Every finding on record at Sunny Acres Nursing Home

Based on interview and record review the facility failed to notify a resident's family of a hospitalization for one (R1) of three residents reviewed for quality of care in the sample of four. Findings include:The Resident Care Policy and Procedure dated 4/2019 documents Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority the resident's representative(s) when there is (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility. Even when a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. The resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make any required decisions, but the resident must still be told what is happening to him or her.On 7/21/26 at 10:35 AM, V13 (R1's Family Member) stated that the facility did not call to report that R1 was going to the hospital. The hospital called V13 on 7/4/26 at 6:19 AM to request permission to treat R1.On 7/23/26 at 9:48 AM, V15 (Agency Registered Nurse/RN) stated that she was working on 7/4/26 when a Certified Nursing Assistant/CNA told V15 that R1 was complaining about his toe hurting. V15 went to check R1's toe. There was some of the bandage from the top of R1's foot that was tangled to R1's toenail. When V15 removed the bandage from the toenail V15 thought she saw some movement under R1's toenail. V15 looked closely and thought she saw some larva. V15 called V7 (R1's Primary Care Physician/PCP) and was told to send R1 to the hospital. V15 also stated that she did not call V13 (R1's Family Member) before sending R1 to the hospital.On 7/23/26 at 11:01 AM, V1 (Administrator) stated that V15 (Agency RN) should have called V13 (R1's Family Member) before R1 was sent to the hospital.R1's admission Record printed 7/22/26 at 9:52 AM, documents that R1 was admitted to the facility on [DATE].R1's Nursing Note written by V15 (Agency RN) dated 7/4/26 at 5:16 AM, documents that bug larvae were found inside R1's big toenail. V15 notified V7 (R1's PCP) and was given the order to send R1 to the hospital. R1 left the facility by ambulance at 5:15 AM.R1's Emergency Department Triage Note dated 7/4/26 at 5:52 AM, documents that R1 arrived at the hospital by ambulance from the facility with complaints of big toe pain.R1's Hospital Consultation Note dated 7/4/26 at 11:45 AM, documents that R1 was admitted to the hospital for a foot infection with maggots in the wound.

Based on interview and record review the facility failed to properly store medication for one (R2) of three residents reviewed for quality of care in the sample of four. Findings include:The Medication Administration policy dated 1/11/10 documents Objective: To provide accuracy during medication pass to assure quality of care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Procedure: 13. Make sure the resident takes the medication. Generally- Do not leave meds at bedside (may be exceptions after thorough assessment and care planning).On 7/20/26 at 4:52 PM, V8 (R2's Family Member) stated that R2's prescription eye drops have been left on R2's bedside several times. R2 is not able to self-administer the eye drops. V8 also stated that she has told Administration about the eye drops left at the bedside and the problem has not been corrected. V8 stated that she had filled out a grievance form and taken pictures of the bottle left sitting by the bed.On 7/21/26 at 8:45 AM, R2 was sitting in her room in her wheelchair watching television. R2 stated that she gets eye drops several times a day. R2 also stated that she cannot administer the drops herself.On 7/21/26 at 9:25 AM, V2 (Director of Nursing/DON) stated It was told to me that there were some eye drops that were left in (R2's) room. I got a grievance form about the eye drops and did education with the staff about not leaving the drops in the room.On 7/21/26 at 10:03 AM, V2 (DON) stated, I got an E (electronic)-mail from (V8 R2's Family Member) with a picture of the eye drops at (R2's) bedside.On 7/23/26 at 11:01 AM, V1 (Administrator) stated that medication including eye drops should not be left at the bedside. R2's admission Record printed 7/23/26 at 11:04 AM, documents that R2 was admitted to the facility on [DATE].R2's Order Summary Report documents, Systane Balance Ophthalmic Solution - Instill one drop in both eyes two times a day for dry eyes. Order date 11/13/24.An In-Service dated 6/29/26 presented by V2 (DON) documents Do not leave medications at bedside including pills, eye gtts (drops), powders, creams.R2's Complaint Form dated 7/5/26 reported by V8 (R2's Family Member) documents, On Sunday, July 5 at 3 (three) PM I visited (R2). (R2's) prescription eyedrops were on (R2's) table. This same situation has been reported to (V1 Administrator) previously on 5/27/26 by my (family member). Investigation: I (V2 DON) have not personally witnessed eye gtts on table in room but am aware they get forgotten in room at times. Findings: On-going education (with) staff. Signed by V2 DON dated 7/14/26. An E-mail sent to V2 (DON) by V8 (R2's Family Member) dated 7/6/26 at 8:21 AM, documents On Sunday, July 5 (2026), I visited (R2) at approximately 3 (three) PM. (R2's) prescription eyedrops were on (R2's) table. This same situation has been reported to (V1 Administrator), by my (family) on 5/27/26. Shouldn't these be on the medicine cart and administered by the nurse as prescribed? They could be cross contaminated or thrown away, etc. (etcetera). I left them on the table but took the picture to document the incident. I will follow up doing the grievance form, so the appropriate paper trail is followed according to protocol. (Attached was a picture of a bottle of eye drops on R2's bedside table.) An In-Service dated 7/14/26 presented by V2 (DON) documents Please, make sure all medications including eye gtts are placed back on med carts after use.

Based on interview and record review, the facility failed to ensure that an established fall intervention was functional and active, failed to keep an assistive device (wheelchair) within a high-risk resident's reach, and failed to investigate a fall incident to implement necessary preventive interventions for one of three residents (R1) reviewed for accidents in a sample of five. Findings include:The facility's fall Assessment and Management Policy, dated 6/2024, documents Policy: It is the policy of this facility to assess each resident's fall risk on admission, quarterly and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. Procedure: 1. Fall Risk and Planning Assessment: F. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk of injury or actual injury or fall. Some examples may be Falls related to gait/balance deficit, Falls related to confusion, Falls related to positioning problems, Falls related to toileting needs, Falls related to syncopal episodes, Falls related to environmental hazards, Falls related to sensory/perceptual problems, Falls related to poor judgment or knowledge deficit. 2. Resident Fall: A. Post fall assessment- immediately after fall: 3. Assessment parameters also may include: A description of how the resident was observed and circumstances surrounding the fall, such as what the resident was doing at the time (ambulating and tripped, going to the bathroom, etc. (etcetera), unusual signs or symptoms (syncope, weakness, etc.), environmental factors (wet floor, uneven surface etc.), first aid will be rendered when necessary, the physician will be notified immediately when an accident involving a resident resulting in injury and has the potential for requiring physician intervention, the responsible party will be notified promptly, point click care incident report is initiated within the shift that the fall occurred. C. Care Planning after a fall: 1. A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regard to future intervention, and resident specific risk factors.R1's admission Record documents R1 was a [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Parkinsons Disease, Cognitive Communication Deficit, Unspecified Abnormalities of Gait and Mobility, Chronic Kidney Disease (stage 4), Arteritis, Hyperlipidemia, Anxiety Disorder, Dementia, Major Depressive Disorder, and Age-Related Osteoporosis. This same admission Record documents R1 expired on [DATE].R1's Morse Fall Scale Assessment, dated [DATE] and [DATE], documents R1 is at high risk for falls.R1's Care Plan documents (R1) is at risk for falls and has history of falling due to unsteady gait. (R1) has Parkinson's disease, Osteoporosis, Hypertension and uses antidepressant medication which could increase fall risks. (R1) has safety awareness deficits and often tries to transfer or ambulate without assistance. Poor use of call light. This same Fall Care Plan documents the following fall interventions: Start date: [DATE]- tab alarm on at all times.R1's Fall Incident Report, dated [DATE], documents (V13/Agency LPN's) Nursing Description: (R1) had an unwitnessed fall on Lily Lane hallway. (R1) was found face down on the ground with blood pouring from (R1's) right side of her forehead. (R1) was in her wheelchair when the incident happened. This same Report documents (R1) was transported to the local hospital.The IDT (Inter-disciplinary Team) Note for New Falls, un-dated, documents New Falls: (R1), date-[DATE], time-5:30 PM, injury-yes, hospital-yes, summary-found face down/bleeding; alarm not attached- implement chair/bed pad alarm.The facility's Report to Illinois Department of Public Health, dated [DATE], documents R1 noted to have an unwitnessed fall on [DATE] at 4:20 PM that resulted in R1 hitting her head and being sent to the local (ED) Emergency Department. This same report documents a CT (Computed-Tomography) obtained in the ED and noted results that showed a small right frontal scalp hematoma.R1's ED (Emergency Department) Note, dated [DATE], documents History of Present Illness: (R1) presents following fall. The onset was just prior to arrival. The occurrence was single episode. The location where the incident occurred was at a local nursing home. Brought to ED by EMS (Emergency Medical Services) after fall at nursing home. The nursing home reported (R1) was in a wheelchair and (unknown) nurse was facing the other direction and then (R1) was on the floor. Reports that (R1) was at her baseline prior to the fall and after. (R1) has an abrasion on (R1's) right forehead with some underlying swelling and ecchymosis. (R1) was already in a (cervical collar) because of recent fall in February and at that time was diagnosed with cervical fracture. EMS reports (R1) were on the floor on the arrival. They placed (R1) on a stretcher and transported. (R1) is awake and alert. (R1) has history of dementia, per EMS is at her baseline. (R1) does not recall falling. (R1) says she has some forehead pain.R1's CT scan, dated [DATE], documents Reason for Exam fall: Right forehead abrasion/swelling, recent cervical fracture, low back pain. History: (R1) presents with abrasion and swelling to right forehead after a fall today, hit head. Impression: Small Right Scalp Hematoma.R1's Progress Note, dated [DATE] and signed by V15/Agency LPN (Licensed Practical Nurse), documents (V22/Agency CNA/Certified Nursing Assistant) called for (V15) and stated (R1) was on the floor. Upon entering the room (R1) was observed on the floor with walker in front of her in between the chair and the bathroom laying on (R1's) right side. This same Progress Note document, R1, was sent to the local ED due to R1's complaints of pain and hitting her head.R1's ED Note, dated [DATE], documents History of Present Illness: [AGE] year-old female (R1) presents to emergency department today from local nursing home via EMS for suspected ground level mechanical fall, although fall was ultimately unwitnessed. Majority of history is provided by (R1), EMS and (V7/R1's Family Member). (V7) tells me that (R1) has dementia and weakness at baseline, (R1) typically moves around the facility with wheelchair. (V7) overheard nursing staff say today that (R1) was trying to ambulate with walker, (R1) was found on the floor when trying to use the restroom once they heard (R1) calling out.The IDT Note for New Falls, un-dated, documents New Falls: (R1), date [DATE]- hospital-yes, summary: on floor with walker between bed and bathroom. Interventions: alarm?; wheelchair?.R1's medical records did not reveal a fall investigation including determining a root cause nor an updated care plan fall intervention for R1's fall on [DATE]. R1's Care Plan does not include a fall intervention for R1's fall on [DATE].On [DATE] at 3:02 PM V2/DON (Director of Nursing) stated that the responsible nurse must complete risk management forms immediately following any resident fall. V2 reported these forms capture crucial data, including fall details, the residents' account of the incident, predisposing factors, notifications made, assessments, and immediate interventions. V2 verified that no fall investigation, root-cause analysis, or post-fall intervention was conducted or added to the care plan for R1 following their fall on [DATE] and should have been.On [DATE] at 12:31 PM V13/Agency RN (Registered Nurse) stated, When (R1) fell on [DATE], (R1) was lying in the hallway, with a bleeding wound to top right side of (R1's) head. (R1) was complaining of pain at that time. I sent (R1) out to the hospital at that time.On [DATE] at 2:06 PM V15/Agency LPN stated, On [DATE], Agency CNA (V22) came and notified me that (R1) was on the floor in her room. I went to (R1's) room immediately. When I arrived, I found (R1) on the floor in the space between chair and the bathroom, with a walker sitting right beside (R1). I observed that (R1's) wheelchair was out in the hallway, which it should not have been. It should have been kept inside her room if she attempted to self-transfer. (R1's) walker should never have been left in her room at all, so I took it out. I assessed (R1) and did not see any visible injuries. However, (R1) told me that she was experiencing left shoulder pain. Because of (R1's) history of past injuries, I decided to send (R1) out to the hospital to be evaluated. V15 verified that a facility risk watch or fall paperwork was not filled out related to R1's fall on [DATE]. V15 stated, I don't know if I even have user access to the facility's Risk Watch to document the investigation regarding the fall.On [DATE] at 2:29 PM, V7/R1's family member reported that R1 fell in the hallway on [DATE]. V7 stated, (V12/RN) reported that (R1's) tab alarm, used for fall prevention, failed to sound during the incident. (R1's) alarm not sounding was part of an ongoing issue with malfunctioning alarms, or (R1's) alarm would not be placed on (R1) which the facility repeatedly promised to fix but failed to do. When (R1) fell on [DATE], Agency CNA (V22) told me when I got to the facility that (R1)'s wheelchair was left out in the hallway and a walker was in (R1's) room. When (R1) got up she was looking for her wheelchair and ended up walking across the room to get the walker and fell. (R1) should not have had a walker in her room, that was only when she was working with therapy. If (R1) had the wheelchair in her room, it could have prevented her fall.On [DATE] at 4:37 PM V16/Agency RN stated, 'I witnessed (R1) fall in the hallway on [DATE]. I observed (R1's) head was bleeding and that (R1's) tab alarm was not sounding. I do not know why (R1's) fall alarm was not going off and I did not assess the alarm device.On [DATE] at 10:29 AM V12/RN stated, I was in the hallway when (R1) had her fall after leaving the dining room. I think (R1) was looking for her old room. I was one of the first staff to see (R1) in the hallway after (R1) had fallen. (R1's) tab alarm was not sounding at the time of (R1's) fall.On [DATE] at 9:02 AM, V1/Administrator in Training stated that R1 experienced a fall with injury on [DATE]. V1 explained that R1 was wearing a pull-tab alarm at the time, but the clip detached from the resident's shirt during the fall. As a result, the magnet remained attached to the unit, and the alarm failed to sound. V1 noted that previous attempts to shorten the string had failed to resolve the issue, prompting the facility to switch R1 to a pressure pad alarm. Furthermore, V1 confirmed that no formal investigation or root-cause analysis was conducted following R1's subsequent fall on [DATE]. V1 stated, I know we talked about it in morning meeting, but not sure why it was not investigated to determine what happened and why an intervention wasn't put in place. V1 verified that no new interventions were added to R1's care plan following the [DATE] fall.On [DATE] at 11:20 AM V20/Certified Occupation Therapist Assistant reported having frequent interactions with R1 during their therapy sessions in March and [DATE]. V20 clarified that R1's wheelchair should have been kept inside the room whenever R1 was in bed or in the recliner, rather than left in the hallway. Conversely, the walker should not have been stored in the room, as it was strictly designated for restorative ambulation supervised by staff. V20 noted that having the wheelchair positioned beside R1, instead of requiring R1 to attempt unassisted ambulation across the room to reach the walker, could have prevented the fall during a self-transfer attempt.

A.Based on observation, interview, and record review, the facility failed to ensure wound treatments were completed as ordered, appropriate infection control practices were followed during wound care, a readmission assessment was completed, physician ordered pressure relieving interventions were implemented, and worsening wound conditions were monitored and reported to the physician for one (R66) of six residents reviewed for wound care in the sample list of 32. This failure resulted in worsening wound conditions with development of osteomyelitis to R66's right foot requiring hospitalization, surgical debridement, and intravenous antibiotic therapy B. Based on observation, interview and record review the Facility failed to follow physician orders and monitor a resident's blood sugar for one of 18 Residents reviewed for following physician orders (R33) and failed to communicate a resident's change of condition with a physician office for one of 18 Residents reviewed for physician communication (R50) in a sample of 32.Findings include: A) The facility's Wound and Ulcer Policy and Procedure revised 3/28/24 documents residents will receive wound assessments upon admission, weekly for four weeks, quarterly, and with any significant change in condition. Licensed nurses are responsible for wound assessment, initiation of ordered treatments, documentation of care, and physician notification of changes in condition. R66's Hospital Discharge Orders dated 3/18/26 document an order for negative pressure wound therapy (Wound Vac) to R66's right foot at 125 mmHg (millimeters of mercury) continuously with dressing changes every Monday, Wednesday, and Friday. R66's Nurse Progress Note dated 3/19/26 documents R66 was admitted to the facility on [DATE] with a negative pressure therapy (wound vac) device to the right great toe amputation site. This note further documents the surgical site to R66's right foot was approximately five centimeters (cm) deep with black tissue and granulation tissue present. R66's Nurse Progress Note dated 3/25/26 at 12:34 AM, documents that R66's wound vac remained in place with intermittent suction noted and spots of dried sanguineous drainage present in the tubing. Documentation further noted redness surrounding the wound site. The note indicated nursing would continue to monitor the resident. There is no documentation in R66's medical record that R66's physician was notified of the change in R66's wound. R66's Nurse Progress Note dated 3/25/26 documents R66's wound vac dressing change scheduled for that date was unable to be completed and was reported off to the next shift nurse. R66's electronic medical record does not contain documentation that this treatment was completed or that R66's physician was notified that the treatment was not completed. R66's Census line documents R66 was transferred out of the facility on 4/3/26 to the hospital and readmitted to the facility from the hospital on 4/22/26. R66's Hospital Records dated 4/3/26 documents R66 presented to the emergency room from a wound clinic appointment with yellow and green drainage surrounding the right great toe amputation site and black eschar (dead tissue) present in the wound bed. Blood cultures were obtained due to suspected osteomyelitis. R66's Hospital Records documents on 4/5/26 blood cultures confirmed osteomyelitis to right foot. R66 started on intravenous antibiotics in the hospital for treatment of infection. R66s Physician Orders dated 4/24/26, documents an order for Metronidazole 500 milligrams (mg) by mouth twice daily for osteomyelitis through 5/28/26. R66s Physician Orders dated 5/1/26, documents an order for Daptomycin 400 mg intravenously every 24 hours for treatment of osteomyelitis through 5/30/26. R66s Physician Orders dated 5/10/26, documents an order for Cefepime two grams intravenously twice daily for osteomyelitis of the left calcaneus through 5/30/26. R66's electronic medical record revealed no documented readmission assessment or a skin assessment on 4/22/26 following R66's return from hospitalization. R66's Minimum Data Set (MDS) assessment dated [DATE] documents R66 is cognitively intact and is dependent on staff for transfers, bathing and needs substantial/maximum assistance with toileting. R66s current care plan documents 4/30/26, an order for placement of an air overlay mattress to help decrease pressure risks. On 5/18/26 at 9:16 AM, observation of R66's bed revealed the ordered low air loss mattress overlay was not in place on R66's bed. On 5/18/26 at 11:45 AM, R66 was sitting in his wheelchair in his room with a large undated bandage on R66's right leg. Observation revealed the bandage did not cover the entire wound area to the inner calf and approximately four inches of dried black scabbed area was left uncovered. R66 stated he was unsure when the bandage had last been changed. R66 stated nursing staff often did not complete treatments to his right leg and foot because staff did not have time or agency nurses were unfamiliar with his care. R66 stated he wanted to improve so he could return home, however that had not occurred. R66 further stated the care in the facility was not great and residents were not always cared for appropriately. On 5/18/26 at 12:12 PM, V11 (Licensed Practical Nurse/LPN) stated R66 came to the facility after toe amputations with a wound vac to the right foot and the wound vac was not being changed correctly, resulting in worsening of the wound. V11 stated the resident was sent to the wound clinic and subsequently transferred to the hospital due to worsening wound condition and returned with a surgical incision to the leg following surgical debridement. On 5/18/26 at 1:00 PM, V11 (LPN) performed wound treatment to R66's leg without applying appropriate personal protective equipment (PPE). Observation further revealed V10 (Certified Nursing Assistant/CNA) and V11 transferred R66 utilizing a mechanical lift from wheelchair to bed without use of isolation gown despite Enhanced Barrier Precaution signage posted on R66's door. V11 and V10 did not perform hand hygiene before or after wound care and resident contact. R66's wound dressing revealed Xeroform dressing (medicated gauze dressing used to keep wound bed moist) was not applied to the entire wound area as ordered. Black eschar was observed extending from the lower extremity above and below the knee. V11 stated the dressing removed from the wound was not dated and she was unable to determine when the dressing had last been changed. On 5/20/26 at 10:00 AM, V2 (Director of Nursing) stated a readmission assessment should have been completed upon R66's return to the facility. V2 further stated weekly wound assessments should have been completed when R66 originally admitted to the facility on [DATE] and R66's Physician should have been notified of any changes to R66's surgical wound. V2 confirmed there was no further documented skin assessments for R66 after 3/19/25 until the R66 was sent to the hospital on 4/3/26 for wound infection and osteomyelitis. On 5/20/26 at 9:15 AM, V24 (Medical Director) stated R66's dressing should have been changed as ordered and the physician should have been notified when the wound appeared to worsen. B) 1. The Facility Care Policy and Procedure, revised 8/2024, documents blood glucose levels will be monitored and obtained per licensed health care practitioner's orders and will be performed by a licensed nurse. The Facility Registered Nurse Job Description, revised 7/1/25, documents: prepare and administer medications and treatments; maintain charts; and responsible for nursing care of assigned residents. R33's Medication Administration Record/MAR, dated 5/1/26 through 5/31/26, documents a physician's order for a blood glucose monitoring test and sliding scale insulin injection to be performed prior to mealtime, every day at 6:00 am. The MAR does not document V15's blood glucose test result (215) that V31 (Agency Registered Nurse) performed. On 5/18/26 at 8:58 am, V31 (Agency Registered Nurse) entered R33's room and performed R33's 6:00 am scheduled blood glucose monitoring test. V31 stated, (R33) just got back from breakfast. I am the night shift nurse, and I am so far behind on my medication pass, I know (R33) already ate but I must get this test done. On 5/19/26 at 10:40 am, V1 (Administrator) stated, Our agency staff gets training on our policies, but any nurse should know how to perform basic nursing duties and not do blood sugar monitoring right after someone eats, they should be done prior to eating. 2. The Facility Guidelines for Physician Notification of Change in Resident Condition Policy, revised 4/2019, documents: to define resident care situations that require physician notification; staff observe, document and communicate to the physician changes in resident condition properly; change in condition includes accidents or occurrences; physician notification is based on the Physician Notification Protocols from the American Medical Directors Association on Assessing and Collecting Data on Nursing Facility Patients; a facility must consult with the resident's physician; and the facility must ensure that all pertinent information is available and provided upon request to the physician. The Facility Registered Nurse Job Description, revised 7/1/25, documents responsible for nursing care of assigned residents; transcribe physicians orders; and personally receive or place phone calls to physicians. R50's admission Record/Resident Information Sheet, dated 5/20/26, documents V29 (Attending Physician) as R50's primary doctor. R50's Nursing Notes, dated 4/20/26, documents R50 went to doctor appointment accompanied by family, no new orders received from visit. On 5/28/26 at 10:43 am, V32 (R50s daughter/emergency contact) stated, On 4/20/26, I had to take my mom (R50) to a doctor appointment because (R50) had fallen. (R50) is not seen by the Facility doctor because we take (R50) to her general practitioner (V29). (V29) recommended some wheelchair modifications to the arms on her wheelchair because she had fallen out of the wheelchair and we thought it would be safer for her to have higher arms on it. I have had phone calls with (V29's) office because they keep telling me that they cannot get through to the Facility. They have called the Facility multiple times, and no one answers, and they have also left messages, but no one has returned the phone calls. They (V29) is trying to get new orders called in for (R50). On 5/20/26 at 11:22 am, V29 (R50's Attending Physician stated), We have made so many attempts to get ahold of someone at the Facility. When we call, the phone rings for eight to ten minutes and no one answers it. When we have gotten through and left messages (with V1/Administrator and V2/Director of Nursing), no one returns our phone calls. I started getting frustrated, so I started documenting all of our attempts to contact that Facility. We are working on getting higher arms on (R50's) wheelchair because (R50) has fallen out of the wheelchair, but no one from the Facility is contacting us. On 5/20/26 at10:05 am, V1 (Administrator) stated, Our phone system does allow for messages to be left directly in management in boxes. I am not sure why the phone calls are not getting answered or returned. I do know that we have had a change in management and maybe the calls got lost in that transition. We do need to work on a better phone answering system.

Based on interview and record review, the facility failed to properly dispose of controlled substances for five residents (R1, R5, R6, R7, and R9) who were reviewed for improper disposal of controlled substances in a sample of nine. Findings Include:The facility's Controlled Drug Handling, Reconciling, Count Discrepancy, & Disposal Policy and Procedure dated 5/30/2017 documents, it is the policy of the facility that controlled medications be counted by nurses between shifts and/or whenever there is a change in nurses. This count is to ensure the correctness of the count of the controlled medication and appropriate documentation. Each controlled medication received from pharmacy will be counted, and a count sheet initiated by a nurse. The individual controlled drug record and the between shift count sheets will be kept on each medication cart. Disposal Procedure, 3. C (class)II (two)-CV (four) controlled drugs shall be destroyed by two licensed staff of the facility. 4. Records shall be kept of all the medications destroyed stating the following information: name of medication, strength and quantity destroyed, name of patient, prescription number, and both signatures and dates destroyed.R1's Controlled Drug Receipt Record/Disposition form dated 2/7/2026 documents R1 has an order for Morphine Sulphate IR 30mg (milligrams) tabs, one tab PO (oral) every six hours. This same document shows that on 2/10/2026, V3 (Registered Nurse/Agency) documented dropped/wasted, and on 2/19/2026, V3 documents dropped/wasted.R5's Controlled Drug Receipt Record/Disposition form dated 2/5/2026 documents R5 has an order for Lorazepam 0.5 mg (milligram) tabs, one tablet PO BID (twice daily). This same document shows on 2/11/2026 that V3 documents dropped.R6's Controlled Drug Receipt Record/Disposition form dated 2/9/2026 documents R6 has an order for Oxycodone/APAP (with acetaminophen) 5/325, one tablet PO every eight hours. This same document shows on 2/10/2026 V3 documented dropped/wasted, and on 2/17/2026 V3 documented dropped/wasted.R7's Controlled Drug Receipt Record/Disposition form dated 2/8/2026 documents R7 has an order for Hydrocodone/APAP tablet 5-325 mg (milligram), one tablet PO every six hours as needed. This same document shows on 2/23/2026, V11 (Unknown Nurse) documented dropped.R9's Controlled Drug Receipt Record/Disposition form dated 2/3/2026 documents R9 has an order for Hydrocodone/APAP 7.5/325 mg tablet, one tablet PO 5x(times) daily. This same document shows no date, no time, and no nurse signature with one pill taken.On 3/26/2026 at 2 PM, V1 (Administrator) stated she was aware of the multiple controlled drug records with nursing staff not properly discarding medications after doing a house audit when V3 (Registered Nurse/Agency) called her on 2/26/2026 about medications being packed wrong. Once she saw this, she realized the discarding of controlled substances was not a one-time occurrence. V1 confirmed that nursing staff were not discarding controlled substances correctly.

Based on observation, interview, and record review, the facility failed to ensure the narcotic count was correct by maintaining the accurate reconciliation and accounting of a controlled substance for one (R3) of nine residents reviewed for improper disposal of controlled substances in a sample of nine. Findings include:The facility's Controlled Drug Handling, Reconciling, Count Discrepancy, & Disposal Policy and Procedure dated 5/30/2017 documents, It is the policy of the facility that controlled medications be counted by nurses between shifts and/or whenever there is a change in nurses. This count is to ensure the correctness of the count of the controlled medication and appropriate documentation. Each controlled medication received from pharmacy will be counted and a count sheet initiated by a nurse. The individual controlled drug record and the between shift count sheets will be kept on each medication cart. Records 3. All shortages/and or overages shall be reported to the Director of Nursing and the Pharmacist on call immediately. Note, the nurse accepting the initial delivery of a C (class) II (two) substance is responsible for making this record and counting the doses received.R3's Controlled Drug Receipt Record/Disposition Form dated 1/2/2026 documents R3 has an order for Lorazepam (benzodiazepine) concentrate 2mg (milligrams) per mL (milliliter) 0.5 cc (cubic centimeters) (1mg) PO (by mouth) every 2 hours as needed. This same document shows that R3 has 2 ml left on 3/26/2026.On 3/25/2026 at 1:10 PM, R3's Lorazepam concentrate 2mg/mL bottle had 12mL in the bottle. V5 (Registered Nurse) confirmed.On 3/25/2026 at 1:10 PM, V5 stated: I just keep deducting from the bottle based on the sheet, even though the bottle shows far more than 2mL left in the bottle.On 3/26/2026 at 2 PM, V1 (Administrator) confirmed R3's Lorazepam concentrate was over by far too much, and the nursing staff kept signing off on the controlled drug record even though the amount in the bottle was far more than what was being recorded.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent verbal and physical resident-to-resident abuse for two of four residents (R1 and R2) reviewed for abuse in the sample of seven. These findings resulted in R1 physically assaulting R2 causing R2 pain, a laceration to the left cheek, and two large hematomas to the bilateral shins which required emergency room services.Findings include:The facility's Abuse Prohibition Policy, dated 1/29/2026, documents Abuse and Neglect Prohibited: 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Physical Abuse means the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse may include, but it is not limited to such acts as hitting, slapping, kicking, hair pulling, and pinching. Verbal Abuse means the use of oral, written, or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend, or disability. R1's admission Record documents R1 is an [AGE] year-old admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Agitation, Major Depressive Disorder, and Anxiety Disorder.R1's MDS (Minimum Data Set) Assessment documents R1 is moderately cognitively impaired and has behaviors every one to three days.R1's current Care Plan documents R1 has behaviors of yelling out, being demanding, making inappropriate sexual comments, touching on staff, and most recently (2/13/26) having physical behavioral symptoms.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Cardiomyopathy, Aortic Aneurysm, Hypertensive Heart Disease with Heart Failures, and Idiopathic Peripheral Autonomic Neuropathy.R2's MDS assessment dated [DATE] documents R2 is cognitively intact and self-propels in a wheelchair.R1 and R2's Final Abuse Report dated 2/12/26 and signed by V1 (Administrator-In-Training) documents that on 2/7/26 at 8:45 PM R1 and R2 had a verbal altercation while in the bathroom that turned into a physical altercation when R1 hit R2 in the face and R1's walker hit R2's leg. This same Abuse Report documents R2 was sent to the hospital for treatment of left cheek abrasion and lower leg bruising.R1's Progress Notes dated 2/7/26 at 10:22 PM document R1 had a physical altercation with another resident (R2).R2's Emergency Department Notes dated 2/7/25 at 8:30 PM document, Chief Complaint: (R2) arrives via EMS (Emergency Medical Services) from (the facility) for assault by another resident (R1). (R2) arrives with abrasion to left side of face and bilateral hematomas to shins from being hit with (R1's) walker multiple times. (R2) punched in head then struck by walker in shins. Left temporal pain and Tramadol 50 mg (milligrams) administered for pain.R1 and R2's Police Report dated 2/7/26 and signed by V4 (Police Officer) documents, Offense: Battery. Offender: (R1). On 2/7/26 (V4) was dispatched to (the facility) for a battery report. The incident took place at (the facility). I spoke to (V7/RN/Registered Nurse). (V7) explained that (R2) and (R1) had gotten into a verbal and physical altercation inside the common bathroom (R2) and (R1) shared. (V7) said both (R2) and (R1) are separated now. (V7) stated that (R2) needed to go to the hospital to get his injuries checked after I was done speaking with (R2). (V7) briefly explained the situation to me, stating that both (R1) and (R2) were arguing and (R1) struck (R2) in the face with (R1's) fists and struck (R2) in the face several times, and hit (R2) with (R1's) walker. (R2) was unable to provide a written statement and wanted to go to the hospital to be checked out. I requested dispatch to send EMS to my location for transport to (ED/Emergency Department). I took photographs of the injuries too (R2). I then went to speak to (R1) inside (R1's) room. I asked (R1) what happened tonight. (R1) stated that he beat (R2) up because (R2) had called (R1) a Son of a bi**h. (R1) stated that he hit (R2) several times and may have hit (R2) with the walker. I photographed (R1's) hands and (R1's) right hand did appear to possibly have some bruising and (R1) stated it hurt. I asked (V7) if any staff witnessed the incident. (V7) stated (Certified Nursing Assistant/CNA/V3) did. (V3's) statement is attached to the report.The Police Report Photos printed 2/9/26 were observed. In the photos R2 had a laceration to the left upper cheek and a softball sized, dark purple hematoma to the right lower leg, and R1 had reddish discoloration to the top of his right hand and end of his right fingers.On 2/27/26 at 9:30 AM R2 was sitting in his room in a wheelchair. R2 had a 2-inch by 2-inch dressing with brownish drainage covering an open area to the top of the left shin. R2 had a baseball sized dark red hematoma to the right shin. R2 stated, Several weeks ago I had a friend visiting me and (R1) was in the bathroom singing a song repeatedly, It's bare a** time. What (R1) was singing was embarrassing and (R1) does it just to aggravate me. I went into the bathroom and told (R1), Shut the h**l up you son of a bi**h! (R1) took his walker and slammed it into my legs over and over and when I grabbed ahold of the walker to get (R1) to stop, (R1) started to punch me in the face. Both of my shins are really swollen and sore and my cheek got busted open. It hurt really badly, and I asked to go to the hospital to make sure my cheek wasn't broken. I definitely felt abused and should not have to deal with (R1). My shins are still swollen and are painful every day.On 2/27/26 at 2:12 PM V3 (CNA) stated, On 2/7/26 around 8:30 at night I heard someone yelling help. I went into (R2's) room and (R2) was in the doorway of the bathroom and (R1) was in the bathroom. I saw (R1) punching (R2) in the chin with closed fists. I yelled at (R1) to stop, and (R1) had ahold of (R2's) wheelchair. I removed (R1's) hands from (R2's) wheelchair and separated (R1) and (R2). (R2) had a bloody mouth and a soft-ball sized bruise to the right shin. (R2's) left cheek was busted open. (R2) told me that (R1) was singing its bare a** time, so (R2) yelled at (R1) and called (R1) a son of a bi**h. (R2) stated (R1) hit him multiple times in the face and hitting (R2) in the shins with (R1's) walker. (R2) was hurting and wanted to go to the hospital.

Based on record review, interview the facility failed to follow all fall management safety protocols by manually lifting a resident from the floor after a fall and transferring them to a wheelchair without utilizing a mechanical lift for one (R1) of three residents reviewed for falls in the total sample of 11.Findings include:R1's medical record documents R1 was a [AGE] year old admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes, Hypertensive Heart Disease with Heart Failure, Bradycardia; Atherosclerotic Heart Disease of Coronary Arteries and Anemia. R1's diagnoses include a recent diagnosis dated 10/21/25 of Non-displaced fracture of the greater trochanter of the Left Femur, Closed Fracture with Routine Healing.Facility record reviews included the following: admission packet; Fall Assessment and Management policy dated 6/2024 and the Reports to the state agency by the facility dated 10/21/25. Other facility records reviewed included the past 3 months of: Facility Staffing data, Direct Care Staff Schedules, Daily Staffing Assignments and postings; Resident Council Meeting Minutes; Resident Shower Sheets, Grievance Logs, Incident Logs and Falls logs.Resident records were reviewed for Physicians Orders; Care Plans; MDSs/Minimum Data Sets; Progress Notes; and Fall Risk Assessments.R1's Progress Notes dated 10/21/25 by V10 prior DON/Director of Nursing documents the following: Unwitnessed fall in (R1's) room on 10/20/25 at 10:15am. The initial Report to the state agency dated 10/21/25 by V10 the facility's prior DON, (no longer employed by the facility), documents R1's fall occurred at 10:15am on 10/20/25. R1 was assessed by the nurse on duty (V4 RN/Registered Nurse) at that time, and R1 denied having any pain. At that time V4 and V5 (CNA-Certified Nursing Assistant) assisted (R1) off the ground and into his wheelchair.V1/Administrator provided V4 and V5's employee records and including Disciplinary Action forms for improper resident transfer after a fall dated, respectively, 10/29/25 and 10/27/25. On 12/16/25 at approximately 11:25am V1 stated V4 and V5 improperly transferred R1 from the floor after R1's fall and should have utilized a mechanical lift to safely transfer R1. V4 and V5 received written disciplinary actions identifying and addressing the improper transfer of R1 from the floor into a wheelchair without utilizing a mechanical lift. V1 stated V4 and V5 lifted R1 off the floor with their arms under R1's arms on either side of R1. V4 RN was no longer employed by the facility and was unavailable for comment.On 12/17/25 at 12:20pm V5 stated she and V4 did not use a mechanical lift as directed by facility policy to transfer the resident after a fall.On 12/17/25 at approximately 2:45pm, V2 DON verified fall management protocol calls for the use of a mechanical lift to safely lift residents after a fall.

Based on observation, interview and record review the facility failed to follow infection control standards for Enhanced Barrier Precautions during wound cares for two of three residents (R4, R5) reviewed for wound care in the total sample of 14 residents.Findings include:The facility's undated Enhanced Barrier Precautions Protocol documents: Enhanced Barrier Precautions are indicated for residents with the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO (Multi-Drug-Resistant Organisms).The facility was unable to provide a wound care policy outlining Standard Precautions to be followed when providing wound care. Published and accepted Standard Precautions guidelines document: Always work on a disinfected surface; For opened dressing supplies, standard precautions mean discarding unused portions of dressing supplies, or retain them in a clean sealed bag (if non-sterile) in a clean, dry area in the residents room avoiding the bathroom, and Never reuse dressings or supplies after they've been opened; Never return opened items to supply carts.R4 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including: Malignant Neoplasm of the Tongue; Cerebral Vascular Accident with Right-sided hemiparesis and Hemiplegia; Dysphagia; Severe Protein-Calorie Malnutrition and Aphasia. R4 has an indwelling enteral feeding device in use.R4's Physicians Orders for wound care documents the following: Cleanse left neck with normal saline and gauze, apply skin prep to perimeter; pack with iodoform ensuring to leave a wick; gauze and medipore tape every day and evening shift.A sign declaring R4 was in Enhanced Barrier Precautions and identifying infection control measures and PPE/Personal Protective Equipment required when providing certain cares to the resident including wound care visible on R4's room door frame.On 12/17/25 at 12:35pm V12 LPN/Licensed Practical Nurse performed wound care for R4's left neck wound. V12 gathered wound care supplies, donned personal protective equipment and entered R4's room. V12 removed the neck dressing and packing. V12 cleansed the wound and applied skin prep to the intact skin around the wound. V12 then realized she had no scissors to cut the packing gauze and asked another staff member to bring a pair to the room. V12 received the bandage scissors without cleansing them and cut a length of packing gauze, packed the wound and placed the bandage scissors in her pocket. V12 then tore a piece of medipore tape and covered the wound with no gauze over the wound. Later, when asked if gauze was needed over the wound, V12 removed the tape and placed gauze over the wound and covered it with a new piece of medipore tape.V12 did not sanitize/cleanse the bandage scissors before or after using them for R4's wound care.2. R5 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including: Left-sided Hemiplegia; Cerebral Infarction with resulting Aphasia; Type 2 Diabetes. R5 also has an indwelling enteral feeding device in use.The facility's Wound Care Report dated 12/15/25 includes the following order for R5's wound care treatment: Cleanse left lateral thigh with wound cleanser and pat dry. Silver Silvadene (a medicated cream), cover with telfa (a non-stick dressing) and Kerlix (a roll of fluffy gauze). On 12/17/25 at 1:20pm V13 LPN performed wound care for R5's left thigh burn site with subsequent skin grafting. V13 gathered R5's wound care supplies including wound cleanser, a pack of 4 by 4 gauze pads, A sealed multi-pack of large absorbent dressings, and tape. V13 then donned appropriate PPE/Personal Protective Equipment and entered R5's room. V13 placed the wound care supplies directly onto R5's overbed table without sanitizing it or placing a clean barrier on the surface of the table prior to setting down the wound supplies on it. V13 removed R5's dressing, cleansed the wound with wound cleanser. R5's left thigh wound measured approximately 5 inches by 7 inches with scattered fluid-filled blisters noted on an otherwise pink granulating wound base. V13 patted the wound dry with gauze, applied a white medicated cream to the wound. V13 opened the roll of gauze and placed the roll directly onto the surface of the overbed table and opened the multi-pack of absorbent dressing and removed one, placing it over R5's wound. V13 picked up the large gauze roll and wrapped it around R5's thigh, securing the dressing. V13 then gathered the remaining portion of the open roll of gauze and the unsealed, open pack of absorbent dressings and carried them out of R5's room, stating I usually put a towel down to put the supplies on. V13 then placed the opened gauze roll and absorbent dressings in a drawer on the multi-use wound cart with other dressing supplies. V13 stated the partially used roll of gauze and opened multi-pack of dressings were stock items and would be used for other resident's wound cares. On 12/17/25 at approximately 3:00pm, V2 Interim DON/Director of Nursing verified V12 and V13 did not follow standard precautions for wound care or infection control measures during R4 and R5's wound care.

Based on interview and record review, the facility failed to follow its hot liquids policy; failed to identify potential hazards relating to hot liquids; and failed to provide staff supervision to prevent hot liquid incident/accident for one (R1) resident of three residents reviewed for accidents/incidents in a sample of three. This failure resulted in R1 sustaining blisters from the spilled hot liquid. Findings include: The facility's (State) Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, dated 11/28/18 documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and, Your facility must provide services to keep your physical and mental health, at their highest practical levels. The facility's Hot Liquids Policy dated 3/7/25 documents: It is the policy of this facility to maintain protocols to assist in preventing injuries related to hot liquids and develop an individualized plan of care to address resident risk. 1. A Hot Beverage Use Assessment will be performed upon admission, quarterly and with a significant change in condition. 4. Residents identified through the assessment process as at risk for injury related to exposure to hot liquids shall not be left unsupervised during meal service. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 7. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R1's diagnoses include: Major depressive disorder, anxiety, chronic pulmonary embolism, repeated falls, chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity, hallucinations, peripheral vascular disease, dementia with other behavioral disturbance, unspecified lack of coordination. R1's current Care Plan documents: (R1) is at risk for impaired cognitive function or impaired thought processes related to dementia. R1's Final Report to (State) Department of Public Health dated 8/31/25 documents: Interviews with staff revealed that incident (hot liquid spill on R1) was not witnessed by staff members. Resident sits in the independent dining room per her normal routine. The date of the occurrence was 8/24/25. R1's Progress Note dated 8/24/25 documents: Resident spilled her hot coffee during lunch. Resident stated, I burnt myself. Can you help me? Left upper thigh assessed; small area of redness noted. (Documentation and Staff interviews indicated that (R1) refers to her hot chocolate as hot coffee and only drinks hot chocolate.)R1's medical record documents on 8/26/25 at 3:07PM resident has three blisters (second degree-partial thickness) on L (left) upper thigh. Both she (R1) and the CNA (certified nursing assistant) stated that she spilled coffee on her.R1's Wound documentation report form documents, date wound identified: 8/26/25, Site: Left Thigh (front) Blister. Comments: 3 different blisters noted- 3x1, 2x1, 0.5x 0.5. R1's Progress Note and Wound Documentation Note dated 8/26/25 indicated that R1 had two open areas and one closed area (blisters) to (R1's) left thigh, one measuring 2.1cm/centimeters, one 3x1cm and the third measuring 0.5 x 0.5 cm. On 9/18/25 at 12:35pm, R1 stated that when she spilled the hot liquid (hot chocolate) on her left thigh, that she completed her lunch meal and then went to inform the staff. R1 stated, No CNAs (Certified Nursing Assistants) or staff around when this happened; and all I got is a little scar left. There was probably no one around except the people I was sitting with (at table); I did not see any staff around. On 9/19/25 at 12:08pm, V2 Director of Nursing/DON stated that a Hot Liquids Risk Assessment had not been done for R1 per their policy and did not know why this was not completed. V2 stated there were no hot liquid burn interventions in place for R1 until after the 8/24/25 incident, and confirmed that the facility had not been following it policy regarding hot liquids. On 9/19/25 at 12:08pm, V2 also stated: No one was supervising residents in the dining on 8/24/25 or prior to (R1's) hot chocolate incident; Management does do supervision in the dining room with residents now.

Based on Observation, Interview and Record Review, the facility failed to ensure resident rooms were kept free from leaking water condensation, water damaged ceilings and dark fuzzy discoloration on the walls and ceilings for 15 of 16 residents (R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16) reviewed for environment in the sample of 16.Findings include:The facility's Resident Rights policy, dated 11/2018, documents As an individual living in long term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities: Your facility must be safe, clean, comfortable, and homelike.The facility's Mold policy, dated 6/14/17, documents Molds are microscopic organisms found everywhere in the environment, indoors and outdoors. Most molds are harmless, but some can cause infections, allergy symptoms and produce toxins. Inhalation is the exposure of most concern to cleanup workers. It is our policy to remediate immediately upon notification of mold. How to recognize mold: Sight, usually appear as gray or black and can be fuzzy. This policy also documents Always notify your facilities manager upon finding mold or mildew. Identify moisture problems and remove excess moisture with a wet-dry vacuum and dry out the building as quickly as possible.The facility's Fall Assessment and management Policy, dated 6/2024, documents It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. This policy also documents Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be, Falls related to environmental hazards.On 8/27/25 at 10:10 AM, R4's room was observed. R4's ceiling near the room's entry way had a strip of black speckled fuzzy substance on the white ceiling that was scattered amongst an approximate two foot by three-inch area, horizontal to the doorway. The ceiling over R4's bed was lowered, and the corners, wallpapered walls and ceiling contained several speckled gray areas.R1's current care plan, dated 8/26/25, documents R1 has diagnoses including but not limited to Lack of Coordination, Unsteadiness on Feet and Abnormalities of Gait and Mobility. This care plan documents (R1) is at risk for falls related to weakness, hypertension, use of devices such as walker for ambulation, use of psychotropic medications. Fall on 6/10/25 and 8/26/25. Interventions, ensure that (R1) is wearing appropriate footwear with non-slip soles or non-skid socks when ambulating or mobilizing in wheelchair. Night light on in room/bathroom to illuminate area and decrease trip/fall hazards.On 8/27/25 at 10:50 AM, R1 was sitting in a recliner chair in her room. R1's ceiling in front of her recliner contained a large square shaped air vent. The ceiling around the vent was stained tan and bubbled in multiple areas. The ceiling also contained a large metal tract for a privacy curtain and some areas along the tract also were surrounded by tan stained marks. At this time, R1 stated When the air conditioning runs a lot, it will drip water on the floor. I usually put some paper towel over the water when it happens. At this same time on the opposite side of R1's room, near R8's recliner chair, the ceiling contained a smoke detector. This smoke alarm had a ring surrounding it approximately two to three centimeters in width of speckled gray and dark gray scattered spots, along with tan stained areas surrounding. R1 stated facility staff and maintenance are aware of the damages. On 8/27/25 at 10:55 AM, R3's room was observed with a ceiling air conditioning vent which was surrounded by multiple areas of tan stains and bubbled paint. R3's smoke alarm was pulled down approximately eight inches from the ceiling and hanging by covered electrical wires. Surrounding the smoke alarm were areas of tan stains on the ceiling.On 8/27/25 at 11:00 AM, V11 (Certified Nursing Assistant) confirmed the ceiling damage in R1, R3 and R8's rooms. V11 stated There is water that drips when it is hot, and the AC (air conditioner) runs frequently. The smoke detector in (R3's room) has been pulled down because they had condensation behind the detector, so they had to pull it out to dry. All the rooms on this side (Rose Lane) drip when it's hot. They all have damage on the ceiling.On 8/27/25 at 11:05 AM, V2 (Director of Nursing) toured the facility's [NAME] Lane hallway and rooms. V2 confirmed that every room in the [NAME] Lane hallway has tan stains surrounding the air vents on the ceilings. V2 stated (V4, Maintenance Supervisor) is trying to reach out to corporate and get a solution for the air conditioner drip problem. It's been an issue for close to a month. When it is hot, the vents will drip onto the floor. The rooms on [NAME] Lane are the ones affected. V2 confirmed the dark gray speckled areas around the smoke detector in R1 and R8's room and the dark black speckled area on R4's ceiling. V2 stated the damage appears to be from water or moisture in the ceiling. On 8/27/25 at 11:20 AM, V4 (Maintenance Supervisor) Confirmed there he has had work orders for the water dripping in [NAME] Lane rooms. V4 stated I believe the room for the work order was room [ROOM NUMBER] or 9 (R14 or R15 and R16's rooms). We had fans blowing constantly in the ceiling. That pulls warm air from the outside and it meets the cool air which causes the moisture. R4 confirmed R17's room has a large black speckled area on the ceiling and over R4's bed there are gray scattered areas on the wallpaper and ceiling. V4 stated There is a vent directly above (R4's) bed and the moisture could be coming from the vents blowing through to the other side of the building. V4 stated he was made aware of the moisture problem, and he has been in contact with (V14, Corporate [NAME] President of Maintenance) for about a month regarding the moisture around air vents, but nothing has been finalized yet to correct the ongoing issue. The facility's (undated) Room Roster provided by V1 (Administrator in Training) on 8/26/25, documents R1, R3 and R5-R16 all reside in the facility's [NAME] Lane hallway.

Based on Observation, Interview and Record Review, the facility failed to ensure a resident was provided with an appropriately sized wheelchair, preferred toileting equipment and showers for one of three residents (R2) reviewed for accommodations in the sample of 16.Findings include:The facility's Resident Rights policy, dated 11/2018, documents As an individual living in long term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities: You have the right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels.R2's current Care Plan, dated 8/26/25, documents R2 has the following diagnoses but not limited to, Congestive Heart Failure, Morbid Obesity, Chronic Kidney Disease, Lymphedema, Irritable Bowel Syndrome and Pain. This care plan documents (R2) is at risk for constipation related to opioid medication use, decreased mobility. She has IBS (irritable bowel syndrome) which could contribute to constipation or cause diarrhea. Encourage resident to sit on toilet to evacuate bowels if possible. (R2) stated that she prefers to do her own favorite activities in her room. Such as television, (social media) and word search. (R2) is active in our Resident Council, and we meet on the first Thursday of each month at 2:00 PM, and she likes to be there. (R2) is at risk for an ADL (Activities of Daily Living) Self Care Performance Deficit related to weakness, need for therapy services to improve mobility and function. Toilet use: Needs one assist for toileting for bowel movement or urination using a bed pan. Transfer: 7/30/25, (mechanical lift) with two (person) assistance for transfers from bed to wheelchair and then can stand and use walker to transfer for toileting needs and into or out of recliner. Will sit in wheelchair and be transferred using (mechanical lift) back into bed from wheelchair as well. 8/26/25, Staff to use bariatric (mechanical lift) only.R2's Minimum Data Set assessment, dated 5/21/25, documents R2 has intact cognition.On 8/27/25 at 10:15 AM, R2 was lying in her room in a bariatric bed. R2 stated she has spent a lot of time in bed lately. R2 stated For several weeks I didn't get out of bed. They (staff) said it wasn't safe for me to be transferred until they had all the proper equipment. I don't have a wheelchair that fits, I have outgrown it. It is miserable for me to sit in the wheelchair that I have, because it is too small. I would like to get up to a wheelchair to get out of the room or go to doctors' appointments and things of that type. I think my current two chairs are around 24 inches and I need larger than that. I am squeezed in there and it's very uncomfortable. Before this week, it has been several weeks that I have just been in bed. I have been told if I want a bariatric bedside commode, I will have to pay for that myself. I can't use the toilet because of the (mechanical lift) and so I have had to use the bedpan, and I do not like it. I would rather be able to get on a commode when I need to use it and not the bedpan. I would also much rather be up in the shower with running water and wash my hair, but I haven't been to the shower room in over a month because the last girl who helped me didn't feel comfortable. There is an aide (V12, Certified Nursing Assistant) who comes in at 5:00 AM because that is when I like my showers, but I don't know if there's not enough help or what, because she is by herself and so I only have gotten bed baths for several weeks.R2's Shower Sheets, dated 7/31/25-8/25/25, document R2 has been given only bed baths and no showers for over three weeks.On 8/27/25 at 12:25 PM, V12 (Certified Nursing Assistant) stated When staff have transferred and assisted (R2) they have been getting hurt. It really does take two people. If I don't have help, then (R2) only gets a bed bath. We have a bariatric shower chair, but our commodes are plastic, and I am not sure they would be safe. (R2) gets scheduled showers on Monday and Friday and she will tell me (if she wants a shower). If there are no other staff to help, (R2) gets a bed bath. (R2) toilets on the bedpan. I don't think we have a bariatric commode to use for her. (R2) could get up to toilet if we had the right equipment. Her wheelchair and the commodes do not fit her and so her recliner is the only place for her to go right now.On 8/27/25 at 12:45 PM, V13 (Certified Occupational Therapy Assistant) stated (R2) has had a recent weight gain. Staff brought to our attention that the shower chair and (R2's) wheelchair are too small now. The largest commode they have here is a size 28 inch and (R2) would probably need larger than that. V13 confirmed that the facility's shower chair is suitable for R2, but her wheelchair and the available commodes are too small to use. On 8/27/25 at 1:10 PM, V1 (Administrator in Training), stated (R2) is adamant that they (showers) occur first thing in the morning. It is a busy time of day for staff, so we have an aide that comes in early. I am not sure why there wouldn't be enough staff to at least get her transferred to the shower chair though. That seems doable for staff to get completed. We have been searching for a commode since we don't have one the appropriate size for (R2). Her wheelchair does not fit her either. We realize these are accommodations that need met to care for (R2) properly.

Based on observation, interview, and record review the facility failed to protect a resident from staff-to-resident mental and verbal abuse for two of three residents (R4 and R9) reviewed for abuse in the sample of 17. These findings resulted in V5 (CNA/Certified Nursing Assistant) yelling at R4 and causing R4 to feel belittled, to feel like a child, and feel verbally abused.Findings include:The facility's Abuse Prohibition Policy, dated 3/15/2018, documents Abuse and Neglect Prohibited: 1. All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by an employee or agent. Verbal Abuse means the use by an employee or agent of oral, written, or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend, or disability. All staff are trained that a facility will treat all residents with respect and dignity, promote and protect the rights of all residents and recognize their individuality.1.R9's Compliment/Complaint From dated 5/15/25 and signed by V17 (Prior Director of Nursing) documents, Care Concern: (R9) stated he has the same (CNA/V5) last night as the night before and (V5) was rude again about (R9's) cares. Investigation: Spoke with (R9) and (R9) stated that (V5) appeared to be frustrated with providing (R9) cares.V5's Employee Disciplinary Action Form dated 5/15/25 and signed by V17 (Prior Director of Nursing) and V5 documents V5 received a verbal warning due to V5's code of conduct for having rude/discourteous behavior toward R9. This same form documents, Plan for improvement: Treat all residents with dignity and respect.R9's Progress Notes dated 5/22/25 document R9 was discharged from the facility.2.R8's admission Record documents R8 is a [AGE] year-old admitted to the facility on [DATE].R8's MDS (Minimum Data Set) dated 7/3/25 document R8 is cognitively intact and has no behaviors.R8's current Care Plan documents R8 has a history of abuse as a very young child and will maintain current level of functioning through next review dated 10/19/25.R8's Compliment/Complaint form dated 7/11/25 and signed by V3 (Speech Language Pathologist/SLP) documents, Reported by (R8) to (V3). Last night (7/10/25), (R8) used her call light to ask for assistance to the restroom. (CNA/Certified Nursing Assistant/V5) answered the light. (R8) states (V5/CNA) was mean to (R8) and yelled at (R8) for using (R8's) call light. (V5/CNA) stated that (R8) has always transferred on her own before and didn't understand why (R8) needed help now.On 7/23/25 at 11:52 AM V3 (SLP) stated, On 7/11/25 (R8) reported to me that (V5/CNA) was mean and yelled at (R8) the night before and did not want to assist (R8) to the restroom. It seemed like it really bothered (R8). I immediately wrote the statement and gave the statement to (V2/DON). I did not report this to (V1/Administrator in Training) as I felt like (V2) would report the allegation to (V1).On 7/23/25 at 12:15 PM R8 was lying in bed. R8 stated with her eyebrows raised and drawn together, (V5/CNA) came into her room (7/10/25) at night and said in a loud voice What do you want? I (R8) told (V5) that I needed to go to the restroom and (V5) stated, You (R8) have been going on your own all along. I do not know why you need my help! I (R8) explained to (V5) that I have been declining and feeling sick lately and needed help. (V5) then helped me to my wheelchair and the restroom and (V5) yelled at me I am not going to wipe your butt either. I felt belittled and verbally abused and felt like (V5) was treating me like a child.

Based on interview and record review the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of abuse and protect residents from the alleged perpetrator (V5/CNA/Certified Nursing Assistant) after an allegation of staff-to-resident abuse was made. These failures have the potential to affect all 78 residents residing within the facility.Findings include:The facility's Daily Census Report dated 7/23/25 documents the facility currently has 78 residents residing within the facility.The facility's Abuse Prohibition Policy, dated 3/15/2018, documents, The administrator or designee shall investigate all allegations of abuse or neglect. The administrator shall be responsible for resident's protection from retaliation during and after the investigation. When an allegation of suspected abuse is received that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution, or disciplinary action against the employee. If the incident involves alleged abuse by an employee as the perpetrator of the abuse, then the administrator shall immediately the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident. If an employee is suspected perpetrator of the abuse, then the employee shall be kept separate from all residents until further orders.R8's MDS (Minimum Data Set) dated 7/3/25 document R8 is cognitively intact and has no behaviors.R8's Compliment/Complaint form dated 7/11/25 and signed by V3 (Speech Language Pathologist/SLP) documents, Reported by (R8) to (V3). Last night (7/10/25), (R8) used her call light to ask for assistance to the restroom. (CNA/Certified Nursing Assistant/V5) answered the light. (R8) states (V5/CNA) was mean to (R8) and yelled at (R8) for using (R8's) call light. (V5/CNA) stated that (R8) has always transferred on her own before and didn't understand why (R8) needed help now.On 7/23/25 at 12:15 PM R8 stated, (V5/CNA) came into her room (7/10/25) at night and said in a loud voice What do you want? I (R8) told (V5) that I needed to go to the restroom and (V5) stated, You (R8) have been going on your own all along. I do not know why you need my help! I (R8) explained to (V5) that I have been declining and feeling sick lately and needed help. (V5) then helped me to my wheelchair and the restroom and (V5) yelled at me I am not going to wipe your butt either. I felt belittled and verbally abused and felt like (V5) was treating me like a child. On 7/23/25 at 11:30 AM V1 (Administrator-In-Training) stated, (V5/CNA) has never been suspended pending investigation regarding (R8's) allegation of (V5) yelling at (R8) and being mean to (R8) and an investigation has not been done.On 7/25/25 at 9:45 AM V1 (Administrator-In-Training) stated V5/CNA has never been suspended pending investigation regarding R8's allegation of V5 yelling at R8 and being mean to R8 and an investigation has not been done. V1 confirmed V5 was not suspended even after this surveyor confirmed V1 was aware of R8's allegation on 7/23/25 at 11:30 AM. V1 stated V5 has worked in the facility since 7/11/25 and helps take care of all residents within the facility.V5's Timecard dated 7/11/25 through 7/24/25 documents V5 has worked 11 days/shifts, with the most recent shift being on 7/24/25 from 10:05 PM through 6:06 AM.

Based on observation, interview, and record review the facility failed to ensure residents' room walls, restroom floors, toilets, and sinks were clean, maintained, and in good repair, failed to ensure the facility was free of odor, failed to ensure waste receptacles were lined, and failed to properly dispose of soiled washcloths for ten of ten residents (R2, R4, R5, R10, R11, R12, R13, R15, R16, and R17) reviewed for clean/comfortable/homelike environment in the sample of 17.Findings include:The facility's Maintenance Supervisor Job Description dated 5/30/24 documents, Job Summary: Provide necessary maintenance for the facility, equipment in every department, and do maintenance and repairs as requested by staff and residents. Essential Job Functions: Replace float units in facility toilets and washers and unclog drains and remove sink traps for cleaning. Replace ceiling and floor tile. Paint walls, ceilings, doors, window and door frames, tables, chairs, shelves, racks, and parking-space stripes.The facility Housekeeping/Laundry Supervisor Job Description dated 3/4/24 documents, Ensure the facility is maintained in a clean, safe, and comfortable manner. Supervise day-to-day housekeeping/laundry functions of assigned personnel. Assure that refuse is disposed of daily and in accordance with the established sanitation procedures.The facility's Resident Council Minute Meetings dated 7/3/25 document, Some agency staff are throwing soiled (adult briefs) onto floor. Housekeeping: Weekends the trash is not being taken out.On 7/23/25 from 10:15 AM through 10:30 AM a tour of the facility was done. During this tour it was noted R4, R11, and R16 all share a restroom. R4, R11, and R16's restroom sink drain was not working and the entire sink was full of standing water and the restroom smelled strongly of urine. R4, R11, and R16's toilet was full of urine and stool and would not flush. The floor tiles surrounding R4, R11, and R16's stool, were stained with an orangish-brownish substance. The wall behind R16's recliner had a baseball sized area of missing drywall and had multiple linear lines of missing paint. R10, R12, and R17's restroom floor tiles surrounding the toilet had a dark black stain and the entire sink had a brownish-greenish stain. R2, R5, R13, and R15 all share a restroom. R2, R5, R13, and R15's floor tiles surrounding the stool had a dark black stain and the lid to the top of the toilet tank was missing. Three used washcloths were sitting on the top of R2, R5, R13 and R15's sink and there was trash in the waste can with no liner.On 7/23/25 at 10:20 AM V6 (CNA/Certified Nursing Assistant) stated, (R4, R11, and R16's) sink drain has not drained, and their toilet has not flushed right for over a year. (R4, R11, and R16's) bathroom sink and the floor is stained.On 7/23/25 at 10:30 AM both R11 and R16 both verified their toilet has never flushed right and their sink does not drain. R11 and R16 also verified their restroom floor has been stained for quite some time and the housekeepers could not do a better job.On 7/23/25 at 10:45 AM R17 stated, My bathroom needs to be deep cleaned. The floor is stained and the sink.On 7/25/25 at 1:45 PM V1 (Administrator-in-Training) did a tour of the facility with this surveyor and verified R4, R11, and R16's restroom sink drain and toilet were not working, the bathroom floor was stained, and the wall behind R16's recliner had missing drywall. V1 also verified R2, R5, R10, R12, R13, and R15's and R17's floor tiles surrounding their toilets had dark black stains and the lid to the top of the toilet tank was missing.

Based on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of abuse to the Administrator and the State Agency for one of three residents (R4) reviewed for Abuse in the sample of 17.Findings include:The facility's Abuse Prohibition Policy, dated 3/15/2018, documents, A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. A facility administrator who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter by telephone and in writing to the resident's representative. The administrator shall provide the Illinois Department of Public Health (IDPH) with initial notice of the alleged abuse, neglect, or incident of unknown origin by telefaxing the Department a copy of a report of the incident completed immediately after the incident becomes known. R8's Compliment/Complaint form dated 7/11/25 and signed by V3 (Speech Language Pathologist/SLP) documents, Reported by (R8) to (V3). Last night (7/10/25), (R8) used her call light to ask for assistance to the restroom. (CNA/Certified Nursing Assistant/V5) answered the light. (R8) states (V5/CNA) was mean to (R8) and yelled at (R8) for using (R8's) call light. (V5/CNA) stated that (R8) has always transferred on her own before and didn't understand why (R8) needed help now.The facility's Abuse Investigations and R8's Electronic Medical Record dated 7-11-25 through 7/24/25 were reviewed and do not include evidence of R8's abuse allegation being reported to the State Agency.On 7/23/25 at 11:30 AM V1 (Administrator-In-Training) stated, No one reported to me that (R8) reported to (V3/SLP) on 7/11/25 that (R8) felt like (V5/CNA) was mean or yelled at (R8).On 7/23/25 at 11:40 AM V2 (Director of Nursing/DON) stated, I was not aware of (R8) reporting to (V3/SLP) that she felt like (V5/CNA) was mean and yelled at her. I just saw (R8's) statement today when I was pulling the grievances from (V9's/Social Service Director's) grievance book. After I saw (R8's) written statement about (R8) reporting (V5) was mean and yelled at her, I did not report this to (V1).On 7/23/25 at 11:52 AM V3 (SLP) stated, On 7/11/25 (R8) reported to me that (V5/CNA) was mean and yelled at (R8) the night before and did not want to assist (R8) to the restroom. It seemed like it really bothered (R8). I immediately wrote the statement and gave the statement to (V2/DON). I did not report this to (V1/Administrator in Training) as I felt like (V2) would report the allegation to (V1).On 7/25/25 at 9:45 AM V1 (Administrator-In-Training) stated the facility still has not reported R8's allegation of V5/CNA yelling at R8 and being mean to R8 to the state agency. (V1) stated, After collaboration with the IDT (Inter-Disciplinary Team) we felt like the report was already late, so it did not matter if I reported the allegation now.

Based on observation, interview, and record review the facility failed to prevent resident injury during transfer in a wheelchair, failed to investigate the cause of the injury, and failed to develop interventions after the injury to prevent future injuries for one of three residents (R4) reviewed for accidents in the sample of 17.Findings include:The facility's Occurrence Reporting to (local State Agency) Policy and Procedure dated 10/3/11 documents, The facility shall maintain a file of all written reports of each incident and accident affecting a resident that is not the expected outcome of a resident's condition or disease process. Procedure: Provide immediate care to the resident. Initiate the appropriate monitoring of the resident. Notify the physician and family of the occurrence. If the occurrence requires it, complete a Risk Watch Occurrence Report form. Staff will document specific information relating to the occurrence including the exact description of facts surrounding the occurrence. Include statements by the resident or any witnesses.R4's admission Record documents R4 is a [AGE] year-old admitted to the facility on [DATE].R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 is severely cognitively impaired.R4's Progress Notes dated 7/14/25 at 10:14 AM and signed by V13 (MDS Coordinator) documents, Therapy staff reported left ring finger bruised. Noted left ring finger with bruise to first and second knuckles. Dark purple and approximately dime sized. Report from (CNA//Certified Nursing Assistant/V6) that finger was pinched between wheelchair ad table in dining room on 7/11/25 which may have resulted in the bruises. (R4) able to move fingers without issues. Grasp is ok. Denies pain when asked.R4's Medical Record does not include a Risk Watch Occurrence Form with an investigation as to how the bruises occurred to R4's left hand fingers, or an intervention and update to R4's care plan to prevent R4 from further injuries.On 7/23/25 at 10:15 AM R4 was sitting in a wheelchair. R4's left third and fourth fingers both had a dime-sized purple bruise. On 7/23/25 at 10:20 AM V6 (CNA) stated, (R4's) bruises were my fault. On (7/11/25) when I was moving (R4) in her wheelchair from the dining room table I did not make sure (R4's) hand was inside the wheelchair and I pinched (R4's) finger between the table and the wheelchair.On 7/23/25 at 11:30 AM (V1/Administrator) stated, There was no investigation done or Risk Watch Occurrence Form completed after (R4) got the bruises to her left fingers. V1 verified at this time that there should have been an investigation done and (R4's) care plan should have been updated with an intervention to prevent further injuries.

Based on interview and record review, the facility failed to report allegations of staff to resident physical abuse to the Administrator/Abuse Coordinator for one (R1) of four residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prohibition Policy, Revised 3/15/18, documents: All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. Reporting - Allegations of Abuse and Neglect: 1. A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) On 6/11/25 at 9:50am, R1 indicated that a couple of weeks ago on Wednesday (5/28/25) two Black Certified Nursing Assistants/CNAs, one male and one female (names unknown-the male later identified by staff as V6 Agency CNA with description), were assisting her at bedtime around 8:30pm. R1 stated that while changing her, (V6) was rubbing her at first and then patted her bottom. R1 stated: I didn't appreciate that; told him to quit, he did and left the room and the girl finished; after that, did not want men taking care of me. Told him to get out and he did. On 6/11/25 at 11:35am, V12 Activity Director stated that at the 6/5/25 Resident Council Meeting, R1 patted R1's right thigh and said, I don't like it when they (Caregivers) do that. V12 stated that she did not get an explanation of R1's statement. V12 stated: Looking back, feel foolish and sorrowful; felt this was about R1's (full mechanical lift); she had also been talking about this, and there was a lot of cross talk with the other residents also talking in the meeting; my mind did not think regarding abuse; would have taken it to (V1 Abuse Coordinator) right away. On 6/11/25 at 12:05pm, V13 Activity Aide stated that when she visited R1 about two weeks ago, that R1 talked to her about two Black caregivers (Certified Nursing Assistants/CNAs), one a Black male. Stated that R1 said she did not like the big black one (male); that on the evening shift, they (two Black CNAs) came in and changed her; and (R1) said she did not like the Black male caregiver. V13 said okay; and then R1 said, I just wanted to let you know I did not like him. V13 stated that she did not let anyone else know about this conversation and did not report this. V13 stated, Thinking back now, maybe should have let someone know about this. On 6/11/25 at 11:40am, V1 Administrator stated that she is the Abuse Coordinator, policy is to tell the Administrator as the Abuse Coordinator immediately. V1 stated, Whether there is doubt or not, both V12 and V13 should have reported R1's concerns to me right away.

Based on interview and record review the facility failed to administer a prescribed opioid medication to keep resident's pain controlled, failed to perform a pain assessment while the resident was not receiving her prescribed opioid medications, and failed to notify the physician of the need for a refill order and complaints of increased pain for one of one resident (R32) reviewed for pain in the sample of 35. These findings resulted in R32 experiencing stress and excruciating pain for over a week, that radiated to the neck and jaw. Findings include: The Facility's Management of Pain Policy dated 4/4/12 documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain. Monitoring treatment efficacy and side effects. Using pain medication judiciously to balance the residents desired level of pain relief with the avoidance of unacceptable adverse consequences. A standard format for assessing, monitoring and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. For the purpose of this policy, pain is defined as Whatever the experiencing person says it is, existing whenever the experiencing person says it does. Procedure 1. Resident/Family Involvement Upon admission, all residents and families will receive the facility handout, A Message of Care to our Residents and Families - Facts about pain, encouraging residents to report pain early so pain management can be more effective. Residents will be asked to periodically measure satisfaction related to pain and its management. 2. Physician Communication and Involvement - Pain will be assessed and managed in a timely fashion, especially if it is a recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. Pain Screening- By receiving input from someone who knows the resident well, pain management can be more specific to the resident. If the resident scores five or above on the pain questionnaire the comprehensive pain assessment must be completed. The United States Food and Drug Administration Safety Communication Website article dated 4/9/19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Rapid discontinuation can result in uncontrolled pain. R32's Face Sheet documents R32 is a [AGE] year-old female admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Primary Generalized (Osteo) Arthritis, Neuropathy, and GERD (Gastroesophageal Reflux Disease). R32's current Care Plan documents (R32) is at risk for pain related to arthritis, neuropathy, GERD. Goal: (R32) will not have an interruption in normal activities due to pain through the review date. Interventions: Administer analgesia as ordered and monitor effectiveness of pain medications used. Evaluate the effectiveness of pain interventions utilized, both medical and non-medical. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record/report to Nurse (R32's) complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from (R32's) past experience of pain. R32's MDS (Minimum Data Set) Assessment, dated 2/21/25, documents R32 is cognitively intact. This same MDS documents R32 frequently had pain or was hurting in the last five days that occasionally made it hard to sleep, occasionally limited her day-to-day activities due to pain, and rated her worst pain as a seven out of ten. R32's Progress Note dated 2/23/25 at 11:41 AM documents Fentanyl Transdermal Patch 72 Hour 100 MCG (microgram)/Hr (hour) apply 1(one) patch trans dermally in the afternoon every 3 (three) days for chronic pain and remove per schedule. Waiting for signed order from doctor. R32's Medication Administration Record (MAR) dated 2/1/25 through 2/28/25 documents Fentanyl Transdermal Patch 72 Hour 100 MCG/HR. Apply one patch trans dermally in the afternoon every three day(s) for chronic pain and remove per schedule. Start date 9/11/24. This same MAR documents R32 did not receive her scheduled Fentanyl Transdermal Patch 100 MCG/HR from 2/17/25 through 2/24/25. The pain assessment documents that R32 rated her pain at a level five or above eight times between 2/17/25 through 2/25/25. R32's Electronic Medical Record and Progress Notes dated 2/17/25 through 2/25/25 (dates R32's pain was rated above a five) includes evidence of only one comprehensive pain evaluation being completed on 2/21/25 during this timeframe. R32's Pain Evaluation dated 3/21/25 documents R32 was experiencing pain frequently over the past five days, rated at a level seven (indicating the pain was as bad as it could be). This same Evaluation documents no new care plan interventions or clinical suggestions were made to address R32's pain. On 3/3/25 at 10:45 AM, R32 stated I wear a pain patch and on 2/17/25 I did not get my new patch. I kept asking the staff and nothing was done about it. I was told at one point that they needed to get a physician's order. I don't know if it was not followed up on or what happened. On 2/25/25 I was so upset because it had been well over a week that I had waited for the pain patch to be replaced. I was having stabbing pain in my neck and jaw I think from the stress from the amount of pain I was under. I thought I was having a heart attack. I was hurting and frustrated that no one would help me get my medication. I was in excruciating pain for over a week. I didn't get the patch until 2/25/25. On 3/4/25 at 11:35 AM, V21/Pharmacist stated We did not get a request to refill (R32's) Fentanyl patch until 2/24/25. The last time the order was filled was 1/13/25 which should have lasted a month. On 3/4/25 at 11:51 AM, V22/R32's Primary Care Physician's Nurse stated 2/24/25 was the first time we were notified that (R32) needed the order for her fentanyl patch. Our office should have been notified of the need for (R32's) Fentanyl Patch refill before (R32) ran out. On 3/5/25 at 8:50 AM, V1 (Administrator) stated, When (R32) was out of her Fentanyl Patch somebody should have reached out to (R32's) physician to get the refill order or to see if the patch could have been pulled from back-up. The staff should have let the physician know that (R32) was in pain and see if there was something else, we (the facility) could do to control (R32's) pain. (R32) should not have had to go without her Fentanyl Patch. The staff should have contacted me or (V2/Director of Nursing) when the Fentanyl Patch was not available so one of us could have followed up on it. There is no documentation that the physician, me, or (V2) were notified of (R32) going without her scheduled Fentanyl Patch or (R32's) complaints of pain from 2/17/25 to 2/25/25. During the timeframe of 2/17/25 to 2/25/25 we had agency staff taking care of (R32) and were not familiar with (R32). I think that is why there was no follow-up. Any pain rating above a seven indicates pain that is as bad as it can be. On 3/5/25 at 9:00 AM V18 (CNA/Certified Nursing Assistant) stated, Every time I would take (R32's) meal tray into her between 2/17/25 to 2/25/25, (R32) would complain of pain and say to me, I just do not understand why they (the staff) are not getting me my pain patch and I have to go this long in pain.

Based on observation, interview and record review, the facility failed to properly cleanse a food thermometer before use and between foods when checking steam table food temperatures, ensure a hairnet was worn correctly in the kitchen, label and date open food items in refrigerators and dry food storage areas, ensure freezers contained internal thermometers and thermometers in working condition, use dishwasher temperature testing strips that reflect the required dish surface temperature, check the surface temperature daily to ensure dishes reach the required temperature during the rinse cycle of a high temperature sanitation dish machine, and ensure juice and coffee dispensers in the main dining room were clean and free from buildup and slime. These failures have the potential to affect all 85 residents residing in the facility. Findings include: The facility's Food and Nutrition Services Manager Job Description (undated), documents Job Summary: Production and service of high-quality meals; organize, supervise, and train dietary employees; purchase food and supplies; provide a sanitary and infection free environment; participate in the assessment process; write care plans; prepare menus; make decisions. This job description also documents Essential Job Functions: Supervise the receiving and storage of food. Supervise food preparation and service. Maintain high sanitation standards. Ensure maintenance of equipment. Supervise cleaning procedures to ensure safe and sanitary conditions are maintained within the food service department, including kitchen, dining room, and freezers. The facility's Personal Hygiene: Illness, Shoes, Hair Restraints policy, dated 2/2022, documents Employees shall use effective hair restraints such as hats, hair coverings or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food, and clean equipment. Anyone entering a kitchen or serving area will have their hair restrained and/or a beard guard. This will be worn throughout the time in the kitchen and when handling food. On 3/3/25 10:50 AM, V7 (Dietary Manger) entered the facility's kitchen and placed a hairnet on her head. Throughout the entire kitchen tour, steam table temperature checks and freezer/fridge walk through, V7 had her hair partially covered in a hair net with approximately six to eight inches of ponytail uncovered and hanging on her shoulder, outside of the hairnet. On 3/3/25 at 10:55 AM, V7 took a food thermometer out of her shirt pocket, rinsed the thermometer probe under tap water for approximately two seconds and then took a paper towel and wiped it dry. V7 then proceeded to check steam table food temperatures of Chicken Breasts, Cheesy Rice, Mixed Vegetables, [NAME] Beans, Ground Chicken, Pureed Chicken, Pureed Rice, and Pureed [NAME] Beans. In between each food temperature, V7 wiped the thermometer probe off with the original dry paper towel and then inserted the probe into the next item. On 3/3/25 at 11:05 AM, upon completing steam table temperatures, V7 confirmed that the thermometer should be wiped with a food safe sanitizing wipe or alcohol wipe between foods. V7 stated Yes, when staff do temperatures they should use the cleansing wipes. Normally I would, but I didn't know where those were at. The facility's Food Labeling and Dating policy, dated 2/2022, documents Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: name of product, date stored and in some cases, the time of the day. The food must be labeled and dated if it is removed from its original container. Leftover foods placed in a container must be cooled down properly, labeled and dated. On 3/3/25 at 11:10 AM, the kitchen reach-in refrigerator contained a large tub of lettuce with a lid that was not labeled or dated. At this time V7 confirmed that the tub should be labeled and dated and now needs to be discarded because it wasn't labeled. On 3/3/25 at 11:12 AM, the kitchen's dry food storage room contained two bags of spiral pasta, one bag of dried milk, one bag of breadcrumbs, and two plastic containers of cereal (out of original package), that all were opened and undated. Directly outside of the dry food storage room was a rack containing packages of breads. This rack contained two loaves of wheat bread, one package of hot dog buns and one package of cinnamon bread, all packages were open and undated. V7 confirmed that this time that the opened dry storage food items and breads should all be dated with the dates the items were opened. On 3/3/25 at 11:15 AM, the facility's walk-in refrigerator contained a large container of ham salad, labeled beets. At this time, V7 confirmed the container does not contain beets and does not have a label for what is inside. In this same refrigerator another large metal container with several sandwiches insides was covered with foil, without a label or date. V7 stated It's ham salad sandwiches and the container should have been labeled and dated. On 3/3/25 at 11:17 AM, the facility's upright walk-in freezer contained a thermometer inside with a broken center and an unreadable temperature recording. At this time, V7 confirmed the thermometer is broken and not readable. On 3/3/25 at 11:19 AM, the facility's large chest freezer contained several bags of vegetables and did not have an internal thermometer. V7 stated I know there was one (thermometer) in here, but it's not in here now. I don't know why. The facility's Heat Sanitizing Log procedure, dated 2/2022, documents Wash temperature, 150 degrees Fahrenheit. Rinse/Sanitize temperature, 180 degrees Fahrenheit. If temperatures are not 150 or 180, notify your manager immediately. The facility's Dishwasher testing strip (undated), documents 71 degrees Celsius/ 160 degrees Fahrenheit. If center (of testing strip) is black, then correct temperature has been achieved. On 3/3/25 at 11:20 AM V8 (Dietary Aide) stated he is the one who checks the dishwasher temperatures each day and stated, It is a high-temp dishwasher. V8 stated he records the outside temperature of the digital reading to check the temperature during a dishwashing cycle. V8 denied using any strips or surface level thermometers during the dish cycle and stated, It isn't broken (outside thermometer) because it's a new machine and gives us the temperature recording on the outside. At this time V8 located some temperature testing strips. V8 stated I forgot we had these. V8 then confirmed that the strips will turn black when they reach a temperature of only 160 degrees. On 3/3/25 at 11:25 AM, the juice machine in the facility's main dining room contained orange slime, a bright red gel-like substance and smeared slime like debris on the underside plastic casing of the machine, where the juice spout nozzles are located. At this time the coffee machine dispenser nozzles and surroundings on the machine's underside, contained dried brown splatters and debris. V7 and V8 both stated those areas on both machines should be cleaned in the evening, but the cleaning is not documented anywhere, to prove it is ever completed. On 3/3/25 at 11:28 AM, V7 stated Staff should be wearing hairnets in the kitchen to contain their hair. V7 confirmed her ponytail is not fully in her hairnet and stated I don't usually go in the kitchen. I am usually out in the dining room or in my office. The facility's Long Term Care Application for Medicare and Medicaid dated 3/3/25 and signed by V1 (Administrator) documents 85 residents reside in the facility.

Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter maintained patency, monitor a resident's urinary output, notify the physician of no/decreased urinary output, obtain physician ordered urinalysis results, and follow up with the physician in regards to abnormal urinalysis results, for two of three residents (R1 and R5) reviewed for indwelling urinary catheters and has the potential to affect all five residents (R1, R3, R4,R5, R6) with indwelling urinary catheter out of a total sample of six. These failures resulted in R1 not having urinary output documented for two days, without physician notification or medical intervention, resulting in R1 being sent to the emergency room (ER) for evaluation and subsequent hospitalization and treatment receiving intravenous fluid and antibiotic medication for the diagnosis of a UTI (Urinary Tract Infection) positive for ESBL (Extended-Spectrum Beta-Lactamase an antibiotic resistant urinary tract infection) and E. coli (Escherichia coli bacteria that is a common cause of UTI), as well as cystitis (bladder inflammation) and hydronephrosis (excess fluid in kidney due to a backup of urine). These failures also resulted in a repeated hospitalization for R1 where again she was diagnosed with a UTI as well as encephalopathy (brain disease that alters brain function or structure, common cause includes infections and can be life threatening if left untreated). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/27/25, the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The Facility Assessment, revised 7/30/24, documents that the facility provides bladder training programs, urinary catheter maintenance, prevention of infections, and management of medical conditions such as urinary tract infections. The facility's Guidelines for Physician Notification of Change in Resident Condition policy, revised 4/2019, documents Certified Nursing Assistants (CNA) are responsible for reporting any changes they observe to their charge nurse and it's the responsibility of the charge nurse to notify the physician of a significant change in condition before the end of the shift. The facility's Catheter Protocol Policy, dated 2/1/10, documents when monitoring for accurate intake and output, the clinical record shall reflect the intake and output for each 24-hour period. Observations of abnormal amounts of urine, color, clarity, or odor shall be documented in the clinical record and notification shall be made to the attending physician and Power of attorney as indicated. Orders shall be followed. 1.) On 1/7/25 at 9:05 AM, R1 was sitting in a manual wheelchair in R1's room with an indwelling urinary catheter. The catheter drainage bag contained yellow urine with sediment in the catheter tubing. R1's Nurse progress notes document on 12/19/24 a fax was sent to V9 Medical Director that R1's urine was dark and slimy with a foul odor. R1's Physician Orders, dated 12/19/24, document V9 gave an order for the facility to obtain a urinalysis for R1. R1's Nurse Progress Notes, dated 12/23/24, document the facility was notified R1's urinalysis indicated a UTI positive for ESBL and E. coli. R1's Point of Care Response History documented on 12/25/24 R1 had no documentation of urine output for second shift (3PM-11PM). On 12/26/24 there was no urine output documentation for third shift (11pm-7AM) or dayshift (7AM-3PM) and 50 milliliters of urine output on second shift. On 12/27/24 third shift and dayshift documented R1's urine output as zero and there was no documentation on second shift. R1's medical record did not contain notification to V9 Medical Director of R1's absent/decreased urine output. R1's current medical chart has no documentation of a physician being notified regarding R1's abnormal urinalysis on 12/23/25 or a follow up with a physician order to treat R1's UTI from 12/23-12/28/24. On 1/7/24 at 10:30 AM, V2 Director of Nursing confirmed nursing staff did not document follow up regarding R1's decreased/absent urinary output and did not document notification of the physician from 12/23/24- 12/28/24. V1 stated I tell the staff all the time to document it, or it didn't happen. On 1/16/25 at 9:08 AM, V13 CNA stated V13 came into work on the 12/28/24 at 6:00 AM, and V13 noticed R1 had no urine in her indwelling catheter bag. V13 stated she reported to V10 Registered Nurse on 12/28/24 in the afternoon that R1 had no urinary output on dayshift. V13 stated V13 and V10 laid R1 in bed after being notified from dining room staff that R1 was throwing up in dining room and was more confused. V13 stated she noticed brown urine in R1's depend, but not in R1's indwelling catheter bag. V13 stated V10 told V13 she was going to irrigate R1's indwelling catheter, but V13 was not successful. R1's Nurse's note, dated 12/28/24 at 9:18 PM, document, R1 complains of pain at the indwelling urinary catheter site, brown mucus discharge coming from vagina. R1 hasn't voided in two days per CNA and documentation. Tried to flush indwelling urinary catheter unable to flush. Took indwelling urinary catheter out and R1 urinated large amount in adult incontinent brief two times. R1 is positive for ESBL and E. coli per urinalysis culture. R1 is more confused than normal. Notified V9 ordered to take indwelling urinary catheter out and send to ER. On 1/8/24 at 11:35 AM, V10 Registered Nurse stated after V13 made her aware that R1 had no urine output in R1's indwelling catheter. V10 called V8 R1's Family Member who requested R1 be sent to emergency room since R1 had not urinated in two days. V10 stated she called 911 and sent R1 to the local emergency room for evaluation. R1's Emergency Department progress notes, dated 12/28/24, document R1 was kept in the hospital overnight and received IV fluids and antibiotics. R1 was noted to have a UTI due to urinary retention and evidence of cystitis and hydronephrosis secondary to urinary retention. The physician documents in R1's Emergency Department/Room progress note, At presentation: the differential diagnosis considered could potentially be life threatening or risk to bodily function. On 1/7/25 at 1:00 PM, V6 emergency room Nurse, stated V6 was working in emergency room when R1 arrived on 12/28/24 and provided her care. V6 stated the facility nurse reported to V6 that R1 had not urinated in her indwelling urinary catheter drainage bag in two days. V6 stated the emergency room placed a new indwelling catheter in R1 and had dark gold urine return. V6 further stated that he felt it was concerning that R1 had not voided in two days before R1 was sent to the emergency room . R1's Nurse Progress note, dated 12/29/24 documents R1 came back from emergency room with orders for Cephalexin (antibiotic) 5 milligrams by mouth, three times a day for seven days for the treatment of a UTI. R1's Point of Care Response History, dated 1/2/25 to 1/23/25, documents that R1's urinary output should be documented every shift. However, there is no documentation of R1's urinary output being obtained on the following dates: 1/2/25 day shift and second shift; 1/3/25 day shift; 1/4/25 day shift; 1/5/25 day shift and second shift; 1/6/25 day shift and third shift; 1/7/25 day shift; 1/9/25 day shift. The Point of Care Response History also documents the following decreased urinary outputs: 1/5/25 100 milliliters on third shift; 1/6/25 15 milliliters on second shift; 1/9/25 50 milliliters on second shift. R1's medical chart has no documentation of V9 being notified of R1's decreased urinary output until 1/9/25. R1's Nurse Progress Note, dated 1/9/25 at 1:06 PM, documents, This nurse was informed that R1's output was 75 milliliters and urine is thick with foul smell. V9 informed through fax, awaiting reply. R1's Nurse progress Note signed by V3 Licensed Practical Nurse, dated 1/9/25 at 2:40 PM, documents Received orders from V9 to recheck R1's urinalysis. On 1/16/25 at 12:31 PM, V3 stated that V3 worked on 1/9/25 and received the order for R1's urinalysis on 1/9/25 because R1 was having decreased urinary output. V3 stated she didn't obtain R1's urinalysis on 1/9/25 because she didn't have time and she passed it on to the oncoming nurse. V3 further stated she returned to work on 1/13/25 and R1's urinalysis was still in the refrigerator at the nurse's station. V3 stated V3 obtained a new urinalysis after finding the lab was not processed on 1/10/25. On 1/16/25 at 1:13 PM, V14 Registered Nurse stated that V14 worked third shift the night on 1/9-1/10. V14 stated V3 asked V14 to obtain the urinalysis for R1. V14 stated R1's urine was dark yellow, contained sediment and was murky. V14 stated she made V3 aware that V14 collected R1's urine early Friday morning (1/10/25) and gave R1's urine sample to V3 on 1/10/25 at shift change. V3 placed R1's urinalysis in refrigerator and stated she would take care of it. R1's medical record has no documentation of R1's urinalysis being obtained from 1/9/25 thru 1/13/25. R1's Point of Care Response History, dated 1/2/25 to 1/23/25, lacks documentation on 1/12/25 of R1's urinary output being obtained on 2nd shift. R1's Nurse Progress Note signed by V3, dated 1/13/25 at 11:45 AM, documents R1 straight catheterized to get urine sample. R1 fought with staff the whole time and stated it hurt. R1's urine sample is green, thick, and has a foul odor so R1 will be sent out to hospital. R1's hospital records dated 1/13/25, documents R1 was admitted to hospital to receive intravenous antibiotics for treatment of a Urinary Tract Infection (UTI) and encephalopathy (brain disease that alters brain function or structure, common cause includes infections and can be life threatening if left untreated). R1's Point of Care Response History, dated 1/2/25 to 1/23/25, documents decreased or absent urinary output on the following days: 1/17/25 zero urine output on third shift, 150 milliliters on day shift; 1/18/25 125 milliliters on second shift. There is no documentation of urinary outputs being obtained on 1/18/25 day shift and third shift. R1's medical record does not contain documentation of physician notification of R1's absent/decreased urine output. On 1/21/25 at 10:00 AM, V2 Director of Nursing confirms there is no documentation of a urinalysis being obtained on 1/9/25. V2 stated that urinalysis should have been collected the same day it was ordered. V2 further stated she was not aware R1's medical chart had days with absent or decreased urinary output. On 1/22/25 at 9:05AM, V9 Medical Director stated V9 would expect the facility to call and notify V9 if a resident with a catheter has not voided in an eight-hour shift. V9 stated my office, nor I received a phone call from the facility that they did not receive antibiotic orders for R1 on 12/23/24. V9 stated she reviewed all phone calls with her office which are documented, and none were received from the facility from 12/23/24-12/28/24. V9 further stated the facility also has my personal cell phone and I was not notified on my cell phone either. V9 stated R1 could have become very sick because of the facility not notifying V9 of absent or low urine output. V9 stated R1 could have developed sepsis (life threatening complication of an infection) and had to be admitted to hospital and receive IV antibiotics. V9 stated the facility has not made V9 aware of low or no urine output for R1. V9 confirms she was not notified R1s urinalysis was not collected on 1/9/25. V9 stated I was not made aware until sometime after. V9 stated there are a couple of good nurses here but the facility uses a lot of agency staff, and it scares me what kind of care they are providing when they work because it's not the same. 2.) R5's Point of Care Response History, documents R5 has a suprapubic indwelling catheter and on 12/31/24, no urine output documented on second shift. On 1/3/25 no urine output documented on dayshift, and second shift documented 100 milliliters. On 1/5/25 200 milliliters of urine output on dayshift and there was no documentation on second shift. On 1/8/25 zero urine output was documented on second shift. On 1/9/25, zero output was documented on third shift, dayshift 150 milliliters of urine output and second shift 50 milliliters. On 1/10/25, 250 milliliters of urine output on third shift, zero output on dayshift, and 250 milliliters on second shift. 1/11/25 175 milliliters on third shift, zero output on day shift and no documentation for second shift. On 1/12/25 zero output documented on third shift and zero on day shift. There is no documentation in R5's medical record that an MD (Medical Doctor) was notified of absent/decreased urine output. An immediate Jeopardy situation was identified to have started on 12/23/24 when the physician wasn't notified regarding R1's 12/23/24 abnormal urinalysis results indicating a UTI positive for ESBL and E. coli, or a follow up with a physician regarding R1's decreased/absent urinary output from 12/23/24-12/28/24. On 1/23/25 at 9:00 AM, the V1 administrator and V2 Director of Nursing were notified of the immediate Jeopardy. The facility submitted an abatement plan on 1/23/25 and was advised by the regional office to make revisions before it would be accepted. The final abatement plan was submitted and accepted on 1/23/25. On 1/27/25, the Removal plan was confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. QA Tool Urinary Status Report. Utilizing Urinary Status Report Tool was implemented 1/23/25 by V2 Director of Nursing and V22 Infection Preventionist. This is a new process for shift-to-shift communication and medical provider notification and follow up to ensure physician orders and labs are obtained timely and physician is notified of results. This is a practice to exchange the information related to urinary output on each shift verbally with a signature from the CNA and the nurse they are giving report to. 2. All clinical staff were in-serviced on monitoring outputs for residents with indwelling catheters which includes completing, monitoring, reporting, and documenting by V22/Infection Preventionist, V2 Director of Nursing, and V1 Administrator on 1/23/25 3. All licensed staff were in-serviced on physician orders and labs being obtained timely and the notification of the physician timely by V22/Infection Preventionist, V2 Director of Nursing on 1/23/25. 4. All licensed staff were in-serviced on physician notification of change in urinary status or any change in condition by V22/Infection Preventionist, V2 Director of Nursing on 1/23/25. 5. New staff will be educated during onboarding and will have an in-service sign off sheet to show the education has been completed. This will be completed by V22 IP Nurse. 4. A binder was created for agency staff with the educational documents of the same information all of the in-house staff was educated on, and they are to read and sign off on prior to starting their next shift. This binder was created on 1/23/25 by V2. 5. V2 Director of Nursing or designee will monitor for compliance to ensure compliance of intervention by auditing three times a week for four weeks.

Based on record review and interview the facility failed to notify the physician of decreased/absent urinary output, resident having a urinary tract infection with no antibiotic medication orders, and urinalysis labwork being collected four days after ordered for one (R1) of five residents reviewed for physician notification in the total sample of six. These failures resulted in R1 being transferred to the emergency room for evaluation and subsequent hospitalization and treatment for an UTI (Urinary Tract Infection) receiving intravenous fluid and antibiotic medication. These failures also resulted in a repeated hospitalization for R1 where again she was diagnosed with a UTI as well as encephalopathy (brain disease that alters brain function or structure, common cause includes infections and can be life threatening if left untreated). Findings include: The Facilities Guidelines for Physician Notification of Change in Resident Condition revised 4/2019 documents it is the responsibility of each nurse to notify the physician of a significant change in condition before the end of each shift. R1's Nurse Progress Notes dated 12/23/2024 at 12:48, documents the facility received a call that R1's urine was positive for ESBL (Extended-Spectrum Beta-Lactamase an antibiotic resistant urinary tract infection) and E. coli (Escherichia coli bacteria that is a common cause of UTI), Faxed results to V9 Medical Director. R1's current medical record has no documentation of the physician being notified to follow up regarding R1's abnormal urinalysis results from 12/23/24-12/28/24. R1's Nurse progress Note dated 12/28/24 at 9:18 PM, documents R1 had no urinary output in indwelling urinary catheter for two days. R1 was sent to emergency room by ambulance for evaluation. R1's Emergency Department progress notes, dated 12/28/24, document R1 was kept in the hospital overnight and received IV fluids and antibiotics. R1 was noted to have a UTI due to urinary retention and evidence of cystitis (bladder inflammation) and hydronephrosis (excess fluid in kidney due to a backup of urine) secondary to urinary retention. The physician documents in R1's Emergency Department progress note, At presentation: the differential diagnosis considered could potentially be life threatening or risk to bodily function. On 1/7/25 at 1:00 PM, V6 emergency room Nurse, stated V6 was working in emergency room when R1 arrived on 12/28/24 and provided her care. V6 stated the facility nurse reported to V6 that R1 had not urinated in her indwelling urinary catheter drainage bag in two days. V6 stated the emergency room placed a new indwelling catheter in R1 and had dark gold urine return. V6 further stated that he felt it was concerning that R1 had not voided in two days before R1 was sent to the emergency room . On 1/22/25 at 9:05AM, V9 Medical Director stated V9 would expect the facility to call and notify V9 if a resident with a catheter has not voided in an eight-hour shift. V9 stated my office, nor I received a phone call from the facility that they did not receive antibiotic orders for R1. V9 stated she reviewed all phone calls with her office which are documented, and none were received from the facility from 12/23/24-12/28/24. V9 further stated the facility also has my personal cell phone and I was not notified on my cell phone either. V9 stated R1 could have become very sick because of the facility not notifying V9 of urine output. V9 stated R1 could have developed sepsis and had to be admitted to hospital and receive IV antibiotics. V9 stated the facility has not made V9 aware of low or no urine output for R1. V9 stated there are a couple of good nurses here but the facility uses a lot of agency staff, and it scares me what kind of care they are providing when they work because it's not the same. On 1/22/25 at 10:04 AM, V16 Physician stated V16 was on call while V9 was on vacation from 12/25-12/31. V16 stated he did not receive any phone calls from facility regarding R1. V16 stated he checked with office staff who also have no record of facility contacting office during that time frame regarding R1. R1's Nurse Progress Notes dated 1/9/2025 at 1:06 PM, documents that R1's urinary output was 75 milliliters and urine is thick with foul smell. V9 informed through fax, awaiting reply. R1's Physician Orders dated 1/9/25 contains an order for a urinalysis to be completed. R1's current medical record has no documentation of R1's urinalysis being collected until 1/13/25 nor of V9 being notified of the delay in the collecting of R1's urinalysis. R1's Nurse Progress Note signed by V3, dated 1/13/25 at 11:45 AM, documents R1 straight catheterized to get urine sample. R1 fought with staff the whole time and stated it hurt. R1's urine sample is green, thick, and has a foul odor so R1 will be sent out to hospital. R1's hospital records dated 1/13/25 documents R1 was admitted to local hospital to receive intravenous antibiotics with a diagnosis of urinary tract infection and encephalopathy (Brain disease that alters brain function or structure. Common cause includes infections and can be life threatening if left untreated). On 1/21/25 at 10:00 AM, V2 Director of Nursing confirmed there was no documentation of a urinalysis being obtained on 1/9/25. V2 stated that urinalysis should have been collected the same day it was ordered. On 1/22/25 at 9:30 AM, V9 stated she was not notified R1s urinalysis was not collected on 1/9/25. V9 stated she expects labs to be collected the same day as ordered unless indicated otherwise.

Based on observation, interview, and record review, the facility failed to develop and implement pressure ulcer prevention measures for two of two residents (R63, R20) reviewed for pressure ulcers in a sample of 35. These failures resulted in R63 and R20 developing stage 4 pressure ulcers. Findings include: A Wound and Ulcer Policy and Procedure policy dated as revised 1/10/2018 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy states that a Specialty mattress with enhanced pressure reducing/relieving properties may be placed on the resident's bed and chair as indicated and skin contact surfaces may be padded to protect boney prominences with approaches/interventions placed in the resident's care plan. In addition, this policy states, When an existing or newly developed pressure ulcer(s) is present, a skin assessment (skin check) will be documented each shift to monitor the individual resident's tolerance to the current repositioning schedule (tissue tolerance) and the facility will re-evaluate the frequency of repositioning if indications of further breakdown occur. 1. R63's Minimum Data Set (MDS) assessment dated [DATE] documents R63 requires extensive assistance of two people for bed mobility, transfers, toilet use, and personal hygiene. R63's Braden Scale for Predicting Pressure Ulcer Risk, dated 11/1/2022, documents R63 is at risk for developing pressure ulcers because R63 responds to verbal commands but cannot always communicate discomfort or the need to be turned, or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities; R63's skin is often but not always moist requiring R63's linen needing changed at least once a shift; R63's ability to walk is severely limited or non-existent and R63 cannot bear own weight and/or must be assisted into chair or wheelchair; R63 moves feebly or requires minimum assistance and during a move, R63's skin probably slides to some extent against sheets, chair, restraints, or other devices; R63 maintains relatively good position in chair or bed most of the time but occasionally slides down. R63's admission nursing progress note dated 12/8/22 at 1:50p.m. states R63 was readmitted from the hospital on that date with, skin is intact with bright redness noted to BLE (bilateral lower extremities) from knees down with 2-3+pitting edema. This same note states, per hospital RN (Registered Nurse) in report, 2 different doctors looked at (R63's) legs with no concerns or new orders. R63's nursing progress note dated 12/12/22 at 8:39p.m. documents, Writer observed a pressure area to outer aspect of left heel. Measuring 3.25 L x 2.5 W. No pain from area. Bil lower extremities remain very tender to touch, bright red/purple in color. This note does not document whether any interventions were developed to treat R63's pressure area or to prevent R63's pressure area from getting worse. R63's nursing progress note dated 12/15/22 at 8:39p.m. documents, Blister to left heel remains intact, skin prep applied to try and toughen skin. This nurse tried to elevate R63's heels off bed, but R63 began screaming, that hurts! I don't like it this way, removed pillow and advised that I will look for booties for protection. There are no nursing progress notes indicating whether booties for protection were ever applied to R63's feet. R63's nursing progress note dated 12/19/22 at 11:21a.m. documents R63 was evaluated by a Wound Physician on that date, who diagnosed R63's left heel wound as an unstageable pressure ulcer measuring 3.0cm (centimeters) x 3.5cm. R63's Medication and Treatment Administration Records (MAR/TAR) dated 12/8/2022 to 12/31/22 do not document R63 was receiving skin assessments every shift after R63 returned from the hospital with bright red lower extremities on 12/8/22, after a pressure area was assessed on 12/12/22, after V14 diagnosed R63's left heel as having an unstageable pressure ulcer on 12/19/22, after V7 (Wound Physician) diagnosed R63's left heel ulcer as deteriorating to a stage 3 pressure ulcer on 12/28/22, or after V7 diagnosed R63's left heel as deteriorating to a stage 4 pressure ulcer on 1/4/23. An Initial Wound Evaluation and Management Summary dated 12/19/22 documents that R63 was evaluated by V14 (Wound Physician) on that date and diagnosed with an unstageable deep tissue pressure injury to the posterior lateral left foot measuring 3.0cm long x 3.5cm wide and without depth which developed 12/12/22. R63's Wound Evaluation and Management Summary dated 12/28/22 and entered by V7 (Wound Physician) documents R63's left heel wound had deteriorated to a stage 3 pressure ulcer by that date measuring 3.0cm long x 3.5cm wide. This note documents that the facility was only using pillows to elevate R63's left heel at that time. V7's recommendation at the end of this visit was for R63 to have a specialized pressure relieving boot for R63's left foot and to off-load R63's wound. R63's Wound Evaluation and Management Summary dated 1/4/23 documents that R63's left heel wound was now assessed to be a full thickness stage 4 pressure wound of R63's left, posterior, lateral heel measuring 3cm long x 2.9cm wide with the depth not measurable. This same summary documents R63 required surgical excisional debridement to her left heel stage 4 wound to remove necrotic tissue and establish margins of viable tissue. R63's Wound Evaluation and Management Summary dated 1/11/23 documents that R63 again required surgical excisional debridement of R63's stage 4 left heel pressure ulcer to establish margins of viable tissue. R63's care plan, dated as revised on 1/31/23, documents R63 is at risk for impaired skin integrity and that R63 developed a stage 4 pressure ulcer to her left lateral heel on 12/12/22. This same care plan does not include any new interventions were added to prevent the development of pressure ulcers since the care plan was initiated 10/5/2022. The only addition to R63's impaired skin integrity care plan was to monitor wound dressing to make sure it is intact and adhering, on 12/12/22. On 2/1/23 at 9:50a.m., V4 (Wound Nurse/Assistant Director of Nursing), V3 (Director of Nursing /DON) and V7 (Wound Physician) entered R63's room to evaluate R63's stage 4 pressure ulcer to R63's left lateral heel. V4 removed R63's dressing. R63's wound was an oval area approximately 3.0cm long by approximately 2.5cm wide with a tannish/orange wound bed and without drainage. V7 stated R63's wound looked 80% (percent) improved from the week before. At 10:10a.m., V7 stated he took over R63's care from V14 at the end of 12/2022. V7 stated R63's left lateral heel wound was already a stage 3 or 4 when he assessed the wound for the first time on 12/28/22. V7 stated that R63's stage 4 left heel pressure ulcer was avoidable and could have been prevented if staff had performed daily skin assessments and implemented pressure relieving interventions while R63's pressure ulcer was only a stage 1. On 2/1/23 at 11:40a.m., V4 stated she is considered the Wound Nurse for the facility. V4 stated she has only been working at the facility since 10/2022. V4 stated she did not know when R63's wound first developed and did not know what interventions were in place for pressure ulcer prevention before R63 developed her initial pressure wound on 12/12/22, before R63's wound became an unstageable pressure ulcer on 12/19/22, before R63's wound became a stage 3 pressure ulcer on 12/28/22 and before R63's wound became a stage 4 pressure ulcer on 1/4/23. V4 verified that R63's wound was not identified until 12/12/22, four days after R63 was readmitted from the hospital. V4 also verified that nursing documentation from 12/8/22 shows that R63's skin was intact at the time of readmission. V4 stated she does not know when R63 was provided with pressure-relieving boots, but states V7 wrote an order for the boots on 12/28/22. 30224 2. On 2/1/23 at 10:32 a.m., R20 was lying in bed and did not have a low air loss mattress in place. R20's Minimum Data Set assessment dated [DATE], documents R20 has severely impaired cognition, requires extensive assist of two staff for bed mobility and transfers, and is unable to ambulate. R20's Care Plan dated 12/7/22, documents R20 has a Stage IV pressure ulcer on her coccyx and is to have a low air loss mattress on (her) bed. R20's Ulcer/Wound documentation dated 1/27/21, documents R20 developed a facility-acquired stage II pressure ulcer on the coccyx on 1/25/21. R20's Wound Physician Evaluation and Management Summary, dated 2/1/23, documents R20's pressure ulcer to the coccyx first identified on 1/25/21, is now a stage IV pressure ulcer that is 2.5 cm (centimeters) by 1.3 cm. with four cm. undermining. On 2/2/23 at 9:58 a.m., V4 (Assistant Director of Nursing/Wound Nurse) stated R20's bed does not have a low air loss mattress in place. V4 stated R20's care plan interventions for the stage IV pressure ulcer include putting a low air loss mattress in place. V4 stated the low air loss mattress is very helpful for residents that have mobility deficits. V4 stated during her investigation of R20's wound, she discovered R20's coccyx wound was facility acquired. V4 stated R20's coccyx wound was identified as a stage II on 1/25/21 and at some point, worsened to a stage IV.

Based on observation, record review, and interview, the facility failed to follow facility policy and procedure related to pressure ulcers, ensure staff were knowledgeable in the assessment and staging of pressure ulcers, develop and implement pressure ulcer prevention interventions, perform treatments as ordered by the Physician, conduct ongoing wound assessments and provide timely turning and repositioning, for three of six residents (R23, R33 and R57) reviewed for pressure ulcers in a sample of 45. These failures resulted in the deterioration of R23 and R33's facility acquired pressure ulcers subsequently resulting in Stage 4 facility acquired pressure ulcers. Findings include: On 05/26/21 at 11:34 PM V2 (Director of Nursing) stated, We (the facility) have identified issues with in-house pressure ulcer development. I think it is due to use of agency staff. The agency staff do not always know our policies and procedures and do not turn and re-position residents like they should. On 5/26/21 at 12:21 PM, V2 stated the facility currently does not have a designated Wound Nurse or anyone Wound Care Certified. According to V2, all wound monitoring/assessments are completed by the floor nurse, which could be a Registered Nurse or Licensed Practical Nurse. V2 stated that nursing staff is responsible for the weekly monitoring of wounds, providing all ordered wound treatments, informing the Physician of changes in wounds, initiating a plan of care for wound prevention in the event of a decline in condition, and developing a plan of care for specific wounds identified. V2 stated frequent turning and repositioning of residents that are unable to do so for themselves is expected by staff to prevent wound development. V2 stated pressure ulcers are to be staged according to their policy and staff are not to stage wounds that have progressed to a prior stage (i.e., a Stage 4 can't later be called a Stage 2). V2 stated that nursing staff needed some education regarding accuracy of wound staging. 1. The Electronic Medical Record documents R33 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . One Braden Scale for Predicting Pressure Ulcer Risk assessment for R33 indicated a score of 17 (at risk), another a score of 13 (moderate risk), and another a score of 11 (high risk). Another Braden Scale for Predicting Pressure Ulcer Risk assessment completed on 1/01/21 scored R33 at 14 (moderate risk). R33's medical record contains no documented evidence the High Risk or Moderate Risk Protocol, as outlined in the Wound and Ulcer Policy and Procedure, was followed. A Minimum Data Set assessment, completed on 1/01/21, documents R33 requires the extensive assistance of two staff for bed mobility and transfers with a mechanical lift. R33's Plan of Care, dated 1/01/21, documents, (R33) is at risk for skin breakdown due to frequent urinary incontinence and the need for staff assistance with dressing, toileting, and grooming tasks and instructs staff to use a pressure reduction mattress, perform daily skin assessments, encourage food/fluids, and provide prompt incontinence care. A Wound Documentation Note, dated 1/27/21, documents R33 developed a Stage 2 Pressure Ulcer on the Coccyx, measuring 2.5 cm by 3.0 cm by 0.1 cm, and the wound was originally identified on 1/25/21; however, there are no initial wound measurements on 1/25/21. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment Administration Records for February 2021 document staff failed to provide Physician ordered wound care on 2/01/21, 2/06/21 and 2/09/21. The next documented wound assessment was over two weeks later, on 2/13/21, when R33's Coccyx wound measured 3.25 cm by 3.0 cm by 0.2 cm. The following day, on 2/14/21, R33's coccyx wound increased in size, measuring 4.0 cm by 3.0 cm by 0.2 cm, with necrosis and drainage. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's Plan of Care up to this point failed to identify that R33 has developed a pressure ulcer, or any new interventions related to pressure ulcer prevention, specifically a turning and repositioning program to decrease pressure on the Coccyx. On 2/16/21, Wound Documentation notes indicate no measurable change in R33's coccyx wound. The next documented wound assessment was on 2/25/21, nine days later, when R33's coccyx wound measured 5.0 cm by 4.0 cm by 0.75 cm and was identified as a Stage 3 pressure ulcer. There is no documented evidence that R33's Physician was notified of the decline in the coccyx wound at that time and there was no change in treatment orders. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Documentation notes, dated 3/02/21, document R33's coccyx wound measured 4.5 cm by 4.0 cm by 1.0 cm, with evidence of slough, necrosis, moderate drainage, and tunneling of 1.0 cm deep. On 3/05/21, Nursing Progress notes document staff obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then, on 3/10/21, Wound Documentation notes for R33 indicate the coccyx wound had deteriorated to 5.0 cm by 5.0 cm by 6.0 cm and is described as unstageable, with tunneling 6.0 cm deep, black/red slough, necrosis and crater like. Nursing Progress notes on 3/10/21 document the Physician was notified, and pain medication was ordered, with no change in wound treatment. At this time, R33's Plan of Care still failed to identify that R33 had developed a pressure ulcer, or any new interventions related to pressure ulcer prevention, specifically a turning and repositioning program to decrease pressure on the Coccyx. Nursing Progress notes, dated 3/12/21, document (R33) has been resting quietly in her bed this shift. New order of [MEDICATION(S)] 50 (milligrams three times per day) for pain control during dressing changes approved 3/10/21. Upon entry of her room every 2 hours for repositioning, this RN observed her eyes wide open. Alert without verbal response. Wincing and facial grimacing also observed during each lateral alternating turn. Fluids encouraged. Dressing on coccyx (clean/dry/intact). Last doses of scheduled (antibiotic) due today. (Assistant Director of Nursing) aware. Afebrile. This (Registered Nurse) suggested another week of (antibiotic) for current wound healing as necessary. (Physician) was faxed overnight on 3/10/21 for approval, after her rounds at the facility earlier in the day. No response yet. (Physician) is usually out of the office on Thursdays. Anticipating a response today. (Physician) observation of resident's coccyx deterioration has not been confirmed thus far. Hands on treatment is imperative at this point. Compassion visits have been approved by facility administration. (Assistant Director of Nursing) is also aware of the need for Hospice evaluation and (Power of Attorney) notification of wound condition. Staff reports resident eats 50% on a regular basis. Discomfort continues indicated by tears and outbursts of OUCH!! Will communicate with day shift to reach out to (Physician) office by phone. Will reiterate importance to (Assistant Director of Nursing). Comfort will continue to be emphasized. Nursing Progress notes dated 3/13/21 at 1:23 am, document During shift report no updates (related to continued antibiotic) for wound to (R33's) coccyx. No response in the fax box to request dated 3/11/21. No documentation regarding a phone call to the (Physician) asking to refill [MEDICATION(S)] 500 mg (twice per day). Will inquire with day shift why this issue was not followed up with during business hours. R33's Progress notes further document at 8:38 am, (R33) in extreme pain overnight this shift. Facial grimacing, clenched fists, squinted eyes with intermittent tears. [MEDICATION(S)] 50 mg given at (2:30 am). When repositioned at (4:30 am), no relief apparent. No response from (Physician related to) extending (antibiotic). (Physician) paged twice. Spoke with (Physician), on call for (Medical Director) and was suggested to send her to (the emergency room ) for proper wound treatment, observation, and pain management. Nursing Progress notes later document R33 was assessed in the emergency room and admitted to the hospital on 3/13/21. On 3/16/21, Nursing Progress notes document R33 was readmitted to the facility with a Stage 4 Pressure Ulcer to the coccyx and treatment order for staff to clean the coccyx/tunneled area with normal saline, pack the wound with wet to dry dressing of Dakin's Solution and sterile gauze twice daily, and repositioning every two hours. There is no documentation of R33's wound being measured upon her readmission 3/16/21. Treatment Administration Records for March 2021, document staff failed to provide the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/21, R33's Plan of Care was updated to reflect the presence of Pressure Ulcers. The next documented wound assessment was on 3/24/21, nine days after R33 being readmitted , and described R33's coccyx wound as 4.3 cm by 5.5 cm by 3.3 cm and Unstageable, even though it had been previously identified as a Stage 4 wound. Nursing Progress notes and Wound Documentation indicate ongoing monitoring of R33's coccyx wound. Treatment Administration Records for April and May 2021 document staff failed to complete R33's wound care as ordered by the Physician on the following dates: 4/01/21, 4/02/21, 4/05/21, 4/07/21, 4/08/21, 4/09/21, 4/14/21, 4/15/21, 4/16/21, 4/18/21, 4/20/21, 4/25/21, 4/26/21, 4/27/21, 4/28/21, 4/30/21, 5/02/21, 5/07/21 and 5/10/21. On 5/24/21, Wound Documentation notes indicate R33's coccyx wound measured 3.0 cm by 3.5 cm by 3.0 cm. On 5/24/21 at 10:05 am, R33 was sitting in her room in a recliner with a mechanical lift sling under her and continuous observation was started. At 12:29 PM, the licensed nurse went in to R33's room to administer medication and no repositioning was offered. At 12:34 PM, V13 and V27 (Certified Nursing Assistants) entered the room to transfer R33 to bed. At that time, V13 stated R33 had been up in her recliner since approximately 9:30 am. V13 and V27 provided R33 with incontinence care once she was in her bed. R33 had been incontinent of urine and once the incontinence brief was removed, the coccyx was noted to not have a dressing in place, and just packed with gauze. V13 stated R33's wound should have been covered with a secured dressing on top of the packed gauze. R33's recliner did not have a specialized cushion to off load pressure. V13 stated, because of R33's pressure ulcer, she is supposed to be repositioned every two hours by staff. On 5/25/21 at 2:42 p.m., V6 (Registered Nurse) changed R33's coccyx dressing and R33 was observed to have an open wound, approximately the size of a golf ball with additional tunneling. 2. The Electronic Medical Record documents R23 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A follow up Braden Scale for Predicting Pressure Ulcer Risk, dated 10/27/20, scored R23 at a 16, which is mild risk for the development of pressure ulcers and reflects a health decline. On 10/29/20, R23's Minimum Data Set assessment documents she required the extensive assistance of one staff member for bed mobility and all Activities of Daily Living. A 10/29/20 Plan of Care documents R23 is at risk for impaired skin integrity, related to immobility and incontinence, and only instructs staff to follow Physician treatment orders per facility protocol, monitor nutritional status, and provide incontinence care after each episode. On 11/14/20, another Braden Scale for Predicting Pressure Ulcer Risk was completed and R23 scored a 12, indicating she was now at high risk for the development of pressure ulcers and further health decline. R23's Plan of Care fails to document any new interventions implemented at that time to prevent the development of pressure ulcers and R23's medical record contains no documented evidence of the implementation of the High Risk Protocol, as outlined in the Wound and Ulcer Policy and Procedure. Nursing Progress notes, dated 1/15/21, document, (R23) has two pressure injuries observed; (R23) has a pressure injury to lower mid back and a pressure injury to right buttocks. Wound Documentation Notes, dated 1/15/21, document R23 as having a Stage 2 Sacral Wound, measuring 2.5 cm (centimeters) by 0.5 cm. Wound Documentation Notes and Nursing Progress notes do not contain any documented evidence that the lower mid back wound was measured and staged by the nurse, that the Physician was notified of either wound, that a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/22/21, Wound Documentation Notes document R23 as having an in house acquired Stage 2 Pressure Ulcer on the low back, measuring 1.0 cm (centimeters) by 0.5 cm by 0.1 cm, and a Stage 2 Pressure Ulcer on the Coccyx, measuring 6 cm by 3 cm by 0.1 cm. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Plan of Care failed to identify any new interventions related to pressure ulcer prevention or her current wounds. Wound Documentation notes, dated 2/03/21, document the Coccyx pressure ulcer increased in size and measured, 8.5 cm by 10 cm by 0.1 cm and the lower back pressure ulcer measured 1.0 cm by 0.25 cm by 0.1 cm. The following week, on 2/11/21, Wound Documentation Notes document both wounds increased in size and had evidence of necrotic tissue, with the Coccyx wound measuring 8.5 cm by 12.0 cm by 0.25 cm, and the lower back wound measuring 2.0 cm by 1.75 cm by 0.25 cm. The Treatment Administration Record, document on 1/22/21, the Physician ordered staff to clean the Coccyx and lower back wounds with wound cleanser, apply Calcium Alginate and cover with a border foam gauze dressing twice per day; R23's medical record documentation indicates staff failed to perform the wound care as ordered by the Physician on 1/24/21, 1/26/21, 1/27/21, 1/30/21, 1/31/21, 2/01/21, 2/02/21, 2/05/21, 2/07/21, 2/08/21, and 2/09/21. The facility failed to assess and measure R23's wounds the week of 2/18/21, which was the same week R23 was placed on Hospice care. The next documented wound assessment was on 2/28/21, 17 days later, in which the Coccyx wound measured 8.5 cm by 14 cm by 0.75 cm and the lower back wound measured 1.75 cm by 1.5 cm by 0.25 cm. Both wounds are documented to have continued necrosis. R23's Plan of Care failed to identify any new interventions related to pressure ulcer prevention or her current wounds. On 3/02/21, the Wound Documentation notes document R23 had a Stage 3 Coccyx Pressure Ulcer that measured 9.0 cm by 14.0 cm by 0.75 cm. There was no change in size of the lower back wound. On 3/09/21, Wound Documentation notes document R23 had a Stage 4 Coccyx Pressure Ulcer, measuring 14.0 cm by 9.0 cm by 2.5 cm, with slough, heavy drainage and tunneling observed at 10 o'clock (approximately) 0.75 cm deep. On 3/11/21, the Wound Documentation notes document R23 has a Stage 3 lower back Pressure Ulcer that measured 2.1 cm by 1.5 cm by 0.5 cm. R23's Plan of Care failed to identify any new interventions related to pressure ulcer prevention or her current wounds, specifically a turning and repositioning program to decrease pressure on the Coccyx and low back. The electronic medical record documents weekly wound measurements continued, along with various wound treatments. R23's Wound Documentation Notes, dated 5/18/21, document the low mid back wound as a Stage 3 pressure ulcer, measuring 1.6 cm by 0.8 cm by 3.6 cm (depth), and the Coccyx wound as a Stage 3 pressure ulcer, measuring 5.7 cm by 3.4 cm by 1.8 cm. R23's Current Plan of Care remains the same as it was on 10/29/20 which was prior to the pressure ulcers developing, only identifying R23 as being at risk for the development of Pressure Ulcers with the same interventions. Wound Documentation Notes, dated 5/22/21, document R23 now has an additional Pressure Ulcer located on her Right Ankle, measuring 1.8 cm by 1.6 cm by 0.3 cm. On 5/25/21 at 9:23 am, V12 (Certified Nursing Assistant) had just finished feeding R23 breakfast, as R23 was lying in her bed, with the head of the bed elevated. At 10:00 am, V12 provided incontinence care to R23 and transferred R23 to a recliner in her room. The recliner did not have any pressure reduction cushion or pillows to shift R23's weight on her coccyx. R23 was observed continuously in the same position in her recliner, until 1:30 PM. During that timeframe, V12 did enter R23's room at 12:20 PM, but no repositioning was provided. At 12:40 PM, V12 entered R23's room again and asked R23 if she wanted to eat her lunch in her recliner or in her bed. V12 did not encourage R23 to reposition or offload the pressure to her coccyx, and R23 stated she would stay in her recliner for lunch. At 12:54, V12 did bring the head of the recliner up, so she could feed R23 her lunch; however, direct pressure remained on R23's coccyx. At 1:08 PM, V12 stated to R23, You need to lay down and get off your bottom and R23 agreed. At 1:30 PM, V13 (Certified Nursing Assistant) and V14 (Admissions Coordinator/Certified Nursing Assistant) transferred R23 with a mechanical lift to her bed. R23 was incontinent of feces and peri care was provided. R23 had intact dressings over an area of her lower spine and her coccyx. R23's vertebrae were very prominent and the skin over the vertebrae directly above the lower spine dressing was reddened. R23's lower buttocks was red and creased from sitting. R23 also had a dressing covering a pressure ulcer on her right inner ankle. After providing care, V13 positioned R23 on her left side, with pillows between her legs and a foam boot on her right foot. At that time, V12 confirmed that R23 is to be repositioned every two hours. V12 was questioned if they ever attempt to off load pressure to R23's coccyx or attempt to shift her weight while she is in the recliner and V12 stated it's difficult to offload pressure to R23's pressure ulcers, because she has three of them. On 5/26/21 at 12:30 PM, V21 (Medical Director) stated she is seeing a trend where individuals who normally might not have skin issues, get COVID and then develop pressure ulcers. V21 stated this can be attributed to their lack of desire to want to get out of bed, lack of appetite, and multiple other issues leading to a general decline. V21 stated R23 and R33, both developed COVID, and shortly after suffered from skin breakdown, leading to their Stage 4 Ulcers. V21 stated that accurate skin assessments, accurate identification of pressure ulcer risk and appropriate implementation of interventions would have been imperative in the attempt to prevent R23 and R33's wounds from developing/progressing. 3. R57's Minimum Data Set (MDS) assessment dated [DATE] documents that R57 had no functional limitations in range of motion to her upper and lower extremities at that time. This same MDS documents that R57 requires only supervision of one person for ambulation. R57's Braden Scale for Predicting Pressure Ulcer Risk dated 3/25/21 documents R57 was at low risk for developing a pressure ulcer at that time. R57's MDS dated [DATE] documents R57 was unable to walk, required extensive assistance of two people for bed mobility and transfers; and had a functional limitation in range of motion to one upper and one lower extremity. R57's fall investigation dated 4/7/21 documents R57 fell on her left side while in the bathroom resulting in hospitalization for left hip and left wrist fractures. R57's Nurse's notes dated 4/12/21 document that R57 was readmitted to the facility following surgical repair to R57's fractured left hip and wrist. These Nurse's notes do not document any measures were put into place to address R57's decrease in mobility or for pressure ulcer prevention. R57's Nurse's note dated 4/17/21 document that R57 had functional impairment in range of motion to one upper and one lower extremity, had an incision to the left hip and a cast to the left arm. R57's medical record does not include any additional Braden Scales for Predicting Pressure Ulcer Risk following R57's readmission from the hospital to determine if her decreased mobility put her at increased risk for the development of pressure ulcers until 5/8/21. R57's Nurse's note dated 5/3/21 documents R57 developed a large fluid filled blister on her left heel. This note does not include documentation that interventions were put into place to treat or to relieve pressure from R57's left heel. R57's Nurse's note dated 5/8/21 documents that a pressure ulcer risk assessment was done at that time and found that R57 was now considered at risk for developing pressure ulcers. This same Nurse's note has an area to list clinical suggestions to address R57's pressure ulcer risk but no clinical suggestions are listed. R57's Nurse's note dated 5/10/21 documents R57's, Blister to heel is now open. Entire area is dark red in color, tender to touch. R57's Nurse's note dated 5/12/21 documents that R57's left heel wound had developed serosanguinous (blood tinged) drainage and yellow slough. R57's Wound Documentation form dated 5/2/21 at 12:05 a.m. documents a pressure ulcer was initially identified to R57's left heel measuring 7.5 cm (centimeters) long x 9.5 cm wide on that date, which developed at the facility. This wound documentation does not identify the stage of this wound, however, a description of pressure wound stages listed on the form describes a blood-filled blister as a suspected deep tissue injury. R57's Wound Documentation form dated 5/13/21 documents R57's left heel pressure wound had deteriorated into a Stage 2 pressure ulcer measuring 8.5 cm long x 9.5 cm wide x 0.25 cm deep. A description of the wound is documented as, Blister opened at some time. Now (with) yellow slough at times, with serous drainage. A description of pressure wound stages on the form describes a stage 2 pressure ulcer as being without slough, but a pressure wound with slough is describes as either a stage 3, stage 4, or an unstageable pressure ulcer. R57's Care Plan does not document a plan with interventions to prevent the development of pressure ulcers until 5/24/21, after R57's left heel pressure ulcer had already developed. On 5/24/21 at 3:44 p.m. V18 (Licensed Practical Nurse/LPN) stated she was the nurse to initially find R57's left heel wound and obtain treatment orders. V18 stated that R57's wound started out as a black fluid filled blister which deteriorated to a black flattened area. V18 stated that R57 was admitted to the hospital on 5/16/21 then returned 5/20/21 and that is when a pressure relief boot was ordered for R57's left foot. V18 stated that there is no trained wound nurse or wound specialist who evaluates, measures, and treats wounds at the facility. V18 stated that every Tuesday R57's wound is measured and described by whoever is R57's nurse that day. On 5/26/21 at 10:51 V15 (Certified Nurse Aide/ CNA) stated she was one of R57's regular CNAs. V15 stated that CNA staff were not given any instructions for turning, repositioning, or relieving pressure from R57's heels when she returned from the hospital following R57's fall with fracture to her left hip and left wrist on 4/12/21. V15 stated that R57 did not have a pressure relief boot for her left foot until she returned from the hospital on 5/20/21. R57's CNA Intervention/Task sheets, which instruct CNAs on what cares and interventions should be done for each resident, dated 4/1/21 to 5/26/21 do not include a program for turning, repositioning, or elevating R57's heels for pressure relief. On 5/24/21 at 3:44p.m. V18 removed the dressing from R57's left heel pressure ulcer. R57's left heel had a large round wound which was covered with blackened tissue and which encompassed R57's entire heel. On 5/26/21 at 8:50a.m. V2 (Director of Nurses/DON) stated that inconsistency among nursing staff for determining the stage of pressure ulcers has been a problem at the facility. V2 stated that he looks at the wound reports once a resident develops pressure ulcers but does not evaluate the wounds to determine if they are staged appropriately. V2 stated the facility does not have a certified wound nurse or a wound specialist to evaluate wounds. V2 stated that R57 did not have weekly Braden scoring done to determine whether R57 was at increased risk for pressure ulcers once she returned from the hospital 4/12/21 following a fracture to her left hip and left wrist. V2 stated that R57 should have had pressure ulcer preventive measures put into place once she was no longer independently mobile. V2 stated that at the time of R57's fall, she was independent with walking, turning, and repositioning but after fracturing her left hip, R57 was no longer able to walk which makes her more dependent on staff for mobility. V2 stated that the facility should have developed a plan of care to include pressure ulcer prevention measures before R57 developed a left heel pressure ulcer on 5/2/21. V2 stated that staff should have ensured R57's heels were elevated to prevent the development of R57's left heel pressure ulcer. The facility policy, titled Wound and Ulcer Policy and Procedure (revised 1/10/2018), documents, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale Ulcer Risk Assessment. The resident will be assessed upon admission, once a week for four weeks, and monthly thereafter. Protocols may include any or all for the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. The policy outlines a Moderate Risk Protocol as the following, Daily skin check - completed by direct care staff. The 'Skin Observation Report' may be used to communicate skin observation(s) or changes to the nurse. Mattress with documented pressure reducing/relieving properties may be placed on the resident's bed. If appropriate, a cushion with pressure reducing/relieving properties may be used in the resident's chair. If incontinent, care may include the use of barrier creams to minimize the effects of urine and feces on the skin. Range of motion and turning and positioning will be provided if clinically indicated. The Dietary Manager will evaluate the resident quarterly for nutritional factors and recommend interventions as needed. Approaches will be placed in the resident care plan. Changes in condition (activity level, mental status, mobility, nutritional status, incontinence) are promptly reported. The policy further outlines a High Risk Protocol as the following, Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. Daily skin check - completed by direct care staff. The 'Skin Observation Report' may be used to communicate observations or changes to the nurse. Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing/relieving properties may be placed on the resident's bed and chair as indicated. Skin contact surfaces may be padded to protect bony prominences. Range of motion may be provided if clinically indicated. The resident may be placed on a turn and reposition schedule if clinically indicated. Dietitian may recommend monthly evaluation of the resident. A resident with existing skin breakdown will be evaluated monthly. Approaches will be placed in the resident's care plan. Changes in condition are properly reported. The policy also documents, When a resident is found to have a wound (or ulcer, our licensed nurse will complete), either on admission or during their stay, the following: Document assessment of the wound/ulcer in the medical record. Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed. The classification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Document wound/ulcer treatment provision on the treatment administration record (eTAR). Notification of the Physician, documenting, and initiating ordered treatment. Transcribing, documenting, and initiating written and/or verbal orders of the Physician. Orders for Vitamin C 500 mg (milligrams) daily and/or [MEDICATION(S)] 220 mg daily and/or MVI (multi-vitamin) daily may be requested in addition to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Notification of the Power of Attorney for Healthcare regarding change in the resident's condition. Care interventions for staff involved in the resident's care are communicated via the resident care plan. Assessment of progress toward healing is completed at least weekly and the Physician is notified at least monthly of progress toward healing. If there is regression, the Physician is notified of the condition change. Treatment continues per the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidance for using dedicated staff in a COVID-19 unit and the CDC's return to work guidance for employees following the development of symptoms after testing positive for COVID-19. These failures resulted in nurses providing direct care to highly infectious Covid-19 positive residents, non-infected residents at the same time, and a Certified Nurse Aide who tested positive for COVID-19 being allowed to return to work caring for non-COVID-19 residents only six days after the onset of symptoms . These failures have the potential to affect all 83 residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/4/20, the facility remained out of compliance at Severity level 2. The facility is in the process of performing daily monitoring to ensure compliance with the Disaster Preparedness Plan, Testing and Response plan, specifically the contingency plan and monitoring the return to work criteria compliance for COVID-19 positive staff. Findings include: A CDC Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 11/4/20 states, As a measure to limit HCP (Healthcare Personnel) exposure and conserve PPE (personal protective equipment), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected, or confirmed [DIAGNOSES REDACTED]-CoV-2 infection (COVID-19). Dedicated means that HCP are assigned to care only for these patients during their shifts. A CDC Preparing for COVID-19 in Nursing Homes guidance updated 11/20/20 states, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at risk of being affected by respiratory pathogens like COVID-19 and other pathogens. This guidance also states, As demonstrated by the COVID-19 pandemic, a strong Infection Prevention and Control (IPC) program is critical to protect both residents, and Healthcare Personnel (HCP). This policy further states, Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19, and Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. A CDC [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance) Return-To-Work Criteria updated 8/10/20 states, Symptom-based strategy for determining when (HCP) can return to work. (HCP) with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever reducing medications and Symptoms (e.g., cough, shortness of breath) have improved. This guidance further defines, Mild illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging. A Facility Disaster Preparedness Plan dated 11/1/16 and updated 11/12/20 states, Every attempt will be made to utilize the same staff to manage the care of the COVID-19 residents. A dedicated COVID-19 care team will be created. A Facility COVID-19 Testing and Response Plan revised 10/27/20 states that when a symptom-based strategy is used to determine when an employee can return to work following a mild, to moderate illness with COVID-19, a. At least 10 days have passed since symptoms first appeared and b. At least 24 hours have passed since last fever without the use of fever-reducing medications and c. Symptoms (e.g., cough, shortness of breath) have improved. This policy further instructs, iv. Consider that staff caring for positive or symptomatic residents do not care for negative or asymptomatic patients. On 11/30/20 at 8:50a.m., 12/1/20 at 10:42a.m., 12/4/20 at 4:23p.m., and 12/7/20 at 8:40a.m., V1 stated that the facility has had an outbreak of COVID-19 among residents and staff since 11/8/20. V1 stated there are currently approximately 10 residents who are positive for COVID-19 and are being isolated on the facility's COVID-19 unit or red zone on the South end of the building. V1 stated that the facility tries to use dedicated staff to work only in the Covid-19 unit during their shift, but it is not always possible. V1 stated that usually during the night shift (11:00p.m.-7:30a.m.) there are only two nurses in the facility which means one nurse is assigned to care for the North end where residents are COVID negative and one nurse is assigned to the South end where that nurse cares for COVID positive residents (red zone), COVID negative residents (green zone), and residents in quarantine because their COVID status is unknown (yellow zone), all during the same shift. V1 stated that the daily assignment sheet indicates which end of the building each nurse is assigned. V1 stated that on the daily assignment sheet when the nurse is providing care for the red, yellow, and green zones on the South end, the assignment sheet either indicates the word South above the nurse's name or it indicates the red and/or yellow units which means that nurse also cares for the residents in the green zone located on the South end of the building. V1 stated that the only way to access the South green, yellow, and red zone hallways is by exiting the building and going into those halls from side entrances. V1 stated the facility closed off the South side from the North side of the building so South side nursing staff do not potentially infect the North side of the building with COVID-19. V1 stated that at the beginning of the outbreak, 11/08/20, there was only one hallway on the South side of the building which was for COVID-19 positive residents, and residents whose COVID status was unknown. V1 stated that around 11/11/20 as more and more residents either became COVID positive or they had an exposure, or their COVID status was unknown, the facility was forced to make one entire South hallway the red zone, one the yellow, and the remaining hallway was still considered the green zone. V1 stated that the facility is planning to move residents from the green zone on the South end of the building to the green zone halls on the North side. V1 stated she is hesitant about that move since the South side green zone residents may have had exposure to COVID-19 since they were cared for by nursing staff who were not dedicated to the red, or yellow zones. On 11/30/20 at 10:40a.m., the North side nurses' station was located between the three halls on the North end of the building, nursing staff were noted sitting at the nurse's station. Each of the three hallway doors was closed but staff were noted to have access to each other between the halls as they walked in and out of each hallway door to access supplies or the nurse's station. The South side of the facility had an access door from the activity room which connected the North, and South sides of the building. This South hall access door was completely covered with plastic indicating that entrance to the South side was not to be used. The South side green zone side entrance was unlocked and opened directly into where the residents' rooms were located. At the end of the green zone hall was plastic covering the entrance to the red zone and the entrance to the yellow zone resident rooms. A Facility floor plan (undated) documents the facility has three green zone halls on the North end and a red zone hall, a yellow zone hall, and a green zone hall on the South end of the building. Facility nursing staff assignment sheets dated 11/08/20, the first day of the COVID-19 outbreak, to 12/01/20 documents that from 7:00a.m. to 11:30p.m. the facility has dedicated nursing staff to the red, green, and yellow zones. These same staff assignment sheets also document that from 11:30p.m. to 7:00a.m. there is either only one nurse assigned to the South end of the building or two nurses split a shift meaning one nurse works the first half of the shift and a second nurse works the last half of the shift. This indicates that one nurse is caring for the Green Zone (COVID 19 Negative), Yellow Zone (PUI) and Red Zone (COVID 19 Positive) residents simultaneously during the same shift. A Facility Line List of residents who tested positive for Covid-19 dated from 11/08/20 to 12/01/20 documents a total of 27 residents have tested positive for COVID-19 in that time period. Of those residents, 16 resided on the South end of the building in the yellow, or green COVID negative units where the night shift nurse provided care to Covid positive and Covid negative residents during the same shift. On 11/30/20 at 9:50a.m., V6 (Registered Nurse) stated that she worked during the night shift on the South end of the building starting at 3:00a.m. on 11/28/20. V6 stated that she was the only nurse on her shift from 3:00a.m. until 7:30a.m. caring for residents in the green zone, yellow zone, and red zones on the South end of the building. V6 also stated that she had to enter all three zones during her shift to care for residents. V6 verified that red zone residents have tested positive for COVID-19, green zone residents are negative for COVID-19, and yellow zone residents are in quarantine because their COVID-19 status is unknown. A Facility Line List of staff who tested positive for COVID-19 dated 11/04/20 to 12/01/20 documents that V15 (Certified Nurse Aide/CNA) tested positive for COVID-19 on 11/18/20 but developed symptoms of fever, cough, and headache on 11/27/20. Facility nursing staff assignment sheets dated 12/01/20 documents V15 was scheduled to work the day shift from 6:00a.m. to 2:00p.m. on the North side of the building or green zone where residents are COVID-19. On 12/01/20 at 8:50a.m., V15 stated this was her first day back to work providing direct resident care following testing positive for COVID-19 on 12/18/20. V15 stated that she did not have any symptoms at the time she tested positive but then developed the symptoms of sore throat, cough, runny/stuffy nose, and a fever over 100 degrees Fahrenheit on 11/25/20. V15 stated she returned to work today, 12/01/20, six days after developing symptoms of COVID-19, because the facility told her she could return to work because she had met their criteria of being fever-free for 24 hours. On 12/01/20 at 9:50a.m., V3 (Assistant Director of Nurses) stated that she is also the facility's Infection Preventionist. V3 stated that she thought an employee who tests positive for COVID-19 is supposed to be off work for 11 days plus 36-72 hours without a fever, however, V3 stated that V1 is making the decision when staff who test positive for COVID-19 can return to work. On 12/01/20 at 10:42a.m., V1 verified that V15 tested positive for COVID-19 on 11/18/20 and developed symptoms on or around 11/27/20 based on V1's COVID-19 outbreak employee tracking sheet. V1 also verified that today, 12/01/20, upon returning to work, V15 was working on a green zone hallway on the North side of the building where residents are COVID-19 negative. V1 stated that it is the facility policy that employees may return to work 10 days after testing positive for COVID-19. V1 stated she was not aware of the CDC return-to-work criteria instructing for employees who test positive for COVID-19 to be off work for 10 days following the onset of symptoms. A Resident Census and Condition of Residents report dated 11/30/20 and signed by V20 (Minimum Data Set Coordinator) documents that at the time of the survey 83 residents resided in the facility. An Immediate Jeopardy was identified on 12/02/2020 at 4:17p.m. The Immediate Jeopardy began on 11/08/20 when the facility scheduled only one nurse to work on nights on the South end of the facility where that nurse cared for COVID positive residents (red zone), COVID negative residents (green zone), and residents in quarantine because their COVID status is unknown (yellow zone), all during the same shift. This Immediate Jeopardy also includes the facility allowing a COVID-19 positive employee (V15) to return-to-work caring for COVID-19 negative residents only 5-7 days after V15 developed her initial symptoms of a sore throat, cough, runny/stuffy nose, and a fever over 100 degrees Fahrenheit. On 12/03/20 at 1:55p.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. On 12/07/20 at 8:30a.m., the surveyor confirmed through observation, interview, and record review, that the facility took the following actions to remove the Immediate Jeopardy: 1. All facility staff were educated by V1 (Administrator), V2 (Director of Nurses), V3 (Assistant Director of Nurses) regarding the following CDC guidance and the facility's Disaster Preparedness Plan to have a dedicated COVID-19 care team to care for COVID-19 positive residents. 2. V23 (Nurse Aide Scheduler) was educated on assigning appropriate levels of dedicated care teams to each of the three zones (red, yellow, green) twenty-four hours a day, seven days a week. 3. All facility staff were educated by V1, V2, and V3 regarding following CDC guidance and the facility's COVID-19 Testing and Response Plan requiring employees who test positive for COVID-19 to not return-to-work until at least 10 days after symptoms first began. 4. A memorandum of individually directed education was completed with V1(Administrator) specifically regarding the return-to-work criteria for COVID-19 staff that later develop symptoms.

Based on interview and record review the facility failed to notify a physician with a significant change in weight for one of three residents (R1) reviewed for weight monitoring in a sample of three. This failure resulted in R1 gaining nine pounds in less than ten days requiring hospitalization for acute kidney injury. Findings include: A Physician order [REDACTED].to provide treatment according to the attending physician for each resident of the facility. and that physician's orders [REDACTED].shall be given as prescribed by the physician . A Standard of Care policy dated 2/20/2013 states, Resident care will be rendered under the direction and order of the attending physician . A Guideline for Physician Notification of Change in Resident Condition policy dated 1/2011 documents, Staff observe document and communicate to the physician changes in resident condition promptly .It is the responsibility of each nurse to notify the physician of a significant change in condition before the end of the shift. R1's physician's orders [REDACTED]. If gain in weight more than five pounds in less than ten days call Principle Care Physician (PCP) Immediately. R1's electronic record of current [DIAGNOSES REDACTED]. R1's care plan dated 10/27/15 states, Monitor/document/report to MD PRN (as needed) any signs and symptoms of [MEDICAL CONDITION] dependent [MEDICAL CONDITION] .weight gain . R1's Weights and Vitals Summary Sheet dated 3/01/16 to 4/19/16 documents R1's weight increased by five or more pounds in less than 10 days five times during that time period. On 3/07/16 R1's weight was 192 pounds (lbs) and on 3/08/16 R1's weight had increased to 198.4 lbs, an increase of 6.4 lbs. From 3/16/16 to 3/18/16 R1's weight increased from 192.6 lbs to 197.8 lbs, an increase of 5.2 lbs. From 3/21/16 to 3/30/16 R1's weight increased from 192.2 lbs to 197.8 lbs, an increase of 5.6 lbs. From 4/17/16 to 4/18/16 R1's weight increased from 200.4 lbs to 205.8 lbs, an increase of 5.4 lbs. From 4/13/16 to 4/18/16 R1's weight had increased by a total of 9.8 lbs. R1's nurses' notes dated 3/07/16 to 3/11/16 do not include any nurses' documentation for the date of 3/08/16. R1's nurses' notes dated 3/18/16 document E15 (Licensed Practical Nurse/LPN) was R1's nurse on that date. R1's nurses' notes do not include documentation related to R1's weight gain or that R1's physician had been notified. R1's nurses' notes dated 3/28/16 to 4/01/16 do not include any nurses' documentation for the date 3/30/16. R1's nurses' notes dated 4/18/16 document E8 (Registered Nurse) was R1's nurse on that date. The nurses' notes state, R1's output was only 240 cc (cubic centimeters) this is significantly less than normal . R1's nurses' notes do not document R1's physician was notified of R1's weight gain of 9.8 lbs or that R1's urinary output was significantly less than normal. R1's nurses' notes dated 4/19/16 document that R1's physician was not notified of R1's weight gain along with the symptoms of [MEDICAL CONDITION], decreased lung sounds, decreased urinary output, and a bounding left radial pulse until that date by E7 (Registered Nurse/RN). And E7's nurses' notes state R1's physician was notified of a 6 lb weight gain instead of 9.8 lbs. E7's note also documents R1 was transferred to the hospital for evaluation. R1's hospital progress note dated 4/19/16 documents R1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. On 4/27/16 at 1:50pm. E15, LPN, verified being R1's nurse on 3/18/16. E15 stated R1's physician ordered for R1 to have daily weights to monitor for [MEDICAL CONDITION] stating, .To see if they are gaining water weight . E15 verified that the doctor's orders are important to follow. E15 stated that he does not look at R1's weights and did not contact R1's physician on the dates 3/18/16. E15 stated, I never compared the weights over a ten day period, for R1. I put R1's fluids into the computer from my shift. I've never looked at R1's total intake or output for the day. On 4/27/16 at 10:55am. E8, RN, verified having been R1's nurse on 4/18/16. E8 stated, R1's daily weights are done to monitor potential fluid retention which is a precursor to [MEDICAL CONDITIONS] and other problems. I didn't necessarily look at R1's weights everyday. In my mind I did think that R1's weight was under 200 lbs. Normally I don't chart his weight. His weight was in the realm I thought was okay. I don't recall calling the physician for any weight changes for R1 on 4/18/16. I told the next nurse to just monitor R1's weight and fluid intake. On 4/27/16 at 11:30a.m. E7,RN, verified being R1's nurse on 4/19/16. E7 stated that E7 thinks that following physician's orders [REDACTED]. I don't usually look at the weights unless that shift tells me that there's a weight gain. I did contact the doctor on 4/19/16 to tell him about the weights. R1 had gained six pounds. E7 stated that E7 did not look back over the nine previous days weights to see how much weight gain R1 actually had during that time frame. Z1/R1's Physician stated on 4/27/16, I put R1 on daily weights because of [MEDICAL CONDITION]. Weight gain (due to [MEDICAL CONDITION]) can cause further liver failure and kidney failure in R1. I wrote the order( for daily weights) and I expect my orders to be followed. I don't write orders without a reason. I have never been notified of a five pound weight gain until 4/19/16. If staff don't call me about weight gain that is absolutely harmful to R1.

Based on interview and record review the facility failed to assess for weight gain and monitor fluid intake for a resident at risk for fluid retention related to [MEDICAL CONDITION] and Kidney Injury for one of three (R1) reviewed for fluid intake and weight monitoring. These failures resulted in R1 being hospitalized for [REDACTED]. Findings include: A Physician order [REDACTED].to provide treatment according to the attending physician for each resident of the facility. and that physician's orders [REDACTED].shall be given as prescribed by the physician . A Standard of Care policy dated 2/20/2013 states, Resident care will be rendered under the direction and order of the attending physician . A Guidelines for Physician Notification of Change in Resident Condition policy dated 1/2011 documents, Staff observe document and communicate to the physician changes in resident condition promptly .It is the responsibility of each nurse to notify the physician of a significant change in condition before the end of the shift. R1's physician's orders [REDACTED]. If gain in weight more than five pounds in less than ten days call Principle Care Physician (PCP) Immediately. R1's Fluid Restriction also ordered on this date is 1200 ml (milliliters). R1's electronic record of current [DIAGNOSES REDACTED]. R1's care plan dated 10/27/15 states, Monitor/document/report to MD PRN (as needed) any signs and symptoms of [MEDICAL CONDITION] dependent [MEDICAL CONDITION] .weight gain . E3, Corporate Dietitian, at 1:20 pm on 4/25/16 stated that fluids are divided up between nursing and dietary, dietary tracts the fluids at meals and puts the amount into the computer, and dietary does not verbally tell nursing when this happens. E3 stated, Sometimes he wants more, we give him more and we record it. They can see it for themselves on the computer. R1's Weights and Vitals Summary Sheet dated 3/01/16 to 4/19/16 documents R1's weight increased by five or more pounds in less than 10 days five times during that time period. On 3/07/16 R1's weight was 192 pounds (lbs) and on 3/08/16 R1's weight had increased to 198.4 lbs, an increase of 6.4 lbs. From 3/16/16 to 3/18/16 R1's weight increased from 192.6 lbs to 197.8 lbs, an increase of 5.2 lbs. From 3/21/16 to 3/30/16 R1's weight increased from 192.2 lbs to 197.8 lbs, an increase of 5.6 lbs. From 4/17/16 to 4/18/16 R1's weight increased from 200.4 lbs to 205.8 lbs, an increase of 5.4 lbs. From 4/13/16 to 4/18/16 R1's weight had increased by a total of 9.8 lbs. R1's fluid intake sheet, dated 4/06/16 to 4/19/16 documents R1's fluid intake above 1200 cc (cubic centimes) three times during that period. On 4/13/16 R1 consumed 1290 cc or 90 cc above R1's fluid allowance. On 4/14/16 R1 consumed 1440 cc or 240 cc above fluid allowance. On 4/18/16 R1 consumed 1290 cc or 90 cc above fluid allowance. This sheet also documents eight days that R1's fluid intake was under 1200 cc. On 4/06/16 R1's fluids intake was 360 cc or 840 cc under the fluid allowance. On 4/07/16 R1's fluid intake was 520 cc or 680 cc under the fluid allowance. On 4/08/16 R1's intake was zero. On 4/09/16 R1's intake was 150 cc, 1050 cc under the fluid allowance. On 4/10/16, R1's intake was 800 cc, 400 cc under R1's fluid allowance. On 4/11/16 R1's intake was 430 cc, or 770 cc under R1's fluid allowance. On 4/12/16 R1's intake was 120 cc or 1080 cc under R1's fluid allowance. On 4/16/16 and R1's intake was 1110 or 90 cc under R1's fluid allowance. On 4/17/16 R1's fluid intake was 840 cc or 360 cc under R1's fluid allowance. R1's nurses' notes dated 3/07/16 to 3/11/16 do not include any nurses' documentation for the date of 3/08/16. R1's nurses' notes dated 3/18/16 document E15 (Licensed Practical Nurse/LPN) was R1's nurse on that date. R1's nurses' notes do not include documentation related to R1's weight gain or that R1's physician had been notified. R1's nurses' notes dated 3/28/16 to 4/01/16 do not include any nurses' documentation for the date 3/30/16. R1's nurses' notes dated 4/06/16 do not document the decrease in fluid intake. R1's nurses' notes dated 4/06/16 to 4/11/16 do not include any nurses' documentation for the dates 4/07/16, 4/08/16 and 4/10/16. R1's nurses notes dated 4/11/16 did not document that R1's nurse reported decreased fluid intake. R1's nurses notes dated 4/12/16 did not document R1's decreased fluid intake. R1's nurses' notes dated 4/12/16 to 4/16/16 do not include any nurses' documentation for the dates of 4/13/16 or 4/14/16. R1's nurses notes dated 4/16/16 document R1 is compliant with fluid restriction and that output is less than usual but does not document R1's decreased fluid intake. R1's nurses notes dated 4/17/16 documents decreased output of fluids but does not document R1's decreased fluid intake. R1's nurses' notes dated 4/18/16 document E8 (Registered Nurse) was R1's nurse on that date. The nurses' notes state, R1's output was only 240 cc (cubic centimeters) this is significantly less than normal . R1's nurses' notes do not document R1's physician was notified of R1's weight gain of 9.8 lbs, that R1's urinary output was significantly less than normal or that R1 had consumed 1290 cc, or 90 cc over his fluid allowance. R1's nurses' notes dated 4/19/16 document that R1's physician was not notified of R1's weight gain along with the symptoms of [MEDICAL CONDITION], decreased lung sounds, decreased urinary output, and a bounding left radial pulse until that date by E7 (Registered Nurse/RN). And E7's nurses' notes state R1's physician was notified of a 6 lb weight gain instead of 9.8 lbs. E7's note also documents R1 was transferred to the hospital for evaluation. R1's hospital progress note dated 4/19/16 documents R1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. On 4/27/16 at 1:50pm. E15, LPN, verified being R1's nurse on 3/18/16. E15 stated R1's physician ordered for R1 to have daily weights to monitor for [MEDICAL CONDITION] stating, .To see if they are gaining water weight . E15 verified that the doctor's orders are important to follow. E15 stated that he does not look at R1's weights and did not contact R1's physician on 3/18/16. E15 stated, I never compared the weights over a ten day period, for R1. On 4/27/16 at 10:55am. E8, RN, verified having been R1's nurse on 4/18/16. E8 stated, R1's daily weights are done to monitor potential fluid retention which is a precursor to [MEDICAL CONDITIONS] and other problems. I didn't necessarily look at R1's weights everyday. In my mind I did think that R1's weight was under 200 lbs. Normally I don't chart his weight. His weight was in the realm I thought was okay. I don't recall calling the physician for any weight changes for R1 on 4/18/16. I told the next nurse to just monitor R1's weight and fluid intake. On 4/27/16 at 11:30a.m. E7,RN, verified being R1's nurse on 4/19/16. E7 stated that E7 thinks that following physician's orders [REDACTED]. I don't usually look at the weights unless that shift tells me that there's a weight gain. And I don't look at the intake unless there is a change in R1's weight. I did contact the doctor on 4/19/16 to tell him about the weights. R1 had gained six pounds. E7 stated that E7 did not look back over the nine previous days weights to see how much weight gain R1 actually had during that time frame. Z1 stated on 4/27/16 I put R1 on daily weights because of [MEDICAL CONDITION]. Weight gain (due to [MEDICAL CONDITION]) can cause further liver failure and kidney failure in R1. I wrote the order( for daily weights) and I expect my orders to be followed. I don't write orders without a reason. I have never been notified of a five pound weight gain until 4/19/16. If staff don't call me about weight gain that is absolutely harmful to R1.

Based on observation, record review and interview, the facility failed to follow their policy regarding application of moist heat hot packs and failed to provide supervision during hot pack treatment of [REDACTED]. This failure resulted in a second degree burn with suspected deep tissue injury to R5's left buttock. Findings include: R5's current face sheet indicates R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/08/12 at 11:10 a.m., R5 was repositioned in bed to R5's right side for treatment to the left buttock. E4 (LPN - Licensed Practical Nurse) stated, "I heard (R5) got burnt from a hot pack and we can't use them anymore." R5's upper left buttock has a 9 cm (centimeter) by 7 cm rectangle shape open skin lesion with a moist dark red wound bed with line of dark purple tissue completely around the edges of the wound. Directly above the 9 cm by 7 cm lesion is a smaller 2 cm lesion that has a dry light brown wound bed and below the larger lesion is a cluster of small open areas 4 cm is diameter. The two larger lesions are weeping a serosanguineous (serum and blood) drainage. R5 denied discomfort from the left buttock but did call out during repositioning stating his back and legs hurt when he is moved. R5 did not recall how his left buttocks was injured. On 11/08/12 at 10:00 a.m., E2 (DON - Director of Nursing) verified R5 had received the injury to his left buttock on 11/03/12 after staff had placed a moist hot pack to the area from a hydrocollator (a liquid heating device used to heat and store hot packs). R5's nurses' notes dated 11/03/12 at 10:30 a.m. indicate R5 calling out and complaining of pain in the left shoulder and back. At 11:00 a.m. a nurses' note written by E9 (LPN - Licensed Practical Nurse) states Z2 (R5's Attending Physician) ordered hot packs to R5's left shoulder and back. E9's (LPN) nurses' note on 11/03/12 at 12:30 p.m. states, "...Redness noted to upper right back and redness note to lower lumbar of back. 2 blisters noted to left upper buttock 1.2 centimeters by 3 centimeters and the other 3 centimeters by 4 centimeters. On 11/04/12 at 4:30 a.m., a nurses' note documents, "...10 centimeter by 6 centimeter burn to left buttock....". R5's nurses' notes indicate R5 continued to complain of discomfort and was restless and at 2:00 p.m. was transferred to a local hospital for evaluation where R5 was admitted from 11/02/12 through 11/06/12. The POS (Physician order [REDACTED]. On 11/09/12 at 1:05 p.m., E9 (LPN) stated, "I applied the hot packs because I couldn't get the man to calm down. He was in pain and hollering. We repositioned him and got a back xray ordered...(R5) had Vicodin (pain medication). I told (E10 CNA - Certified Nursing Assistant) to put the hot packs on..." E9 (LPN) verified hot packs from a hydrocollator were used for R5 on 11/03/12. E9 (LPN) stated, "..There was a terry foam cover there and that's what I used for both hot packs. The packs were put on (R5's) lower back and left shoulder area. Then xray showed up and were in there for 25 minutes. My timer went off. I had it set for 20 minutes but I was with another resident when it went off." E9 (LPN) reported another nurse (E13 LPN) helped take the hot pack off of R5. E9 (LPN) stated, "There was a lot of redness when we pulled them off, chaffing and I noticed a couple blisters to the left upper buttock area...I have never used the hot packs before. I've never had an order to use them. I was taught you leave a hot pack on for 20 minutes. Honestly, I thought that the terry foam was enough...". On 1/09/12 at 12:40 p.m., E10 (CNA) stated, " I was told by the nurse (E9 LPN) to put hot packs on (R5). I had never done that before. I put the hot pack across the lower back and on the right shoulder. It was very hectic. Alarms were going off and I was answering them and when I went back down xray was there. I didn't question it. (E9 LPN) was my nurse....(E9 LPN) handed the hot packs to me. There were 2 and the nurse had wrapped them in the covers you use for them. (R5) had a dry (incontinent pad and brief) on and it was under that. For the shoulder I doubled it over...I had never used a hot pack before...The CNAs are not to do them and I honestly didn't know that...". On 11/09/12 at 2:00 p.m., E13 (LPN) stated, "I helped (E9 LPN) take the hot packs off of (R5). It was covered with a foam terry cloth cover. (R5) was rolled over and the head of the bed was up probably 35 degrees. The hot pack at (R5's) shoulder was doubled over and the other hot pack was at the middle of the back on the right side of the back. (R5) was laying on them when we pulled them out. I said to (E9 LPN) I think (R5) may have just got burnt. It was red, chaffing a little at the left shoulder. I didn't see a blister there (R5's buttock) but you could see it was forming...". An undated policy titled (Moist heat hot pack) Use and Care states, "...Application: Carefully remove (hot pack) from water using tabs. Place (hot pack) in a hydrocollator (terry cloth/foam cover)...with several layers of dry terry toweling between (hot pack) and skin. The steam from the (hot pack) will penetrate the layers of toweling. To vary the heat intensity, increase or decrease the number of toweling layers...Caution: Treatment time should not exceed 30 minutes. Constantly monitor (hot pack) application to ensure that the skin is not becoming too hot. Damage to skin can occur from exposure to extreme heat or cold. Note above instructions for proper use. Do not apply over insensitive skin or in the presence of poor circulation. Never lay or sit on top of the (hot pack)...". A wound care consultant note dated 11/05/12 states, "...(R5) is from an (Extended Care Facility) and had placed a heating pad to left buttock area. The heating pad subsequently left a burn to this area. On assessment noted large 9 centimeter by 7 centimeter by 0 centimeter second degree burn (partial thickness) with dark purple edge medially, suspicious for (Deep Tissue Injury). Wound had a large amount of serosanguineous drainage noted which is typical of a burn within the first 72 hours...". An admission skin assessment on 11/06/12 shows R5 had a 9 cm by 7 cm burn to the left upper buttock and areas of redness surrounding the burn. R5's care plan entry dated 11/06/12 states, "...Deep tissue injury noted at left buttock..."