia, and Urinary Tract Infection (UTI). R21's Care Plan, dated 12/10/24, documents R21 required assist with daily care. R21 is incontinent of bowel and bladder. Interventions: Check for incontinence at least every two hours and PRN (as needed). Incontinent care, peri-care, toileting hygiene provided after each episode and PRN. R21's Minimum Data Set (MDS), dated [DATE], documents R21 has a severe cognitive impairment and is dependent on staff for toileting. On 12/10/24 at 10:55 AM, V7, Certified Nursing Assistant (CNA), and V8, CNA, was seen donning gloves and checking R21 for incontinence and R21 was dry. Both CNAs got R21 out of bed to her chair and then doffed their gloves. There was no Hand Hygiene seen done before care, after care, or before leaving the room. 4. R27's Face Sheet, undated, documents R27 was originally admitted to the facility on [DATE], with diagnosis of Parkinson's disease, and Palliative care. R27's Care Plan, dated 10/16/24, documents R27 requires assist with daily care. R27 is incontinent of bowel and bladder. Interventions: Incontinent care after each incontinent episode, wears incontinent liners and pullups, encourage and assist to restroom often to help keep skin clean and dry, toilet as she requests and PRN with assist X 2, provide incontinent care, peri-care toileting hygiene care after each episode and PRN, change pads or briefs as needed. R27's MDS, dated [DATE], documents R27 has a severe cognitive impairment and is dependent on staff for toileting. On 12/10/24 at 9:35 AM, After transferring R27 to bed, V7, CNA, and V8, CNA, checked R27 for incontinence with a bowel movement noted and incontinent care was completed. Both CNAs donned gloves with no hand hygiene seen before care started. After care was rendered, both CNAs left the room without doing hand hygiene. On 12/12/24 at 8:45 AM, V8, CNA, stated We should be doing hand hygiene before resident care and after care before leaving the room. If our gloves are soiled and we are changing gloves, we should be doing hand hygiene before applying new gloves. On 12/12/24 at 9:00 AM, V1, Administrator, stated We talk about hand hygiene all the time. The staff always tell me that is all we talk about at our meetings. I will reeducate them again at our next meeting. They should be doing hand hygiene before care, during glove changes, and after care and before leaving resident rooms. The Facility's Glove Changing Policy, dated 12/20/16, documents It is the intent of this policy to control the spread of infectious bacteria through the proper process of using and changing gloves. Gloves shall be worn by all direct care staff when providing care that will contaminate the hands and spread infectious bacteria. Hand washing is done before and after using gloves. If gloves are required to perform an activity then gloves must be removed and hands washed before touching anything else to prevent contamination of clean surroundings. The Facility's Hand Washing Policy, dated 9/14/14, documents Purpose: To prevent cross contamination and control infection. 5. R12's Face Sheet, undated, documents R12 was admitted to the facility on [DATE] with diagnosis of Fracture left femur, Type 2 Diabetes Mellitus, and Chronic Kidney Disease - stage 2. R12's Care Plan, dated 12/11/24, documents R12 is at risk for pressure ulcer and is incontinent of urine at times. Interventions: skin checks, encourage and assist to restroom often and help keep skin clean and dry, apply skin prep to right upper thigh until healed, betadine to left heel and cover with protective dressing. R12's MDS, dated [DATE], documents R12 is cognitively intact and is dependent on staff for toileting and transfers. The Facility's Skin/Wound Log, dated 12/10/24, documents R12 has a Stage 2 Pressure Ulcer on his left buttock and on his left heel, both were present on admission to the facility. R12's Nursing Note, dated 11/5/24 at 2:56 PM, documents Re-admission skin assessment done. Noted to have a blister area to left heel approx. 4 CM (centimeters) x 4 CM, surrounding skin is pink, noted some pain when removing his sock. Left hip continues to have 10 staples intact, no redness to stapled areas noted. 5 CM x 5 CM x 0.1 CM sheared area to left buttock, wound bed is pink, surrounding skin is normal. Resident also noted to have two pink areas to back, one right upper back and mid lower back. Also noted to have skin tears to right elbow area and right wrist. On 12/11/24 at 1:15 PM, V19, Registered Nurse (RN), and V14 was about to perform wound care/dressing change on R12. All supplies were on bedside table and both Nurses had gloves on and ready to go. When asked if R12 was on Enhanced Barrier Precautions (EBP), V14 stated Oh, Yes, he should be on it. I thought he had a sign on his door but I see it is not there. Both Nurses left the room and obtained appropriate Personal Protectant Equipment (PPE) and donned the gown and gloves prior to performing wound care. 12/12/24 at 9:00 AM, V1, Administrator, stated Anyone with wounds should be on EBP and appropriate PPE should be used. The Facility's Enhanced Barrier Precautions Policy, dated 7/22/24, documents (The Facility) is determined to help fight against the increasing spread of multidrug-resistant organisms (MDROs), extensively drug-resistant organisms (SDROSs), and emerging pathogens is particularly challenging in skilled nursing facilities. Enhanced Barrier Precautions (EBP) require staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO. (The Facility) is following the recommendations of Illinois Department of Public Health (IDPH) and Center for Disease Control and Prevention (CDC) to help protect residents, staff, and visitors from these infections. Procedure: The new guidance calls for the use of EBP in residents with any of the following: Infection or colonization with an MDRO when contact precautions do not otherwise apply, Indwelling medical devices (urinary catheters, feeding tubes, tracheotomies, central lines), Chronic wounds: Diabetic foot ulcers, Unhealed surgical wounds, Venous stasis ulcers, Chronic wounds such as pressure ulcers. Enhanced barrier precaution supplies will be stocked in a holder on the outside of the resident's room. There will also be a sign hung on the door alerting staff of the appropriate PPE that needs to be worn prior to giving high-contact care activities.

Based on interview and record review, the facility failed to prevent misappropriation of a residents medication in 1 of 4 residents (R2), reviewed for Misappropriation in the sample of 4. Findings include: The Facility Final Report, dated 3/6/24, documents the following: On Thursday, February 29, 2024, during the evening, the administrator received notice that approximately 29.75 ml of concentrated liquid Ativan (2mg/ml) was missing from the nurse medication room properly stored in the locked refrigerator. Interviews of all staff nurses began. Management nurses reported to facility. All areas of the medication room, refrigerator, and both medication carts were searched. This same evening it was realized that pharmacy documents were missing as well (pink pharmacy sheets for usage and destruction) of missing medication. At that time large shred box was opened to find the pharmacy medication documents folded in half to be shredded. Interviews with nurses, whom all did respond by phone, were received this evening. After review of nurse schedule it was realized the time frame of the drug diversion occurred on 2/27/24. At this time, the administrator began review of surveillance for the nurse's medication room. It was found after multiple entries into the medication room by V3, LPN, and the following information to be factual and true. Camera footage shows said nurse on 2/27/24 at 2007 (8:07 PM) removing the box Ativan from the top shelf in the refrigerator door, then removes the bottle of liquid Ativan, flattens the package/box, and places the bottle in a small zipper bag and puts it in her purse. V3 then replaces the box in the trash and removes the trash. Later at approximately 2140 (9:40 PM), V3 takes her purse/bag out of the medication room/facility and to her car (just prior to 2200 (10 PM) nurse reporting to shift. V3 was spoken to multiple times and denied seeing the medication. V3 stated she was not aware of that medication and felt like she was being set up and continued to deny any involvement. On Friday 3/1/24, early morning, Pharmacy, Medical Director, Sheriff, IDPH (Illinois Department of Public Health), County Commissioners and the State's Attorney was notified. On this date the County Sheriff came to the facility to review surveillance and captured time frame when nurse is removing the missing controlled medication and takes it by putting it in her personal bag and later removes the bag from the facility to her car. Asked the surveillance company to capture time frame from incident and provide a USB drive to the facility. V3 very angry when advised she alone was being investigated for drug diversion and advised if she had anything to report or would like to speak with myself over the incident, she could and she refused. Administrator did not inform of surveillance as was instructed by law enforcement and the Department of Professional Regulations in this matter. We will continue to follow polices directly related to such event and will function to protect residents from such. R2's February Physician Order Sheet, documents an order, dated 2/23/24, for Lorazepam (Ativan) oral solution 2mg (milligrams) / ml (milliliter), 0.25ml every 4 hours as needed for anxiety/agitation. On 10/10/24 at 8:35 AM, V1, Administrator, stated a bottle of Ativan was observed to be missing. The facility notified local law enforcement, IDPH and the Physician. V1 stated after a review of the facility cameras, it was determined that V3, Former LPN (Licensed Practical Nurse), had taken the medication, disposed of the box and pharmacy delivery sheet and left the facility with the medication in her purse. V1 stated in working with law enforcement, the video footage was given to them. V1 stated V3 was immediately suspended and then terminated. V1 stated IDFPR (Illinois Department of Financial and Professional Regulation) was also notified. V1 stated the medication belonged to R2. V1 stated R2 had passed away and the medication was in the refrigerator in a locked box in the locked medication room, waiting to be disposed of due to having to have 2 nurses witness the destruction. V1 stated they have not had any other drug diversions, theft or misappropriation since this incident. V1 stated prior to V3 being hired a background check was completed with no findings, her license was reviewed on the IDFPR website with no disciplinary actions and her reference checks didn't reveal any concerns with prior employers. The Abuse, Neglect and Mistreatment Prevention Program Facility Procedures Policy, dated 1/26/24, documents the following: This facility advocates for the prevention of, reporting of, and immediate investigation of allegations of abuse, neglect, mistreatment of residents and misappropriation of resident funds or property.

Based on interview and record review, the facility failed to provide assessment or timely treatment for 1 of 3 residents (R9) reviewed for change of condition in the sample of 34. This failure resulted in R9 being in pain for 3 days without physician notification. R9 sustained a right fractured clavicle. Findings include: R9's Face Sheet, undated, documents that R9 was admitted on [DATE], and has diagnoses of a history of a stroke and heart failure. R9's Minimum Data Set, dated dated [DATE], documents that R9 is severely cognitively impaired, requires limited assistance of 1 staff member for bed mobility, eating and hygiene, extensive assistance of 2 staff members for transfer, and extensive assistance of 1 staff member for dressing. R9's Progress Note, dated 06/25/2023 12:04 PM, documents, resident has c/o (complaint of ) shoulder pain to right shoulder past couple of days. today writer noted she has decreased ROM (range of motion) to this shoulder and area is slightly discolored area is darker than surrounding tissue, tan/pink, slightly warm to touch. note - this is the side resident lays on in bed most of the time. she denies injury. she is OOB (out of bed) for lunch today and in good spirits chatting and joking with staff. Tylenol given as ordered. will monitor and report significant changes. R9's Progress Note, dated 06/26/2023 08:56 AM, documents, Reported to writer by staff res (resident). c/o right shoulder pain when getting up for breakfast. On assessment: res is noted leaning on the right shoulder in w/c (wheelchair). It has been noted the res. also sleeps on the right shoulder in bed. Res. verbalizes not to touch her shoulder because it hurts. Yellow and pink discoloration noted to the top of shoulder. Slight swelling and warm to touch. Limited rage of motion. Called res MD (Medical Doctor), spoke with MD nurse. NO (new order) for Shoulder x-ray x3 views and Keflex 500mg (milligram) TID (three times a day) x7days Dx (diagnosis): possible infection in shoulder. HCPOA (Health Care Power of Attorney) notified. R9's Progress Note, dated 06/26/2023 09:14 AM, documents, scheduled R shoulder x-ray x3 views with biotech. awaiting Biotech to call with time. R9's Progress Note, dated 06/26/2023 05:50 PM, documents, Received x-ray results, faxed MD. Awaiting further instructions. Results filed in res. chart. , R9's Progress Note, dated 06/27/2023 12:42 AM, (V2 Director of Nurses, (DON)) and V1, (Administrator), were both made aware of the fx (fracture) at the time of the xray report return in the evening by the previous nurse. R9's Progress Note, dated 06/27/2023 10:08 AM, documents, Called and spoke with (V19, Doctor) nurse regarding x-ray results, states (V19) wants her to see ortho (orthopedics). R9's Progress Note, dated 06/28/2023 03:30 AM, documents, Resident has slept during the night. Does not complain of pain unless she is being turned and repositioned and then will subside after she lays still. Resident did take liquids for staff without any problems. R9's Progress Note, dated 06/30/2023 11:00 AM, documents, Resident returns via mass transit from ortho appt. It continues, Direct staff accompanying. Resident returns in wheel chair with immobilizer sling to right arm. Resident responds appropriately. Denies pain in right shoulder N.O may remove for bathing, avoid lifting arm above shoulder height. No PT (Physical Therapy) on right upper extremity and no use of right extremity. R9's Medical Record fails to document any pain, discomfort or assessment for R9 on 6/23/23, 6/24/23 or 6/25/23. R9's Right Shoulder Xray, dated 6/26/23, documents, Acute fracture of the distal clavicle. R9's Resident Incident Investigation Report, dated 6/26/23, documents V2, DON's, interviews with staff. Care givers interviews prior to discovery of injury: 6/23/23: (V8, Certified Nurse Aide, (CNA)), stated on Friday about 1130 she has got (R9) up for lunch. when getting her up she kept saying that her arm was broke and hurting. she didn't notice any bruising, reported to (V22, Licensed Practical Nurse, (LPN)) that she was saying that her arm was broke and hurting. (V17, CNA) overheard resident say she was hurting in her shoulder at lunch on Friday, seen nurse (V22) give her meds (medication) and then resident was taken by another CNA to lie down in her bed. (V15, CNA) seen resident leaning in chair in dining room and went to help set her back up and resident said her shoulder was broke and crying, told nurse (V22). (V22) (Unknown) CNA reported resident having shoulder pain, assessed and found no redness, bruising or marks on the area, was able to push staff away as she did not want staff near her, resident then taken to bed to lay down. (V18 LPN) resident c/o pain in shoulder, hurting but did not see anything abnormal when looking at shoulder, no bruising seen. 6/24/23: (V19, CNA) aware of pain in shoulder per other staff members. (V20, CNA) aware resident is painful in shoulder. (V21, CNA) gave resident a shower and seen light yellow bruising to R (right) shoulder, nurse informed, c/o pain while in shower. (V23, CNA) helped with getting resident up for shower, resident was c/o right should pain, screaming, told nurse (V22), site was assessed and wasn't red or swollen, but was tender to touch, pain medication was given per nurse. (V24, CNA) assisted with resident on Saturday, voiced c/o right shoulder pain while eating supper and taken to lie down in bed. Resident hurt with taking sweater off and putting her gown on, once laying her down it helped ease her pain to prop her shoulder with small pillow. She slept on her back where she normally sleeps on her right side. With transfers she could cry out it hurt and voiced pain in her shoulder. (V22, LPN) residents c/o pain with transfer, observed in shower with not redness or swelling, had no c/o pain without movements, was up for meals. (V18, LPN) looked at shoulder with nurse (V22, LPN), area was noted at shoulder to have a pink/ tiny bit of brown discoloration but did appear bruised, felt as though it was an area of inflammation. 6/25/23 (V22, LPN) assessed and noted darkness to shoulder, c/o pain with transfers, able to move extremity independently with guarding, shoulder slightly warm to touch, relief with rest, no c/o pain without movements. On 1/24/24 at 2:45 PM, V2, Director of Nurses, was questioned if there were any written assessments available for review on R9 between 6/23/23 and 6/25/23, V2 stated, No there is not. On 1/24/24 at 2:55 PM, V1, Administrator, stated that she agreed that R9's Doctor should have been notified of R9's pain before 6/26/23. On 1/25/24 at 10:19 AM, V22, stated that at the time she would have assessed her but if she did not find anything alarming she would not have done a written assessment. V22 stated, You know older people generally have aches and pains. The policy on Contacting a Physician, dated 8/14/18, documents, When a change in condition (depending on severity) occurs in a resident, the resident's personal physician or the on-call physician will be contacted.

Based on interview, observation and record review, the facility failed to disinfect a multiple resident use blood glucose monitor to prevent contamination for 2 of 3 residents (R2, R16) reviewed infection control in the sample of 34. Findings include: On 1/23/24 at 11:54 AM, V4, Licensed Practical Nurse (LPN), entered R2's room. V4 obtained R2's blood glucose level. V4 took the blood glucose monitor back to her medication cart and laid it on top. V4 retrieved a Sani wipe (disinfecting wipe) and with 3 quick swipes cleansed the blood glucose machine and then placed it in the top drawer of the medication cart. On 1/24/24 at 11:00 AM, V5, LPN, obtained a blood sugar blood level for R16 using a blood glucose monitor. After completing the test, V5 took the monitor and went to R2 and obtained a blood sugar level on R2. V5 failed to cleanse the machine between the use of R16 and R2. After completing the test V5 grabbed a Sani wipe to cleanse the monitor with, V5 stated, Oh, I didn't clean that off did I. I got distracted. On 1/24/24 at 4:10 PM, V1, Administrator, stated that she had just in-serviced all the nursing staff to keep the monitor wet for the needed contact time. The facility supplied list of residents that receive blood glucose monitoring, dated 1/20/24, documents that R2, R16 and R22 receive blood glucose monitoring. The Sani wipe container documents that to disinfect, the item needs to have a wet contact time of 2 minutes.

Based on record review an interview the facility failed to employ a Registered Nurse, (RN), in the facility for 8 hours a day, 7 days a week. This has the potential to affect all 34 residents at the facility. Findings include: 1. The facility nursing schedule dated 01/29/2023-02/21/2023 documents the facility did not have an RN 8 hours a day on 01/29/2023, 02/11/2023, 02/12/2023 and 02/20/2023. On 02/22/2023 at 9:51AM V2, Director of Nursing, (DON), stated, the facility did not have an RN on duty at the facility on 01/29/2023, 02/11/2023, 02/12/2023 and 02/20/2023. On 02/22/2023 at 11:20AM, V1 Administrator stated, the facility does not have a specific staffing policy, but is documented in the resident admission packet. V1 stated, the facility follows stated guidelines. The facility important facts dated January 25, 2022, documents, staffing, it is the intention that all units of the facility are staffed in a manner appropriate to the needs of the residents. Guidelines from various entities (The Center for Medicaid/Medicare Services, and the Illinois Department of Public Health) are considered when determining appropriated staffing levels.

Based on interview, observation and record review, the facility failed to store dry goods properly, handle utensils in sanitary manner and ensure the ice machine had an air gap. This failure has the potential to affect all 34 residents living in the facility. Findings include: 1. On 02/23/23 at 10:40AM, V22, Dietary Aide, washed her hands, then as she was talking, kept touching her face mask. V22 then donned gloves and then began to fill up the plastic silverware bin out of a larger storage bag. V22 removed her gloves, failed to wash her hands and then started to put plastic trays on the food cart. 2. On 02/23/23 at 11:55AM, V16, Cook, was pulling the noon meal out of the oven for temperature checks and then service. V16 grabbed a serving ladle from the overhead hook by the ladle to stir the chicken and check the temperature of the food. V16 repeated this action 4 separate times to check all the hot foods being served. V16 was not wearing gloves. V16 had not washed her hands before each time she grabbed ladles. 3. On 02/23/23 at 12:10PM, on a kitchen storage table a 14-ounce box of Minute Rice, a 28-ounce box of Wheat Cereal, a 36-ounce box of Malt-O-Meal and 42-ounce box of Quick Oats were not sealed properly. All were noted to have an opening which potentially let the food become contaminated. 4. On 02/23/23 at 12:45PM, the facility ice machine did not have an air gap. The ice machine drainage has a flexible tube that runs down into the floor drain approximately 1.5 inches from the bottom of the drain. On 02/23/23 at 2:30PM, V15, Dietary Manager, stated, that she did not notice the boxes of food had an unsealed opening. V15 expects staff to not touch serving utensils at the serving end. V15 did not realize that the ice machine did not have an air gap. V15 also, stated, that hands should be washed before donning gloves and when soiled. The Nutritional Services Department, undated, documents, Utensils, cups, glasses and dishes shall be handled in such a way as to avoid touching surfaces that food or drink will come into contact with. It continues, 25. Dry cereal such as, oatmeal, malt -o-meal, cream of wheat etc. (etcetera), must be put in clear plastic containers with lid after opening. Dated and labeled. The Resident Census and Conditions of Residents, CMS 672, dated 02/21/23, documents that the facility has 34 residents living in the facility.

Based on interview, observation and record review, the facility failed to utilize Personal Protective Equipment, (PPE), isolation trash bags, isolation linen bags, gloves, hand hygiene, multiuse resident equipment and accurate surveillance to prevent the spread of Gastrointestinal Norovirus which is spreading throughout the facility and lack of hand hygiene between gloves changes. This has the potential to affect all 34 residents living in the facility. Findings include: On 02/21/23 at 9:30AM, V1, Administrator, stated, that a stomach virus started this weekend. When questioned as to what they are doing, V1, stated, that the residents are being kept in their rooms and after 24 hours of no symptoms they can come out of their room. V1 stated, that if a resident is symptomatic there will be an orange dot in their doorway. On 02/22/23 at 1:42PM, V10 Infection Preventionist Nurse, stated, V13, County health Department Nurse, was contacted on Monday morning and updated again today about the GI, (Gastrointestinal), outbreak. V10 stated, that she is unsure why staff are not using PPE and that she will obtain the P and P, (Policy and Procedure), for Gastroenteritis. V10 stated, We are keeping them in their rooms for 24 hours after their last symptom. On 02/22/23 at 2:06 PM, V1, Administration, stated, Everyone is working together on this. The nursing staff reporting to me or V10, infection Preventionist about who is sick or showing symptoms. There is no real one person in charge. Over the weekend, residents started to come down with GI symptoms, nothing the same, some had diarrhea, some with nausea and then some with vomiting. I told the staff to keep the symptomatic residents in their rooms, and that they could come out after they had been symptom free for 24 hours. When we came in on Tuesday the nursing staff had all residents eating in their rooms on Styrofoam. Which I did not agree with, that is why lunch was served in the dining room. V1 was questioned about why the staff are not wearing PPE or using isolation bags or laundry isolation bags while working with the symptomatic resident, V1 stated, I guess we should have. V1 stated, I did not have anyone tested for anything. I think this is just a 24-48-hour bug. (V12), Medical Director, is in the building now and he is looking at residents. V1 was questioned if the facility has a Gastrointestinal Norovirus policy, V1 stated, I think so. I will have to look for it. V1 stated, that she expects staff to wash their hands after working with residents, removing gloves, before putting on gloves and between each meal tray delivered. V1 also, stated, that multiple use equipment should be sanitized after it is used on a symptomatic resident. On 02/23/23 at 8:32AM, V1 stated, We have 2 new cases that came down with symptoms last evening R8 and R6. They have been isolated to their rooms and we were able to get a stool sample and I have sent it to the lab as a STAT, (immediately). We should have the results this afternoon. V1 further stated, that residents can come out of their rooms after they have been symptom free for 24-hours. V1 was questioned if she was aware of the CDC, (Center for Disease Control), guidance documenting that resident should be in isolation for 48 hours after the last symptom. V1 stated, that she was not aware of the CDC guidance. On 02/23/23 at 10:10AM, V13, Health Department, stated, The facility did call me on Monday and let me know that they had a few residents and staff having GI symptoms. V1 told me they were isolating the residents. I told them that they need to contact me with updates. V13 was questioned if she was aware of the number of the residents that have come down with symptoms, V13 stated, that she did not realize that many residents were affected. 16 residents noted on log, per GI event tracking Surveillance for Congregate Setting Outbreak Log. V13 was asked about her feeling on residents being let out of isolation after 24-hours, and not using PPE or hand hygiene not being performed. V13 stated, I really didn't delve, (careful or detailed search for information), that much into it when I spoke to them. I am really surprised that the facility is having trouble, because they handled COVID so well. Isolation, PPE and basic handwashing are normal things that should be done. V13 stated, If the facility does not have a policy and procedure, I would think they would go to the CDC and follow their guidance on Gastrointestinal Norovirus. On 02/27/23 at 9:15 AM, V2, Director of Nurses, stated, that all of the soiled linens and trash should have been put in isolation bags. 1. On 02/21/23 at 1:59PM, V7, Certified Nurse Assistant, (CNA), entered R26's room to toilet R26. V7 did not wear a gown. V7 transferred R26 from the wheelchair to the toilet using a partial mechanical lift. R26's room or bathroom has no isolation trash or isolation linen bag. When V7 finished assisting R26 she removed the partial mechanical lift and put it in the 100-hall shower room without disinfecting the lift. V7 stated, that lift is used for the 100 hall. V7 stated, This partial mechanical lift is used only for the 100 hall and each hall has its own. V7 did not cleanse the partial mechanical lift once in the shower room. 2. On 02/21/23 at 2:05PM, V7 went to the 100-hall shower room and obtained the partial mechanical lift, V7 then took the lift to R3's room. R3 was transferred using the partial mechanical lift from her wheelchair to the toilet. V7 failed to wear a gown or gloves. R3's room or bathroom has no isolation trash or isolation linen bag. 3. On 02/22/23 at 1:32PM, V8 CNA came out of R11's room with the partial mechanical lift. V8 stated, that R11 was transferred from the bed to the recliner. V8 failed to cleanse the partial mechanical lift before putting it in the 100-hall shower room. V8 did not cleanse the partial mechanical lift once in the shower room. 4. On 02/22/23 at 8:18AM, V20, CNA, entered R3's room with her meal tray. V20 did not don gloves or a gown. V20 arranged items on R3's tray table to make room for the meal tray and then assisted R3 with sitting up straight in her wheelchair. V20 exited the room without hand hygiene. V20 then went to the breakfast cart in the hallway and obtained R12's (R3's roommate) meal tray. V20 did not don gloves or a gown. V20 assisted R12 up to the bedside and set the breakfast tray up for R12. 5. On 02/22/23 at 11:25AM, V8 and V18 CNAs entered R31's room to provide R31 with incontinent care and getting her up in her wheelchair. Both V8 and V18 failed to perform hand hygiene before donning gloves or wear a gown. V18 left the room with her gloves on, went to shower room to get an incontinent brief, V18 came back to the room, with the same gloves removed soiled incontinent brief, wiped R31's left and right groin, pubic area and labia, changed gloves with no hand hygiene in between, rolled R31 over and cleansed the buttocks and rectal area. V18 changed gloves with no hand hygiene in between. R31 was dressed and then put in her high back reclining chair using a mechanical lift. R31's room did not have isolation linen or isolation trash in her room or bathroom. On 02/22/23 at 11:35AM, V18 stated, (R31) has not had any loose stools or nausea or vomiting today but, she did have some yesterday. On 02/22/23 at 12:15PM, R31 was in the dining room being assisted with her meal. 6. On 02/22/23 at 12:00PM, V16, Dietary Cook, was observed passing the lunch trays on the hallway. V16 set up the residents for the meal service. V16 did not utilize hand hygiene or gloves between residents. V16 did not use a gown either. V16 served R7, then to R13's room, then to R19's room, then to R23's room, then to R16's, then to R3, then to R25's room, then to R2 room and finished in R137's room, passing lunch trays and did not utilize hand hygiene or gloves between any of the residents. 7. On 02/21/23 at 11:44AM, V5, Licensed Practical Nurse, (LPN), gave R2 her noon medications. V5 stated, that R2 is having stomach issues. V5 did not wear a gown or gloves. After R2 took all the medications, V5 took the medication cups grabbing the top of lip of the cup with her bare hands and threw the cups away. V5 exited the room and did not perform hand hygiene. 8. R11's Progress Note, dated 02/22/23 at 4:40PM, documents, resident stayed in bed for breakfast and lunch. She did have loose stools x's 3 this shift. She was assisted up to her recliner this afternoon and is alert and oriented x's 2 per her normal. Denies stomach upset or pains. fluids encouraged. Due meds as ordered. PRN, (as needed), Imodium given with some relief as has not had any loose stools this afternoon. Will con't, (continue), to monitor. Afebrile T, (temperature), - 97.6. On 02/22/23 at 1:05PM, R11's room was entered, V9, Certified Nurse Aide (CNA), was providing incontinent care for R11. V9 had placed a soiled urine and feces disposable pad and disposable incontinent brief on R11's bathroom counter and sink area. V9 was not wearing a gown during the incontinent care. V9 changed her gloves, 2 times without hand hygiene. After completing the care, V9 then collected the soiled linens off the counter and sink and placed them in her right hand extending up her foreman and held the soiled linens against her shirt. V9 went into the shower room and placed the soiled linens onto the soiled linen barrel lid. V9 removed her gloves and failed to sanitize her hands. V9 then raised the soiled linen barrel lid and placed the soiled linens in it and discarded the trash. V9 did not clean the soiled linen barrel lid or R11's bathroom counter or sink. The facility supplied document, Transfer and Ambulation, dated 02/27/23, documents that R16, R11, R5, R8, R26, R10, R18 and R19 all use the partial mechanical lift. The facility GI event tracking Surveillance for Congregate Setting Outbreak log dated 02/22/23, documents R2, R14, R10, R11, R5, R31, R16, R23, R28, R3, R12, R13, R26, R87, R7 and R25 all were affected with GI symptoms of diarrhea, nausea, vomiting or elevated temperature. 32874 9. On 02/21/23 at 03:29PM V7, Certified Nursing Assistant, (CNA), enters R5's room which there was a strong BM, (bowl movement), odor. V7 exits R5's room went to the shower room and retrieved the sit to stand then entered back into R5's room with sit to stand lift. After care of R5, V7, CNA grabbed the soiled laundry and placed it in a bag, then washes her hands with soap and water. Then picks up the dirty bag with no gloves and exits room pushing the lift. V7 pushes the lift down to the shower room and did not cleanse it after placing it back into shower room. V6 CNA exits R5's room with gloves on and then enters R2's room, V6 went to R2's bathroom removes her gloves and throws them in R5's waste can, then washes her hands with soap and water and exits bathroom through R2's room. R5's progress notes dated 02/20/2023 at 10:42AM documents R5 noted to have an increase of occasional loose stools and voiced experiencing nausea. On 02/22/23 at 11:52AM V17, Licensed Practical Nurse, (LPN), stated, she was told if no symptoms or fever for 24 hours residents could come out of room. V17 did state some residents also, had diarrhea as a symptom. The facility policy Infection Control undated policy documents Standard Precautions: standard precautions include the following procedures appropriate cleaning of client care equipment. 43847 02/22/23 10:40AM interview with V1 and V10 stated, they would put together the log for the residents with GI symptoms. V1 stated, I have a handwritten list of them that the nurse told me was sick over the weekend. 10. R12's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 4, which indicates R12 is severely impaired. MDS documents that R12 is dependent with bathing, dressing, toileting, transfers and personal hygiene. R12's progress notes dated 02/21/23 at 9:28PM documents, R12 had Diarrhea stool x1 this shift. Did eat snack tonight. Has been in bed most of day. R12 is listed on the facility provided event GI log as having loose stools on 02/21/23. On 02/22/23 at 11:47AM V8 and V9 performed peri care on R12. V8 entered room and put gloves on. V9 entered room and washed hands and applied gloves. V8 sat R12 on edge of bed and applied gait belt. R12 then stood her up and V9 removed saturated incontinent brief and bed pad. V9 handed saturated linens to V8 and V8 placed linens on floor. V9 then put a clean incontinent bed pad on bed. V8 assisted R12 to lay down on the incontinent bed pad. R12 was laying on her back with her hands on her chest. V8 pulled R12's gown up to R12's chest and laid it on her hands and chest. R12's gown was saturated with urine. V8 then picked up urine saturated linen off the floor and put it in a plastic bag on the foot of the bed. V8 removed her gloves and applied new gloves without hand hygiene. During peri-care to R12's labia, V9 removed her gloves and applied new gloves that she reached into her pocket to retrieve without performing hand hygiene. V9 then provided peri-care to R12's buttocks, V9 wiped one area of R12's buttock then removed gloves and applied new gloves without performing hand hygiene, multiple times. V9 covered R12 with blanket while R12 still had urine saturated gown on. V8 pulled cover down and removes the urine saturated gown and then applies clean gown without changing gloves or performing hand hygiene. 11. R19's MDS dated [DATE] documents, a brief interview of mental status of 3 which indicates R19 is severely impaired. MDS documents that R19 needs assist with bathing, dressing, toileting, transfers and personal hygiene. R19's diagnosis include, Primary osteoarthritis, unspecified site (Primary), Type 2 diabetes mellitus without complications, Pain, unspecified, Gastro-esophageal reflux disease without esophagitis, Other kyphosis, site unspecified, Edema, unspecified, Personal history of COVID-19, Major depressive disorder, single episode, unspecified. R19's Progress Note dated 02/22/23 at 5:44AM documents, R19 Diarrhea stool x 1 this a.m. Colace held. States feels ok denies any nausea at this time. Will continue to monitor. On 02/22/23 at 11:08AM V19 performed peri-care on R19. R19 is currently experiencing diarrhea and has been eating in her room. V19 states, that no one has told her to wear any other PPE when providing care to R19 except gloves and hand hygiene. R19's Progress Note dated 02/22/23 at 4:59PM documents, R19 has had loose stool x's 2 this shift. She denies feeling ill. No nausea. Appetite per her normal. Takes due meds as ordered. No s/s of distress, is afebrile T-97.9, will con't to monitor and assist with cares as needed. On 02/23/23 R19 is not on the facility provided GI event tracking log. 12. R23's MDS dated [DATE] documents a brief interview of mental status of 12 which indicates R23 is moderately impaired. MDS documents that R23 needs limited assist with bathing, dressing, toileting, transfers and personal hygiene. R23's diagnosis include: Paroxysmal atrial fibrillation (Primary), Chronic diastolic (congestive) heart failure, Type 2 diabetes mellitus without complications, Chronic kidney disease, stage 3, unspecified, Peripheral vascular disease, unspecified, Unspecified macular degeneration, Essential (primary) hypertension, non-ST elevation (NSTEMI) myocardial, infarction, Atherosclerotic heart disease of native coronary artery without angina pectoris, Dilated cardiomyopathy, Dysphagia, unspecified, History of falling, Presence of aortocoronary bypass graft, Presence of automatic (implantable) cardiac defibrillator, Depression, unspecified, Hyperlipidemia, unspecified, Metabolic encephalopathy, other specified hypothyroidism. On 02/21/23 at 9:00AM R23 stated, that he has had diarrhea a few times over the weekend, and he has had to stay in his room. Facility provided event tracking log on 02/23/23 at 12:00PM documents, R23 on log as having diarrhea and as being cleared of symptoms on 02/22/23. R23 Progress Notes on 02/23/23 at 7:14PM documents R23 had loose stool x's 1 early this shift Imodium given per prn order. No further loose stools. Resident denies any c/o. Afebrile T - 97.4, due meds as ordered. Up in room per his normal. No s/s of distress will con't to monitor. R23 Progress Notes on 02/22/23 at 4:27PM documents, R23 up in his room today. He states, he is feeling better and does not feel unwell, he has had 2 watery stools this shift, is afebrile T - 97.8. and takes due meds without difficulty. No s/s, (Signs or Symptoms), of A/R, (autoimmune and inflammatory disease), appetite is good, will con't to monitor and assist as needed. R23 progress notes on 02/22/23 at 4:46AM documents, R23 Diarrhea x2 this shift. Encouraged to take fluids, will continue to monitor. R23 progress notes on 02/18/23 at 7:38PM documents, R23 vomited x2 with large emesis. Resident having loose stools x3. Writer sat resident up in bed and encouraged resident to sip on water when needed and rest his stomach. Resident a/ox4 and replied, ok I will do that, thank you Writer provided saltine crackers, will cont to monitor. The facility policy Infection Control undated policy documents Standard Precautions: standard precautions include the following procedures appropriate cleaning of client care equipment. The facility Infection Control policy, undated, documents, Handwashing is the single most effective way to reduce the number of microorganisms on the surface of the skin. It should always be performed: before and after contact, before and after using gloves, after contact with used equipment. Body Protection: Gown and clothes such as overalls will reduce the possibility of contact with hazardous or contaminated substances. They also will protect from contact with microorganisms. Paper gown. Wear to protect self from infectious resident. Wear to protect resident from possible exposure to microorganisms. Ties at the neck and waist. Tie securely. Discard after use. Change between residents. Linen Handling. Appropriate personal protective equipment's should be worn when handling soiled linen with bodily substances. Linen that is heavily soiled with blood or other bodily substances should be in leak proof bags and securely tied. Hands should be washed after handling used linen.

Based on interview, observation and record review, the facility failed to provide timely incontinent care for 2 of 4 residents (R11, R12) reviewed for incontinent care in the sample of 25. Findings include: 1. R11's Face Sheet, print date of 02/22/23, documents R11 was admitted on [DATE] and has diagnoses of Dementia and Urinary Tract Infection. R11's Minimum Data Set, (MDS), dated [DATE], documents R11 is cognitively intact, requires extensive assistance of 2 for toileting, is frequently incontinent of bladder and occasionally incontinent of bowel. R11's Progress Note, dated 02/22/23 at 4:40PM, documents, Resident (R11) stayed in bed for breakfast and lunch. She did have loose stools x's 3 this shift. She was assisted up to her recliner this afternoon and is alert and oriented x's 2 per her normal. Denies stomach upset or pains. Fluids encouraged. Due meds as ordered. PRN, (as needed), Imodium given with some relief, as has not had any loose stools this afternoon. will con't, (continue), to monitor. Afebrile T, (temperature), - 97.6. On 02/22/23 at 11:30PM, a strong foul smell of urine is noted from R11's room. R11 is lying in bed asleep. On 02/22/23 at 1:05PM, R11's room was entered. V9, Certified Nurse Aide, (CNA), was providing incontinent care for R11. V9 had placed a heavily soiled urine and feces disposable pad and disposable incontinent brief on R11's bathroom sink and bathroom counter. On 02/22/23 at 1:25PM, V9 stated, that she had not provided incontinent care for R11 previously in the day. On 02/22/23 at 1:30PM, V18, CNA, stated, that the last person to provide care for R11 was V8, CNA. On 02/22/23 at 1:35PM, V8, CNA, stated, that R11 was provided incontinent care after breakfast. On 02/27/23 at 9:15AM, V2, Director of Nurses, stated, that residents should be checked for incontinence, every 2 hours and changed if needed. 43847 2.) R12's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status, of 4 which indicates R12 is severely impaired. MDS documents, that R12 is a Physical help limited to transfer only, with ADL support provided by staff, with bathing, dressing, toileting, transfers and personal hygiene. R12's progress notes dated 02/21/23 at 9:28PM documents R12 had Diarrhea stool x1 this shift. On 02/22/23 at 11:47AM V8 and V9 performed peri care on R12. V8 entered room and put gloves on. V9 entered room and washed hands and applied gloves. V8 sat R12 on edge of bed and applied gait belt. R12 then stood her up and V9 removed saturated incontinent brief and bed pad. V9 handed saturated linens to V8 and V8 placed linens on floor. V9 then put a clean incontinent bed pad on bed. V8 assisted R12 to lay down on the incontinent bed pad. R12 was laying on her back with her hands on her chest. V8 pulled R12's gown up to R12's chest and laid it on her hands and chest. R12's gown was saturated with urine. V8 then picked up urine saturated linen off the floor and put it in a plastic bag on the foot of the bed. V8 removed her gloves and applied new gloves without hand hygiene. During peri-care to R12's labia, V9 removed her gloves and applied new gloves that she reached into her pocket to retrieve without performing hand hygiene. V9 then provided peri-care to R12's buttocks, V9 wiped one area of R12's buttock then removed gloves and applied new gloves without performing hand hygiene, multiple times. V9 covered R12 with blanket while R12 still had urine saturated gown on. V8 pulled cover down and removes the urine saturated gown and then applies clean gown without changing gloves or performing hand hygiene. Policy titled Incontinent Care states, all residents with incontinency shall receive perineal care following any episode of incontinency. Same, document states, purpose as the following: To reduce the incidence of UTI as a result of cross contamination. To reduce the incidence of increased skin breakdown.

Based on observation, interview and record review the facility failed to identify and implement interventions to reduce the use of restraints for 2 of 2 residents (R4 and R9), reviewed for restraints in the sample of 18. Findings include: 1. On 01/19/22 at 10:37 AM V9, Licensed Practical Nurse, (LPN), stated R4 has a lap buddy because, with his dementia he is always leaning over in chair, to call for the cats and has fell out on his head. On 1/19/2022 at 1:20PM, R4 sitting up in chair with lap buddy in place. R4's Care Plan dated 7/29/2021, documents R4 requires assist with Activity of daily living, (ADL). R4's Care Plan, documents R4 continues to try to self-transfer to toilet, to bed and even to his recliner at times. The Lap Buddy Cushion is used while he is up in the wheelchair for balance support, safety and to help prevent falls. Functional alarms are used when he is in bed and in any other type of chair, other than the wheelchair. The Lap Bubby Cushion is released every two hours. To toilet and as needed. R4's Care Plan does not document interventions in place, for the reduction or elimination of restraint 2. On 1/18/2022 at 11:20AM, R9 was up to use rack in go wheelchair with seat belt in place, around R9's waist. R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Care plan dated 8/1/2021 documents R9 requires assist with all ADL's, (Activities of Daily Living). R9 has a history of a right [CONDITION(S)]. R9's Care Plan documents, R9 uses lap safety belt, it is to be released every 2 hours and as needed. R9's Care Plan does not document a plan with interventions to decrease the use of the restraint, the lap safety belt. On 1/20/2022 at 11:40AM V1, Administrator stated she would expect there to be interventions in place to reduce the use of restraints. The facility undated Restraint Policy documents, Care Plans-Alternative interventions used in place of restraints. If restraint must be used, include reason for restraint, type of restraint used, duration and time of day restraint is to be used, where less restrictive measures have not been successful and physical restraints have been applied.

Based on observation, interview, and record review2 the facility failed to safely transfer a resident using a full mechanical body lift for 1 of 3 residents, (R10) reviewed for transfers in the sample of 18. Findings include: On 1/19/22 at 11:50 AM, V12 Certified Nurse Aide, (CNA), and V13 CNA, placed the sling under R10 and attached the full mechanical lift to the sling, V12 and V13 raised R10 up off of the bed and transferred R10 over to the high back wheelchair and lowered her down to the chair. V12 and V13 did not lock the high back wheelchair wheels. On 1/20/22 at 10:03 AM, V1 Administrator stated, I would expect the wheelchair wheels to be locked when lowering her to the seat. The manufacturers guidelines for Invacare Reliant 600 dated 2018, documents. Using the sling WARNING: If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards. Transferring the patient WARNING: Wheelchair wheel locks must be in a locked position before lowering the patient into the wheelchair.

Based on interview, observation and record review the facility failed to properly label medications for 2 of 13 residents (R23, R30) reviewed for medications in the sample of 13 and 2 other residents (R24, R34) outside the sample. Findings include: 1. On 01/30/18 at 7:45 AM, V3, Licensed Practical Nurse (LPN), administered [MEDICATION NAME] 8 units, subcutaneously (SQ) to R34. The [MEDICATION NAME]bottle did not contain a pharmacy label. A sticker was on the side of the bottle with R34's initials, the date the bottle was opened and the date the insulin would expire. On 01/30/18 at 11:15 AM, V3 administered [MEDICATION NAME] 9 units SQ to R34. The [MEDICATION NAME]bottle did not contain a pharmacy label. A sticker on the side of the bottle with R34's initials, the date, the bottle was opened and the date the insulin would expire. R34's Physician Order, dated 01/26/18, documents, [MEDICATION NAME] 8 units breakfast, 9 units lunch, 8 units supper. Diagnosis: [REDACTED]. 2. On 01/30/18 at 11:09 AM, V3 administered Humalog 6 unit SQ to R30. The Humalog insulin bottle did not contain a pharmacy label. A sticker was on the side of the bottle with R30's initials, the date the bottle was opened and the date the insulin would expire. R30's January 2018 Physician order [REDACTED]. DX: IDDM 3. On 01/31/18 at 8:40 AM, R23's Humalog insulin bottle did not contain a pharmacy label. A sticker was on the side of the bottle with R23's initials, the date the bottle was opened and the date the insulin would expire. R23's January 2018 POS documents, Humalog inject 5 units SQ at breakfast, 8 units SQ at Noon, 3 units SQ at supper, only give scheduled Humalog @ (at) meal times only if resident eats 50% or more. DX: Diabetes. 4. On 01/31/18 at 8:40 AM, R24's Humalog insulin bottle did not contain a pharmacy label. A sticker was on the bottle with R24's initials, the date the bottle was opened and the date the insulin would expire. R24's January 2018 POS documents, Humalog inject 4 units SQ every evening, DX: Type 2 diabetes mellitus. On 01/31/18 at 8:40 AM, V5, LPN, stated, I put stickers on the insulin bottles with the resident's initials along with the date they were opened and the date they expire, I'm the guilty one. (R30's) insulin came in a bag with the pharmacy label on it, but I'm the one that started putting stickers on the insulin bottles and getting rid of the bags. On 02/01/18 at 12:25 PM, V2, Director of Nurses (DON), stated, I would expect all our medications to have pharmacy labels on them. The Facility's policies document, General Medication Information (undated), all medications shall be labeled by the pharmacy with the physician's orders [REDACTED]. All medications located in the med carts are to be reviewed for physician's orders [REDACTED]. 5 Rights of Medication Administration (undated), you should always give the right dose of the right medication to the right resident at the right time by the right route. You should, also have the right documentation to show all these things.

Based on interview, observation and record review the facility failed to administer insulin at the proper time. There were 25 opportunities with 3 errors resuliting in a 12% medication error rate. The errors involved one resident (R30) in the sample of 13 and 1 other resident (R34) outside the sample out of 5 residents observed during medication administration. Findings include: 1. On 01/30/18 at 7:40 AM, V3, Licensed Practical Nurse (LPN), performed a blood glucose test on R34 with a result of 99 blood glucose level. At 7:45 AM, V3 administered 8 units of [MEDICATION NAME], fast acting insulin, subcutaneously (SQ) to R34. R34's meal tray was delivered to her room at 8:15 AM, 30 minutes after receiving her insulin, and R34 began to eat her meal. On 01/30/18 at 11:15 AM, V3 performed a blood glucose test on R13 with a result of 112 blood glucose level. At 11:20 AM, V3 administered 9 units of fast acting insulin, [MEDICATION NAME] SQ to R34. R34's meal tray was delivered to room at 12:10 PM, 50 minutes after receiving her insulin and R34 began to eat her meal. R13's Physician Order, dated 01/26/18, documents, [MEDICATION NAME] 8 units breakfast, 9 units lunch, 8 units supper. DX (Diagnosis): IDDM (Diabetes Mellitus). 2. On 01/30/18 at 11:08 AM, V3 performed a blood glucose test on R30 with a result of 220 blood glucose level. At 11:09 AM, V3 administered 6 units of fast acting insulin Humalog SQ to R30. R30 began eating his meal in the dining room at 12:04 PM, 55 minutes after receiving his insulin. R30's January 2018 Physician order [REDACTED]. DX: IDDM. On 02/01/18 at 9:45 AM, V13, Primary Care Physician for R30 and R34 stated, Not eating shortly after receiving their insulin is a medication error, but it is not a significant medication error, there was no harm. Facility policy documents, Medication Administration (dated 09/14/16), Policy: It is our intent to give the resident the correct medication at the correct time.<BR/(NAME)Lilly and Company, dated 1996, documents, Humalog is man-made, fast-acting insulin used to control high blood sugar in adults and children with diabetes mellitus. Humalog starts acting fast, so inject it up to 15 minutes before or right after you eat a meal. It also documents, [MEDICATION NAME] is fast acting. Eat a meal within 5 to 10 minutes after taking it.

Based on interview, observation and record review the facility failed to develop and implement written policies/procedures regarding various aspects of the grievance requirements; and failed to inform residents of these grievance policy requirements for 1 of 1 resident (R13) interviewed about the facility's grievance procedures in the sample of 13, and 4 other residents (R1, R3, R31, R32) outside the sample. Findings include: On 01/29/2018 at 3:00 PM, the facility was noted not to have their grievance policy posted anywhere in the facility for residents to review. On 01/30/2018 at 10:15 AM, during the group meeting, residents attending the meeting, R1, R3, R13, R31, and R32, stated that they were unaware the facility had a specified Grievance Official or that the facility had a procedure to file a complaint in writing and could also, receive a response in writing. Residents stated they were not aware of how to file an anonymous complaint. Residents stated that they are free to express complaints in the resident council meetings, but other than that they would just express their complaint to any staff member available at the time. The Facility's Grievance Policy, not dated, was noted to be within the facility's admission packet. This Grievance Policy is the same policy that V1, Administrator, presented as the facility policy on the survey. This policy does not include the following requirements: a statement specifying the Facility's Grievance Official and the official's contact information; a statement about the right to file a grievance orally or in writing; a statement about the resident's right to file a grievance anonymously; a statement about how residents will be informed of the Facility's Grievance policy procedures, including how to files an anonymous grievance and how to obtain complaint results in writing whether the grievance was confirmed or not confirmed. The Facility's Grievance Policy documents the following complaint procedure, 1) Discuss your concern with the charge person at the time of the incident. 2) If you feel the discussion has not been to your satisfaction, contact the Director of Nursing within 36 hours. 3) If after discussion with the Director of Nursing you feel your need has not been met, contact the Administrator within 36 hours. This document continues stating that if you are still not satisfied you are requested to reduce your complaint to writing, leaving copies for the Administrator and the Chairman of the(NAME)County Nursing Center Board no more than 10 days after the incident. On 01/30/18 at 3:15 PM, V1, Administrator, stated that the Facility's Grievance Policy has not been updated since she has been Administrator, which was 2012. She stated that V12, Social Service, has a grievance log, but it does not have any new inputs since 2016. She stated she was not aware of these new requirements and they need to update their policy. On 01/31/18, at 3:20 PM, V12 stated that she does not have any written grievances or written complaint investigations since 2016. In addition, she stated she does not have a complaint log which would outline complaint dates, subjects, resolutions and the like.

Based on interview and record review, the Facility failed to notify the physician of a missed dose of a prescribed medication for 1 of 10 residents (R4) reviewed for physician notification in the sample of 10. Findings include: R4's Nurse's Note, dated 11/17/16 at 3:15 PM, documents, in part, readmitted resident to room [ROOM NUMBER]-3 with a new dx (diagnosis) of left [MEDICAL CONDITION]. R4's written prescription dated 11/17/16 documents, [MEDICATION NAME] (a blood thinner) 40 MG (milligram) subcutaneous q (every) day X (times) 2 weeks. R4's Medication Administration Record [REDACTED]. This MAR indicated [REDACTED]. No documentation of a reason the dose was not given was provided. On 12/8/17 at 11:25 AM, E1 Administrator, stated, The physician should be notified if an important medication is not given or unavailable. The facility Policy on Contacting a Physician undated, does not address notifying the Physician for a medication error.

Based on observation, interview and record review the facility failed periodically reassess the use of restraints for or 1 of 2 residents (R1) reviewed for restraints in the sample of 10. Findings include: On 12/5/16 at 12:00 PM, R1 was sitting in her wheelchair in the dining room eating lunch. R1 has a seatbelt on and secured. Physical Restraint Reduction Assessment was last done on 2/4/16 and documents, Action Plan Occupational Therapy (OT) is going to trial resident in wheelchair with seatbelt. That would allow her to propel herself within facility. Safety belt is needed due to (R1) constantly moving when in chair and leaning forward. Balance is poor. R1's Nurse's Note, dated 2/16/16 at 10:45 AM, documented, Spoke with residents daughter, Power of Attorney (POA) regarding trial period for different wheelchair as attempt to increase resident safety. Daughter OK with trial period. States, 'If it causes her to become too upset may need to return to other chair.' There is no other documented consent from the POA regarding R1's safety belt in R1's medical record. Physicians Order Sheet (POS) dated 12/1/2016 to 12/31/2016 documents orders for, Wheelchair with seat belt and alarm to allow independence with wheelchair mobility when up. Seat belt is self release. On 12/7/16 at 10:25 AM, E12, Licensed Practical Nurse (LPN), when asked if R1 could release her seatbelt stated, It depends on her behaviors at the time. On 12/7/16 at 10:27 AM, E13, LPN, when asked if R1 could release her seatbelt stated, I don't know if she can. On 12/7/16 at 10:45 AM, E14, Certified Nurse's Aide (CNA), asked R1 to remove her seatbelt, R1 stated I don't want too. On 12/7/16 at 2:00 PM, E2, Director of Nurses (DON), asked R1 to remove her seatbelt, R1 stated I can but I am not going too. On 12/8/16 at 9:40 AM, E14, CNA asked R1 to remove her seatbelt, R1 felt the seatbelt and buckle, but was not able to release it. R1 stated, I think it is stuck. On 12/8/16 at 11:25 AM, E1, Administrator, stated We failed to see her seatbelt as a restraint, that is why the quarterly assessments were not done or the proper consent was not obtained. The facility RESTRAINT POLICY dated 11/26/16, documents, Restraints- any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Based on interviews and record review, the facility failed to adequately assess, monitor and seek treatment for [REDACTED]. This failure resulted in R4 developing septic shock from a perirectal abscess requiring surgery. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] indicates R4 was admitted to the facility on [DATE] with diagnoses, in part, non-insulin diabetes, [MEDICAL CONDITION] fib, and multiple falls. According to nurses noted dated 11/4/11 at 11am, "CNA (Certified Nurses Aide) noted/reported 5cm L (centimeters long) x 6cm W (Wide) hard area Lt (left) lower buttock c (with) 0.1cm diam (diameter) raised red bump. O (no) warmth or other redness noted. T. (temperature) 98.1 c/o (complained of) tenderness c palpatation - states also c sitting. communication sent to Dr." The next entry into the nurses notes is at 11:15am on 11/1/2011 when the Power of Attorney (POA) was notified and documentation that R4 has an appointment with the doctor on 11/8/11. There are no entries in the nurses notes that indicate the physician responded back. On 11/5/11 at 1700 (6pm), the nurses notes document R4 "had uncontrolled shaking all over. VS (Vital signs) are stable, BP (blood Pressure) 150/80. The note also documents R4 ate 50%of her dinner and then fell asleep. There is no documentation regarding the red area identified the day earlier on R4's buttock. At 2045 (8:45pm), the nurses notes documents her feeling warm with a temperature on 99.6. On 11/6/11 at 1am, her temperature was 98.7. The next entry is at 1800 (6pm) on 11/6/11 and documents "res (resident) shaking and c/o pain on L (left) buttock and anxiety. Temp in am was 99.1 and temp before supper was 100.5. Large lump still on buttox about 5 in (inch) and raised, warm + red." On 11/7/11 at 4am, R4 is documented as having a 100.2 temperature with the left buttock red, firm, and tender to touch. At 6:50am, the noted indicates an update was sent to R4's physician which included new measurements of hard/firm raised area on left buttock 12/7cm long x 7 cm wide area firm/red/warm tender to touch "no specific" head area, 1 cm purple area. Running low grade temp 99.6 at this time." The next entry is at 1530 (3:30pm) and documents R4's appetite poor, "sleepy all day, has dr appt tomorrow. Have examine butt area. no c/os voiced at this time." At 4pm, the nurses notes document R4's POA "came to writer stated res is down in her room moaning + I think she needs to be sent out to (hospital) for eval (evaluation) + tx (treatment). Writer went down to talk c res ask res if she wanted to go to hospital. Res said yes I need to get somewhere to get things taken care of so I get to feeling better." The note continues to document that the physician's office was called and told R4's POA wanted her sent to hospital. At 5:15pm, the physician responded with an order to send R4 out. Hospital History and Physical dated 11/7/11 indicate R4 was admitted to the hospital with [REDACTED]. Physical exam at the time documents R4 being somnolent and lethargic and appeared to have a inflamed buttock with a black area present. According to R4's POA Z1 on 1/5/12 at 2:45pm, she was told the physician did not respond to the original faxed communication on 11/4/11 when she came in on 11/7/11 and thought she needed to be seen right away. Z1 stated she had thought they had probably gotten an order for [REDACTED]. On 1/5/11 at 3:45pm, E5 Licensed Practical Nurse (LPN) provided Fax Transmittal Forms dated 11/4/11 and 11/7/11 which shows the physician being faxed with information but was unable to provide any information/documentation that the facility received any response from R4's physician. E5 stated they did not follow up with a call nor did they contact the medical director until the evening of 11/7/11 when R4's POA came in and insisted she be sent to the hospital. E5 stated they assumed R4 would be seen in the office on 11/8/11 anyway.

Based on record review and interview, the facility failed to implement fall interventions for 2 of 6 residents (R7, R8) reviewed for falls in the sample of 10. This failure resulted in R8 sustaining a left femoral fracture during self ambulation and R7 sustaining a left hip fracture during self transfer. Findings include: 1. R8's Incident Report, dated 12-8-11, documented R8 fell during self ambulation which resulted in a left femoral fracture. It was also noted R8 was admitted to a local hospital. R8's Nursing Notes, dated 10-11-11 to 12-8-11, documented repeated incidents of confusion., attempted self ambulation and complaints of urinary discomfort. R8's Urinalysis, dated 10-6-11, documented R8 was positive for a Urinary Tract Infection. E7, Licensed Practical Nurse (LPN), stated, on 1-5-12 at 12:50p.m., that R8 had been confused prior to her fall, required supervision and that R8 did not have safety awareness. E8, Physical Therapy, stated, on 1-5-12 at 1:30p.m., that R8 was confused prior to her fall and that she had unsafe judgement. R8's chart and Nursing Notes did not document the facility put in place fall preventive measurements or interventions to ensure R8's safety during R8's periods of confusion and self ambulation. It was also noted the facility did not document monitoring R8's complaints of urinary discomfort or urinary follow-up. R8's chart documented R8 was re-admitted to the facility on [DATE]. R8's Urinalysis, dated 12-22-11, documented R8 was positive for a Urinary Tract Infection. The facility did not provide a fall prevention program and interventions addressing R8's periods of confusion and ambulation needs prior to R8's 12-8-11 fall. The facility's Resident Accident/Incident Prevention Program, dated 2-24-11, documented all resident's are assessed upon admission and every 90 days thereafter or as he residents condition warrants for their risk of accident/incidents to occur. 2. R7's Minimum Data Set (MDS), dated [DATE], documented supervision with assistance of one person physical assistance with ambulation and toileting and impaired balance. R7's Incident Report, date 3-16-11, documented R7 was a cognitively impaired resident and observed on the floor after attempted self transfer and self toilteing. R7's Incident Repot, dated 4-6-11, documented R7 fell after self transfer. R7's Incident Report, dated 4-18-11, documented R7 was observed on the floor after attempted self transfer and self toileting. R7's Incident Report, dated 7-11-11, documented R7 received a laceration after attempting self transfer. R7's chart also documented he sustained a left hip fracture with his 7-11-11 fall. R7's Incident Report, dated 10-2-11, documented R7 fell after attempting self-transfer. The facility did not provide a fall prevention program and interventions addressing R7's repeated documented falls during self transfer prior to his 7-11-11 fall.