Every finding on record at Twin Lakes Extended Care

Based on observation, interview, and record review the facility failed to ensure a resident was properly supervised during a transfer with a mechanical lift. This failure resulted in a fall for one resident (R1) of three reviewed for accidents, causing an acute break to both sides of the nasal bones as well as a break in the nasal septum and a laceration to the nose. Findings Include:The facility's Policy and Procedure for Use of a Mechanical Lift, dated November 1, 2025, and revised September 2, 2025, states the purpose of using a mechanical lift is to assist in lifting residents who are too heavy to lift manually, to promote comfort, and to maintain proper body alignment while residents are being moved. The procedure includes ensuring the resident is placed comfortably in the chair by grasping the top of the sling with one hand and pulling back on the sling while lowering the resident into the chair. Staff may also gently push on the resident's knees while lowering the resident into the chair to ensure comfort.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has an anxiety disorder, a cognitive communication deficit, and severe cognitive impairment.R1's Care Plan dated 9/21/25 documents interventions for communication deficits related to developmental delays, including allowing R1 adequate time to respond, repeating information as necessary, not rushing R1, requesting clarification to ensure understanding, making eye contact, using task segmentation by breaking tasks into one step at a time to support short-term memory deficits, and using alternative communication tools as needed.In addition, R1's Care Plan dated 12/15/25 documents R1 experienced an actual fall while staff were attempting a transfer with a mechanical lift to a wheelchair, during which R1 rolled out of the sling onto the floor. R1 was noted to have excessive bleeding and was sent to the emergency room, where R1 was diagnosed with a broken nose.On 2/6/26 at 10:51 a.m., V9, Certified Nursing Assistant (CNA), stated R1's fall was very traumatic. V9 reported that V7 (CNA) was operating the mechanical lift controls while V9 was positioned behind R1, guiding her into the wheelchair. V9 stated they were using a sling R1 does not like because the material is fuzzy, making it easier for a resident to slide. V9 stated R1 repeatedly leaned forward during the transfer. V9 attempted to guide R1 by holding the straps on the back of the sling; however, R1 leaned forward again, as she often does, and fell forward, landing face-first on the foot of the mechanical lift.On 2/6/26 at 11:16 a.m., V7, Certified Nursing Assistant (CNA), stated she assisted with transferring R1 on the day of the fall and was operating the mechanical lift using a regular sling. V7 stated R1 frequently leans forward in the sling and staff must remind her to lean back to complete the transfer. V7 stated she repeatedly instructed R1 to sit back; however, R1 continued to lean forward. V7 stated they proceeded with the transfer, and while lowering R1, she fell from the sling like she was doing a somersault.On 2/6/26 at 10:25 a.m., V6, Licensed Practical Nurse (LPN), confirmed that on the day of R1's fall from the mechanical lift, a CNA summoned her for assistance. V6 stated she found R1 lying face down with her face resting on the leg of the mechanical lift and noted R1 was bleeding. V6 instructed the CNAs to leave R1 in that position while she called for emergency assistance.On 2/6/26 at 11:38 a.m., V8, Certified Nursing Assistant (CNA), stated she has transferred R1 several times and that staff often must instruct R1 to sit back because she is known to lean forward. V8 stated R1 usually follows instructions. V8 stated that when R1 leans forward, staff stop the transfer until R1 is in a safe position before proceeding.On 2/6/26 at 12:46 p.m., V10, Certified Nursing Assistant (CNA), stated staff are trained not to rush transfers and should not proceed if the resident is moving in the sling or leaning forward. V10 stated she would not feel comfortable continuing a transfer if a resident was leaning forward and that she always ensures the resident is properly positioned before proceeding.On 2/6/26 at 1:19 p.m., V11, Certified Nursing Assistant (CNA), stated she is new but has been taught that during mechanical lift transfers, the CNA is responsible for ensuring proper positioning and confirming the resident is not leaning forward during the transfer.On 2/6/26 at 12:37 p.m., V3, Social Services Director and CNA Supervisor, stated R1 frequently leans forward and staff often must remind her to sit back. V3 stated R1 follows instructions approximately 80% of the time but sometimes requires additional prompting. V3 stated the CNAs should not have continued the transfer on the day R1 fell until R1 was in a safe position.On 2/6/26 at 3:15 p.m., V2, Director of Nursing (DON), stated the facility removed the sling and provided staff training on the same day as R1's incident, primarily because she anticipated questions regarding staff training if the incident was investigated. V1, Administrator, and V2 were unable to provide training materials documenting the content of the in-service, and were only able to provide the in-service sign-in sheet.R1's X-ray results dated 12/15/25 document R1 sustained acute fractures of the bilateral nasal bones and nasal septum, as well as a laceration to the nose.

Based on observation, interview and record review the facility failed to protect a resident's right to dignity for two of two residents (R1, R11) by another resident (R5) reviewed for dignity in the total resident sample list of 27. Findings Include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated 11/2018 documents that all residents have a right to dignity and respect and the facility must care for residents in a manner that promotes their quality of life. The facility must provide services to keep each resident's mental health at the highest practical level. On 6/24/24 at 1:20 PM R11 stated R5 is very loud and constantly talking and he makes derogatory and prejudice comments as well as false comments. R11 states this makes him uncomfortable, bothers him a lot and also bothers others in the room. R11 stated he will often forgo activities or community outings if R5 is going because he doesn't want to be subjected to the negativity. R11 stated he has not complained about this to anyone in particular but staff are around and have heard these comments. R11 states staff tell R5 to stop but he just keeps doing it. On 6/24/24 at 1:25 PM R1 stated R5 does talk all of the time, is disruptive, and does make derogatory and racist comments about Chinese people. R1 stated it does bother her and she wishes that he would stop. R1's Medical Diagnoses list dated June 2024 documents R1 is diagnosed with Depression, Insomnia, and Obsessive Compulsive Disorder. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact. R11's Medical Diagnoses list dated June 2024 documents R11 is diagnosed with Diabetes. R11's Minimum Data Set, dated dated dated [DATE] documents R11 is cognitively intact. R5's Medical Diagnoses list dated June 2024 documents R5 is diagnosed with Depression, Cerebral Palsy, and Mental Disorder. R5's Minimum Data Set, dated dated dated [DATE] documents R5 is moderately cognitively impaired. On 6/24/24 at 1:30 PM V1 Administrator stated she had not been told about any prejudice or derogatory remarks made by R5 but will begin an investigation into the allegation. On 6/25/24 at 11:30 AM V1 Administrator stated she is conducting the investigation from the complaints of R1 and R11 and feels it is a resident rights issue. Residents have the right to be comfortable in their home and R5 should not be making comments that create a bad or negative atmosphere for others. Staff need to be more vigilant and intervene when necessary. V1 confirmed when R5 makes negative and prejudice comments it can impede on other resident's right to dignity.

Based on interview and record review the facility failed to document psychotropic medication assessments, identify and track targeted behaviors, and attempt non-pharmacological behavioral interventions for two (R15, R20) of five residents reviewed for psychotropic medication in a sample list of 27 residents. Findings Include: The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team. 1. R15's Care Plan revised 6/25/24 includes the following diagnoses: Major Depression and Mild Dementia with Anxiety. R15's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Sertraline HCL (antidepressant) Give 75 milligrams by mouth one time a day. Aripiprazole (antipsychotic) 20 milligrams by mouth in the morning. There is no documentation of psychotropic assessments observed for R15. No targeted behaviors are identified or tracked for R15. No non-pharmacological interventions are documented as initiated for R15. 2. R20's Care Plan revised 6/5/24 includes the following diagnoses: Dementia with Agitation and Major Depressive Disorder. R20's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Fluoxetine HCl (antidepressant) Oral Capsule 40 MG Give 80 mg by mouth one time a day. Quetiapine (antipsychotic) 25 MG Tab Give 12.5 mg by mouth two times a day. Divalproex Sodium DR (neuroleptic) 125 MG Give 1 tablet by mouth two times a day for dementia with behaviors. R20's most recent Psychotropic Medication Assessment is dated 9/29/23 and includes only the Fluoxetine. No targeted behaviors are identified or tracked for R20. No non-pharmacological interventions are documented as initiated for R20. On 6/25/24 at 10:01AM V16, Care Plan Coordinator stated I wasn't aware I needed to do quarterly assessments for residents with psychotropic medications. I will be doing the assessments and documenting specific behaviors and non-pharmacological interventions in the future. I do see this was not done for (R15 and R20).

Based on observation, interview and record review the facility failed to dispose of expired schedule two narcotics for one (R6) of three residents reviewed for medications from a total sample list of 27 residents. Findings Include: The facility provided Procurement and Storage of Medications Policy dated [DATE] documents that all discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. R6 's undated physician order sheet documents an order for Morphine 20 milligrams per milliliter per 30 milliliter bottle, administer .25 milliliters, sublingually as needed, every four hours as needed for pain. On [DATE] at 9:30AM, two bottles of Morphine Sulphate were in cart two's narcotic box. One bottle had 13 cubic centimeters of medication left in it and one bottle was full with 30 cubic centimeters in it. Both bottles had expiration dates of [DATE]. On [DATE] at 9:35AM, V4 Licensed Practical Nurse stated, They are expired. It should have been destroyed.

Based on observation, interview and record review the facility failed to implement interventions in response to signs and symptoms of shortness of breath for a resident and ensure respiratory tubing is maintained in a sanitary manner for a resident receiving oxygen therapy. These failures affect one (R183) of three resident's reviewed for respiratory care from a total sample list of 27 residents. Findings include: The Facility provided Respiratory Assessment Policy dated 8/2003 documents that respiratory assessments and interventions are to be documented in the resident's medical record. R183's undated diagnoses sheet documents diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R183's care plan dated 6/19/2024 documents to monitor R183 for signs and symptoms of respiratory distress and to report to the physician changes in respiratory condition including respirations, pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage and skin color. R183's progress notes document on 6/24/24 an oxygen saturation level of 88 percent. On 6/23/24 at 9:33AM, R183 appeared short of breath. Her color was pale, and she was using abdominal muscles to breathe. R183 was sitting up in the bed with oxygen at one liter being administered via nasal canula. The oxygen tubing nor water was dated, and the tubing was laying on the floor. On 6/23/24 at 9:35AM, R183 stated, This is a bad breathing morning. On 6/23/24 at 1:30PM, R183 remained in bed, resting her eyes and pursed lip breathing (breathing technique). On 6/24/24 at 10:35AM, R183 appears very short of breath and gray in color. R183 is breathing with accessory muscles and cannot speak due to shortness of breath. R183's oxygen continues at one liter per nasal cannula and the tubing, nor the water is dated. On 6/24/24 at 10:36AM, V15 Certified Nursing Assistant was taking R183's vital signs. R183's oxygen saturation was 89 percent on one liter of oxygen and her pulse rate was 125 beats per minute. R183 was not able to speak and was gasping. R183 is opening and closing her eyes and appears very uncomfortable. On 6/24/24 at 10:38AM, V2 Director of Nursing (DON) said that she had a discussion with R183 and V16 (Family Member) about hospice and comfort care options but that they were not wanting that at this time. When asked about the plan for R183's comfort during periods of air hunger, V2 DON said that it was a difficult situation to manage. On 6/24/24 10:40AM V4 Licensed Practical Nurse (LPN) stated, I just turned her oxygen up to two liters because of her vital signs. I will notify the doctor. On 6/24/24 11:00AM, V1 Administrator stated, I went down, and her coloring isn't good, and she doesn't look comfortable to me. We are going to send her to the ER. On 6/24/24 3:50PM V3 LPN stated, I saw that she was struggling before she went to the hospital and I'm sure that it is the Lasix (diuretic) that made the difference. On 6/25/24 at 9:30AM, R183's coloring is much improved to pale pink and R1 is able to speak while breathing more easily. On 6/25/24 at 9:31AM, R183 said that she was very scared yesterday and that she received an extra dose of Lasix (diuretic) in the hospital and that seems to have helped. On 6/25/24 at 10:44AM, R183's oxygen remains undated. On 6/25/24 at 10:45AM, V11 LPN stated, Oxygen tubing is supposed to be labeled weekly. They usually do it on nights.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per resident bed in 28 of 56 resident rooms at the facility, 28 of these rooms were occupied by residents. This failure affects all 31 residents residing in the facility. Findings include: Historical room documentation and actual onsite measurements on 6/25/24 at 12:00PM with V13 Maintenance Director, determined rooms 2, 4 through 11, and 14 through 32 are undersized; providing either 73.11 square feet per resident bed in rooms 9-11, 14-24; and 75.65 square feet in rooms 2, 4-8, 25-32. The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated, documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2, and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14 through 32 are double occupancy and certified for Medicaid. The facility's Daily Roster dated 6/23/24, documents 31 of these 56 certified beds are occupied by residents residing in the facility. On 6/25/24 at 11:30AM, R18 said that his room was big enough for one person, but not two people. On 6/25/24 at 11:32AM, R19 said that his room is big enough for two people and that he wouldn't mind having a roommate. On 6/25/24 at 11:35AM, R6 said that his room is big enough for himself but that he could not have another person in it because it would be too small. On 6/25/24 at 12:42PM, R4 said that she and her roommate get along well and that there is enough room for the two of them. On 6/25/24 at 12:43PM, R1 said that her room isn't really very big and that she and her roommate don't have enough space, but the facility can't help it because her roommate has to have a bed. On 6/25/24 at 12:44PM, R14 said that she shares with a roommate and that the space is ok. On 6/25/24 at 12:45PM, R12 and R17 said that they have enough room in their room. On 6/25/24 at 3:00PM, V14 Regional Director of Operations said that she was aware that some of the facility rooms do not meet the size requirement per resident.

Based on interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident by failing to supervise a resident (R1) with known sexual behaviors from making non-consensual sexual contact with another resident (R2) and failed to protect other vulnerable residents (R4, R5), from inappropriate sexual behaviors by another resident (R1). These failures affect four (R1, R2, R4, R5) of eight residents reviewed for abuse in the sample list of eight residents. These failures resulted in (R1) having unrestricted access to (R2) resulting in (R2) being sexually abused by (R1). Based on V17's (R2's Power of Attorney) statement that R2 would have been angry, upset, sad and would have fought back if R2 did not have Dementia it can be determined that R2 would have experienced psychosocial harm (e.g., embarrassment, humiliation, anxiety) because of the sexual abuse. These failures also resulted in R4 experiencing psychosocial harm as evidenced by V18 (R4's Power of Attorney) stating R4 was withdrawn, feared R1, and had increased anxiety after being harassed by R1. The Immediate Jeopardy began on 9/9/23 when R1 began to display sexually inappropriate behaviors and no interventions or increase in supervision were implemented by the facility. V1 Administrator was notified of the Immediate Jeopardy on 12/12/23 at 2:02 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/12/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the Abuse in-service training. Findings include: The Facility Reported incident dated 11/27/23 at 2:30 PM documents on 11/18/23 at 10:00 AM that, (V3 Housekeeper) noticed that (R1) and (R2) were sitting together very closely in the TV (television) Lounge. (V3) observed (R1's) hand down the front of (R2's) pants. R1's Admission assessment dated [DATE] at 2:40 PM, documents R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Seizures, Tremors, Hypertension, Heart Failure, and Psychosis. This assessment documents R1 is alert to person and place. This assessment did not document any behaviors for R1. R1's Behavior Notes document the following: 9/9/2023 at 10:55 AM, written by V5 Licensed Practical Nurse (LPN), (R1) Attempted to grab staff inappropriately when being taken down to the dining room for lunch time. 9/9/2023 at 10:59 AM, written by V5 LPN, Staff alerted me resident (R1) had pulled his private parts out et (and) stated, 'come play with this baby.' 9/10/2023 at 9:04 AM, written by V5 LPN, (R1) Inappropriateness towards staff before et after breakfast. 9/12/2023 at 3:02 AM, written by V10 LPN, (R1 continues) to be inappropriate with staff during HS (hour of sleep). Tries to grope staff members while they are at desk charting. Constantly being told, 'No, that's inappropriate et. Let's not be doing that.' (R1) cont. (continues) to have smile on face and cont. to advance towards staff. Redirection unsuccessful. R1's Psychiatry note dated 10/2/23 documents R1 also has the diagnosis of Inappropriate Sexual Behavior. R1's Care Plan with an initiation date of 9/20/23 does not document interventions for R1's sexual behaviors. R1's Behavior Notes document the following: 10/5/2023 at 11:10 PM, written by V11 RN (Registered Nurse), (R1) attempted to get in (R4's room) several times. Entered (R4's) room et approached bed 2. (R4) yelled for (R1) to get out. (R1) redirected out of room. 10/6/23 at 4:25 PM, written by V5 LPN, (R1) Keeps following (R4) into rooms, dining rooms even after (R4) doesn't want him to follow (R4) or be around (R4). 10/6/2023 at 4:27 PM, written by V5 LPN, (R1) playing with (R4's) hair and (R4) screamed not wanting to be bothered. R1's Alert Note dated 10/7/2023 at 12:24 PM, written by V5 LPN documents, (R1) went into (R4's) room around 10:40 PM, woke (R4) up by trying to touch (R4), (R4) yelled no and for him to get out. CNA (Certified Nursing Assistant) removed him from the room and asked him to stop, that's a lady's room and to go back to his own room. R1's Behavior Note dated 10/7/2023 at 12:25 PM, written by V5 LPN documents, (R1) keeps following (R4) around after meals, scaring (R4) and (R4) is yelling out loud. We have asked him to leave (R4) alone, removed him from the area, removed (R4) from the area, he still wheels himself to where (R4) is located. R1's Care Plan with an initiation date of 9/20/23 does not include any new interventions for R1's behaviors towards R4. R4's Care Plan with an initiation date of 3/22/23 documents R4 has a diagnosis of Dementia and has impaired safety awareness. This care plan also documents that R4 has impaired decision making, and long and short-term memory loss. On 12/11/23 at 6:00 PM (V18) R4's Power of Attorney (POA) stated, The facility did not tell her about R1 coming into R4's room and touching her leg. V18 stated They (facility) called me and asked if they could increase her medication due to 'social anxiety.' That would have been right after (R1) came into her room. (R4) was very withdrawn after that. When I would visit (R4), she would hide behind me whenever (R1) came around her. You could tell (R4) was scared of (R1) and now that explains why. I started visiting more often because I thought something was going on. That explains it. (R4) has advanced Dementia. (R4) was married to my dad. (R4) would never allow any other man to touch her in an intimate way. (R4) would be ashamed of something like that happening. It would devastate her. (R1) would come up to (R4) and say, 'there's my girl' and (R4) would try to back away from (R1). (R1) was on her like a magnet. (R1) just couldn't stop trying to be around her. R1's Behavior Note dated 11/15/2023 at 3:26 PM, written by V5 LPN documents, Trying to touch another (R5's) buttocks as they were walking in front of (R1). (R5) said 'hey stop that,' as he (R1) smiled and rolled away. R1's Behavior Note dated 11/18/2023 at 9:41 AM written by V5 LPN documents, Trying to follow (R5) and get (R5's) attention, (R5 stated) 'no sir or I will slap you.' (R1) left the area and walked away. R1's Care Plan with an initiation date of 9/20/23 does not include any new interventions for R1's behaviors towards R5. R5's Care Plan with initiation date of 11/8/23 documents R5 is alert and oriented. On 12/11/23 at 10:50 AM, R5 stated Oh yes. I remember that clearly. I was standing at the nurse's desk there by the dining room and that man (R1) wheeled up behind me and goosed me right on the bottom. The staff were at the nurse's desk and moved (R1) away. There was another time when (R1) wheeled up to me when I was sitting and eating lunch. I was sitting at my dining room table. The dining room was full of other residents. (R1) came up to me and started grabbing my arm trying to pull me away from the dining room table. R1's Behavior Note dated 11/18/2023 at 10:33 AM written by V5 Licensed Practical Nurse documents, (R1) was witnessed touching another resident (R2) inappropriately in the dining room/activity room. Escorted (R1) away from other (R2). The facility's Incident Investigation Form dated 11/18/23 at 10:19 AM, written by V5 LPN documents, I was alerted by (V3 housekeeper) that (R1) was touching another resident (R2). I went down and saw (R1) with his hand in (R2's) pants and he was rubbing back and forth in her pants. (R2) was just sitting there not doing or saying anything. On 11/30/23 at 11:14 am, V3 Housekeeper stated on the morning of 11/18/23 she was getting ready to clean the activity room and saw R1 standing really close to R2 and she thought that was strange, so she approached R1 and R2 and observed R1 having his hand down R2's pants. V3 stated she left the activity room and went to the nursing station and reported the incident to V5 LPN. V3 stated V5 came and told R1 that was inappropriate and to remove his hand from R2's pants. On 11/30/23 at 1:37 PM, V5 LPN stated on 11/18/23, V3 came to the front desk and stated R1 was doing something inappropriate to R2. V5 stated R1 had his hand down R2's pants. V5 stated R1's hand was inside R2's brief. R2's Care Plan with an initiation date of 3/29/23 documents R2 is cognitively impaired and requires total assistance for all daily living activities. On 12/11/23 at 12:40 AM, V17 (R2's POA) stated the facility called him and told him about the incident between R1 and R2. V1 stated R2 would be p***** (expletive) if she didn't have Dementia. V17 stated R2 would have been upset and sad and ready to get out of the facility. V17 stated R2 would have never consented to R1 doing that to her. V17 stated if R2 knew what was going on R2 would have fought back. On 12/11/23 at 9:10 AM, V1 Administrator in Training stated the facility was aware that R1 had inappropriate sexual behaviors prior to the sexual abuse incident with R2 on 11/18/23. V1 stated R1 had previous incidents with R4 that should have been reported to facility management. V1 stated R1 had attempted to touch R4 and R5 inappropriately prior to the 11/18/23 incident with R2. V1 stated I was shocked when I read the nurse progress notes and saw that (R1) had been harassing these other women (R4, R5) prior to (R1's) sexual abuse incident with (R2). We (facility) should have put (R1) on continual monitoring on 10/5/23 when (R1) tried to chase after (R4). We (facility) could have made some kind of medication changes or something. We (facility) didn't do anything about (R1's) behaviors towards other female residents. I did not know about them until I read all those progress notes yesterday (12/10/23). I was just shocked. On 12/11/23 at 10:00 AM, V12 Nurse Practitioner stated, The facility was aware of R1's inappropriate sexual behavior prior to 11/18/23 when R1 sexually abused R2. V12 stated This is an unfortunate situation. (R1) has had multiple episodes of inappropriate sexual behavior with other female residents (R2, R4, R5). (R1) should have been put on continual monitoring from the first event on 10/5/23. (R1) has exposed himself to other residents, (R1) has followed other female residents around, touched other female residents inappropriately and nothing was done until 11/18/23 when (R1) put his hands down (R2's) incontinence brief. V12 stated Our female Dementia residents are the most vulnerable in this facility. I was never informed of the previous two female residents (R4, R5) having been in incidents with (R1). (R1) should have been placed on continual monitoring from the first time that happened with (R4) on 10/5/23. You do not need a physician order to place someone on continual monitoring. The facility should have done that immediately when it happened on 10/5/23 when (R1) was found in (R4's) room touching (R4's) leg when (R4) was in bed. The facility really should have protected their vulnerable female residents better so this incident with (R2) may not have happened. The Immediate Jeopardy that began on 9/9/23 was removed on 12/12/23 when the facility took the following actions to remove the immediacy: 1. On 12/29/23, V25 Regional Director in-serviced V1 Administrator on the Abuse Prevention Policy and the importance of doing a thorough investigation on all allegations/incidents and the importance of ensuring that new interventions are being followed and are effective. 2. On 11/18/23 one to one supervision of R1 was implemented and remains in place and will continue until the Interdisciplinary team determines it is no longer necessary based upon review of resident's record, behavior monitoring and potential to abuse others or until R1 discharges from facility. 3. On 12/11/23, V1 Administrator initiated additional in-servicing on the Abuse Prevention Policy including types of abuse, identifying abuse and inappropriate behaviors, reporting abuse, and investigating abuse allegations. In-servicing also included the importance of one to one supervision, and the use of the communication book for new behaviors and interventions. 4. On 12/12/23, V6 Care Plan Coordinator reviewed R1's care plan and behavior tracking to ensure all identified behaviors are addressed and appropriate resident centered intervention are in place to prevent any further sexual behaviors. 5. On 12/12/23, V34 Social Service Director and V2 Director of Nursing identified residents at risk for abuse. Residents were determined to be at risk if BIMs (Brief Interview for Mental status) score was below 13 (moderately or severely cognitively impaired). V6 reviewed and updated the resident's care plans to ensure interventions are in place to prevent abuse. 6. On 12/12/23, V1 Administrator and V25 Regional Director in-serviced the Interdisciplinary team to review residents for changes in behaviors and to investigate and identify potential triggers prior to an incident, and to ensure that person centered interventions are developed and communicated to staff. 7. V1 Administrator confirmed on 12/12/23 that going forward the facility will discuss in daily morning meetings, residents who display new behaviors or increased behaviors, and a root cause analysis will be completed to determine potential triggers and individualized interventions will be developed. 8. On 12/12/23 V6 Care Plan Coordinator confirmed V6 will communicate new interventions to staff through use of the communication book. 9. On 12/12/23 V1 confirmed the Interdisciplinary Team will review residents with behaviors in morning Quality Assurance meetings, and care plans, progress notes, behavior documentation and effectiveness of current interventions will be reviewed during weekly Behavior Quality Assurance Meetings. The facility presented an abatement plan to remove the immediacy on 12/12/23 at 5:17 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 12/13/23 at 10:22 AM and 12/13/23 at 1:10 PM. The facility presented revised abatement plans on 12/13/23 at 11:56 AM and 12/13/23 at 1:36 PM, and the survey team accepted the abatement plan on 12/13/23 at 2:45 PM.

Based on observation, interview, and record review the facility failed to employ a full time licensed Administrator. This failure has the potential to affect all 33 residents residing in the facility. Findings include: The facility's census sheet provided by V1 Administrator in Training documents there are 33 residents residing in the facility. On 11/30/23 from 9:45 AM to 3:30 PM and on 12/11/23 from 9:00 AM to 3:00 PM, there was not a licensed Administrator in the facility. On 12/12/23 at 10:05 AM, V25 Corporate Licensed Nursing Home Administrator stated she is the Administrator for the facility since V1 is an Administrator in Training. V25 stated she is present in the facility 16 hours a week.

Based on interview and record review the facility failed to follow its Abuse Prohibition Policy by failing to determine the risk of abuse for six of eight residents (R1, R2, R3, R4, R7, and R8) reviewed for abuse on the sample list of eight. Findings include: The facility's Abuse Prevention Program with a Revision date of 11/28/2016 documents, Resident Assessment. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. On 12/11/23, R1, R2, R3, R4, R7, and R8's medical records nor care plan contained their risk for abuse. On 12/12/23 at 2:30 PM, V6 Care Plan Coordinator stated prior to 12/12/23 the residents' risk for abuse was not determined and was not added to the care plans. On 12/12/23 at 3:00 PM, V1 Administrator in Training stated the facility's Abuse Prevention policy does direct staff to identify residents' risk for abuse and stated that this has not been being done.

Based on interview and record review the facility failed to report allegations of resident to resident abuse to the Administrator for three (R1, R4, and R5) of eight residents reviewed for abuse in the sample list of eight. Findings include: 1. R1's Behavior Note dated 10/6/2023 on 4:27 PM, written by V5 LPN documents, (R1) playing with (R4's) hair and (R4) screamed not wanting to be bothered. R1's Alert Note dated 10/7/2023 at 12:24 PM, written by V5 LPN documents, (R1) went into (R4's) room around 10:40 PM, woke (R4) up by trying to touch (R4), (R4) yelled no and for him to get out. CNA (Certified Nurse's Aide) removed him from the room and asked him to stop, that's a lady's room and to go back to his own room. R1's Behavior Note dated 10/7/2023 at 12:25 PM, written by V5 LPN documents, (R1) keeps following (R4) around after meals, scaring (R4) and (R4) is yelling out loud. We have asked him to leave (R4) alone, removed him from the area, removed (R4) from the area, he still wheels himself to where (R4) is located. On 12/11/23 at 3:00 PM, V1 Administrator stated the staff should have reported the incidents between R1 and R4 so that they could be investigated. V1 stated the staff did not report these incidents to her. 2. R1's Behavior Note dated 11/15/2023 at 3:26 PM, written by V5 LPN documents, Trying to touch another (R5's) buttocks as they were walking in front of (R1). (R5) said hey stop that, as he (R1) smiled and rolled away. On 12/11/23 at 3:00 PM, V1 Administrator stated the staff should have reported the incident between R1 and R5 so that it could be investigated. V1 stated the staff did not report this incident to her.

Based on interview and record review the facility failed to notify a resident's power of attorney of a change in dosage of an antipsychotic medication and a change in behavior for one of eight residents (R1) reviewed for change in resident condition in a sample of eight. Findings include: R1 was admitted to the facility on [DATE] from a behavioral management facility. R1 was on a regimen of antipsychotic medication Zyprexa 5mg BID (twice a day) for inappropriate behaviors. R1 was seen by the Psychiatrist on 9/11/23. The Psychiatrist decreased R1's Zyprexa from 5mg BID to 2.5 mg BID. The following Facility Notes document behaviors R1 demonstrated after R1's Zyprexa dosage was decreased: 10/5/23- R1 attempted to enter R4's room several times on 10/5/23 at 11:10 PM when R4 yelled at R1 to get out of her room. 10/6/23-R1 followed R4 into different rooms and the dining room even after R4 told R1, R4 did not want R1 to follow R4 or be around R4. 10/6/23--R1 was witnessed playing with R4's hair when R4 screamed not wanting to be bothered. 10/6/23-R1 wheeled into R4's room, woke R4 up by trying to touch R4-R4 yelled 'no' and staff responded. 10/7/23-R1 follows R4 around facility after meals 'scaring' R4 and R4 is yelling out loud; staff documented 'we have asked R1 to leave R4 alone, removed R1 from the area, removed R4 from the area, R1 still wheels himself to where R4 is located.' 11/15/23-R1 trying to touch another resident's (unknown) buttocks as they were walking in front of R1. Unknown resident told R1 to stop touching her. 11/18/23-R1 was trying to follow R5 to get her attention. R5 turned and told R1 No sir. Or I will slap you. The facility's investigation report dated 11/27/23 documents on 11/18/23 V3 Housekeeper approached R1 and R2 and observed R1 with his hand down the front of R2's pants and V3 reported the incident to V5 LPN. On 12/11/23 at 3:00PM V20 (R1's POA) stated the facility did not call him when they changed R1's medication on 9/11/23. V20 stated he did not know about the behaviors R1 displayed until he was called about the 11/18/23 incident. V20 stated he would have told the facility not to decrease R1's medication because this is why R1 was at the behavior facility before coming to this facility - to control (R1's) behaviors. V1, Administrator stated on 12/12/23 at 9:40 am Yes, V20 is correct we failed to call (V20) about the change in medication or the additional behaviors. The facility policy titled Notification for Change in Resident Condition or Status with the revision date of 12/7/17 states The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA, etc.) of changes in the resident's medical/mental condition and/or status.

Based on interview and record review the facility failed to ensure one resident (R1) of three residents reviewed for accidents in a sample list of three was not entrapped in the mechanism of a recliner chair prior to lowering the footrest. This failure caused (R1) to sustain a 12 Centimeter laceration requiring 13 sutures to close. Findings include: R1's Diagnoses list printed 9/25/23 includes the following diagnoses: Age-Related Osteoporosis, Hypertension, Gastro-Esophageal Reflux Disease, Anxiety Disorder, Chronic Atrial Fibrillation, Repeated Falls, and Dementia. R1's Brief interview of Mental Status dated 6/29/23 documents R1 scored 3/15 on her Brief Interview of Mental Status indicating R1 is severely cognitively impaired. R1's Progress Note dated 8/25/2023 at 10:13PM documents CNA (V3, Certified Nurse's Aide) getting (R1) ready to transfer and was putting recliner down. (R1's) legs were in between recliner and where it closes, (V3) didn't notice (R1's) legs were hanging off due to blanket covering (R1's) legs. Resident stated 'Oww' and (V3) noted legs were hanging off sideways where recliner closes. (V3) moved blanket and noted resident right leg bleeding. (V3) notified Nurse (V7, Licensed Practical Nurse LPN). (V7) went in and assessed (R1's) right leg and large skin tear/laceration down front of right shin to almost (R1's) ankle. Bleeding profusely. Applied pressure and (abdominal gauze) with tape to area to try and stop bleeding. NP (Nurse Practitioner) notified at 9:06PM and gave order to Send to emergency room . Notified daughter 9:20PM. 911 called at 9:30PM. Director of Nursing /Administrator notified at 9:40PM. R1's Progress Note dated 8/25/2023 at 11:50PM documents Received report from emergency room nurse. (R1) received sutures in Right Lower Extremity and (nylon wound closure strips) applied over them. (R1) will need to return in 10-14 days to Emergency Department to have them removed. No immersing leg in water, sponge baths only. Family was notified and updated on condition as well. R1's Progress Note dated 9/12/2023 1:22PM documents New order received to remove sutures from right shin. 13 sutures were removed without difficulty. Steri Strips applied with (nonstick gauze) and wrapped with (stretch gauze) until fully healed. Will continue to monitor. New treatment order to change dressing daily to right shin until healed. Leave (nylon wound closure strips) in place until fall off on their own. Report any signs/symptoms of infection. On 9/25/23 at 12:53PM V3, CNA (Certified Nurse's Aide) stated. I was taking care of (R1) on 8/25/23 evening shift. (R1) put (R1's) call light on. I went in to get (R1) ready for the CNA's to transfer to bed. I was a Nursing Assistant then. I have since passed the test and have my certificate. (R1) had a blanket over her legs so I did not see her right leg was in the space between the chair and the footrest. I lowered the footrest. R1 screamed Owe. I put the footrest back up and (R1) was bleeding quite a bit. I got the nurse who came in right away. The nurse put pressure on the cut, and we sent (R1) to the hospital. (R1) came back with stitches and a bandage. On 9/25/23 at 1:00PM V6, Nurse Practitioner stated The laceration absolutely was caused by (R1) catching her leg in the recliner. The facility could have prevented this by taking off the blanket and making sure (R1's) leg was not caught. On 9/25/23 at 10:00AM V2 Director of Nursing stated, At the time (R1's) leg was injured by the recliner (V3) had taken her CNA classes and passed her test but was not yet on the registry. The blanket should have been removed and (V3) should have made sure (R1's) feet and legs were on the footrest before it was lowered. On 9/25/23 at 2:00PM V1, Administrator stated the facility has no specific policy in regard to incidents (other than falls) which cause injury.

Based on interview and record review the facility failed to implement/update interventions following an accident/fall for two residents (R1, R3) of three residents reviewed for care plans in a sample list of three residents. Findings include: The facility's policy Fall Prevention revised 11/10/18 states Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on an AIMS for wellness form along with any new interventions deemed to be appropriate at the time. 1. R1's Progress Note dated 8/25/2023 at 10:13PM documents CNA (V3, Certified Nurse's Aide) getting (R1) ready to transfer and was putting recliner down. (R1's) legs were in between recliner and where it closes, (V3) didn't notice (R1's) legs were hanging off due to blanket covering (R1's) legs. Resident stated 'Oww' and (V3) noted legs were hanging off sideways where recliner closes. (V3) moved blanket and noted resident right leg bleeding. (V3) notified Nurse (V7, Licensed Practical Nurse LPN). (V7) went in and assessed (R1's) right leg and large skin tear/laceration down front of right shin to almost (R1's) ankle. Bleeding profusely. Applied pressure and (abdominal gauze) with tape to area to try and stop bleeding. NP (Nurse Practitioner) notified at 9:06PM and gave order to Send to emergency room . Notified daughter 9:20PM. 911 called at 9:30PM. Director of Nursing /Administrator notified at 9:40PM. R1's Progress Note dated 8/25/2023 at 11:50PM and R1's Progress Note dated 9/12/2023 1:22PM go on to document (R1) received 13 sutures and (Nylon wound closure strips) at the emergency room to close the wound. R1's Care Plan printed 9/25/23 at 11:40AM does not document any resident centered interventions were initiated following this incident to prevent reoccurrence. 2. R3's Progress Note dated 8/23/2023 at 1:04PM documents: (R3) was ambulating with wife without a gait belt, wife was walking in front of him, leaving the dining room table. (R3) stated he blacked out. (R3) then fell back into the nurse's cart, knocked the water pitcher over, hit the trash can on the way down. (R3) moves all extremities, no rotation/shortening noted, complains of pain only back of head, (R3) has a knot on the back of the head left midline, (R3's) back is red. (mechanically lifted) resident to bed. Doctor notified. order to send out. emergency room called. Wife was here for incident, agreed to send to emergency room per Doctor request, Vital Signs 129/70 Blood Pressure, 97.7 Temperature, 99 Oxygen, 80% Pulse, 22 Respirations. Pupils Equal, Round, Reactive to Light and Accommodation. Resident on Eliquis (blood thinner). R1's Care Plan printed 9/25/23 at 12:33PM does not document any resident centered interventions were initiated following this incident to prevent reoccurrence. On 9/25/23 at 2:15PM V2, Director of Nursing stated We have been without a Care Plan Coordinator for a while and have had to depend on Corporate staff to do Care Plans. We are aware we have some issues but are currently training our new Care Pan Coordinator.

Based on interview and record review the facility failed to immediately report an allegation of resident to resident physical abuse to V1 Administrator. This failure affected four of four residents (R1, R2, R11, R15) reviewed for staff mistreatment in the sample of 16. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the rights of the residents to be free from abuse. The policy defines physical abuse as hitting, slapping, punching, and kicking. The policy documents employees are required to immediately report any potential or alleged abuse to their supervisor and administrator. 1. R1's Medical Diagnoses dated August 2023 documents R1 is diagnosed with Dementia. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is severely cognitively impaired. R1's Psychosocial Evaluation dated 7/5/23 documents R1 is disruptive, disorientated, experiences difficulty with impulse control, is delusional, gets agitated, angry, aggressive, shows physical aggression, is physically abusive, and verbally abusive. R1's Care Plan dated 3/15/23 documents R1 has a behavior problem when other residents are near the table she eats at or near the bench she sits at, and staff are to intervene when necessary to protect the rights and safety of others. R1's Behavior Note dated 6/14/23 documents V5 Licensed Practical Nurse (LPN) witnessed R1 walk up to another resident (R15) who was resting his head on a table in the dining room where R1 normally sits and R1 smacked R15 on top of the head with force. R1 then walked away cussing and yelling in German. R1's Behavior Note dated 7/30/23 documents V5 Licensed Practical Nurse (LPN) noted R1 was walking down the hall and smacked another resident (R2) on the back of the head. R2 was in her wheelchair wheeling herself down the hall. R1's Behavior Note dated 8/18/23 documents V4 Licensed Practical Nurse (LPN) noted R1 had an altercation with another resident (R11) and shoved R11 in the chest while he was sitting in his wheelchair. 2. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with a healing fracture of the right lower leg. R2's Minimum Data Set, dated dated dated [DATE] documents R2 is cognitively intact. On 8/18/23 at 1:58 PM R2 stated she was in her wheelchair moving herself down the hallway when R1 walked by her going in the opposite direction and hit her in the back of the head two times very hard. R2 stated she is no longer comfortable around R1 and tries to avoid her at all costs because R1 is confused and could hit her again if she wanted to. 3. R11's Medical Diagnoses dated August 2023 documents R11 is diagnosed with Dementia with Agitation, Parkinson's Disease, and Anxiety. R11's Minimum Data Set, dated dated dated [DATE] documents R11 is severely cognitively impaired. 4. R15's Medical Diagnoses dated August 2023 documents R15 is diagnosed with Dementia and Anxiety Disorder. R15's Minimum Data Set, dated dated dated [DATE] documents R15 is severely cognitively impaired. On 8/18/23 at 1:20 PM V1 Administrator stated the allegation of physical abuse on 6/14/23 where R1 smacked R15 on the back of the head was never reported to her by staff. V1 confirmed staff are supposed to immediately report any suspicion or allegation of abuse directly to her so that she can begin the investigation and ensure the resident's safety.

Based on interview and record review, the facility failed to protect a resident's right to be free from resident to resident physical abuse. This failure affected four of four residents (R1, R2, R11, R15) reviewed for staff mistreatment in the sample of 16. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the rights of the residents to be free from abuse. The policy defines physical abuse as hitting, slapping, punching, and kicking. 1. R1's Medical Diagnoses dated August 2023 documents R1 is diagnosed with Dementia. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is severely cognitively impaired. R1's Psychosocial Evaluation dated 7/5/23 documents R1 is disruptive, disorientated, experiences difficulty with impulse control, is delusional, gets agitated, angry, aggressive, shows physical aggression, is physically abusive, and verbally abusive. R1's Care Plan dated 3/15/23 documents R1 has a behavior problem when other residents are near the table she eats at or near the bench she sits at, and staff are to intervene when necessary to protect the rights and safety of others. R1's Behavior Note dated 6/14/23 documents V5 Licensed Practical Nurse (LPN) witnessed R1 walk up to another resident (R15) who was resting his head on a table in the dining room where R1 normally sits and R1 smacked R15 on top of the head with force. R1 then walked away cussing and yelling in German. R1's Behavior Note dated 7/30/23 documents V5 Licensed Practical Nurse (LPN) noted R1 was walking down the hall and smacked another resident (R2) on the back of the head. R2 was in her wheelchair wheeling herself down the hall. R1's Behavior Note dated 8/18/23 documents V4 Licensed Practical Nurse (LPN) noted R1 had an altercation with another resident (R11) and shoved R11 in the chest while he was sitting in his wheelchair. 2. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with a healing fracture of the right lower leg. R2's Minimum Data Set, dated dated dated [DATE] documents R2 is cognitively intact. On 8/18/23 at 1:58 PM R2 stated she was in her wheelchair moving herself down the hallway when R1 walked by her going in the opposite direction and hit her in the back of the head two times very hard. R2 stated she is no longer comfortable around R1 and tries to avoid her at all costs because R1 is confused and could hit her again if she wanted to. 3. R11's Medical Diagnoses dated August 2023 documents R11 is diagnosed with Dementia with Agitation, Parkinson's Disease, and Anxiety. R11's Minimum Data Set, dated dated dated [DATE] documents R11 is severely cognitively impaired. 4. R15's Medical Diagnoses dated August 2023 documents R15 is diagnosed with Dementia and Anxiety Disorder. R15's Minimum Data Set, dated dated dated [DATE] documents R15 is severely cognitively impaired. On 8/18/23 at 12:30 PM V5 Licensed Practical Nurse stated he has witnessed R1's physical aggression increase over the last two months or so. V5 confirmed on 6/14/23 he witnessed R1 come up to the table where R15 was sitting with his head down and R1 smacked R15 on the back of his head really hard. R15 was very startled and confused as to what was happening. V5 also confirmed he was the nurse on duty on 7/30/23 when R2 reported that R1 hit her in the back of the head two times when she was propelling herself down the hallway in her wheelchair. On 8/18/23 at 1:20 PM V1 Administrator stated the type of physical aggression and behaviors R1 has been having is not acceptable and the facility has decided they need to transfer her to a more appropriate setting. V1 confirmed it is not ok for R1 to be physically abusive to other residents like she was with R2, R11, and R15. On 8/22/23 at 12:40 PM V4 Licensed Practical Nurse stated she was the nurse on duty on 8/18/23 when R11 yelled out and was holding his chest stating that R1 had just shoved him in his chest and pushed his wheelchair backwards. V4 stated R11 said R1 is crazy and didn't know why she shoved him. V4 stated although R11 is cognitively impaired he is reliable enough to tell you about something like that which just occurred.

Based on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed for 28 resident rooms 2,4-11, and 14-32. Findings include: Historical room documentation and actual onsite measurements on 5/16/23 at 11:10 AM with V14 Maintenance Director, determine rooms 2, 4 through 11, and 14 through 32 are undersized, providing only 77.3 square feet per resident bed. The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated, documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2, and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14 through 32 are double occupancy and certified for Medicaid. The facility's Daily Roster dated 5/14/23, documents 36 of these 56 certified beds are occupied by residents residing in the facility. On 5/16/23 at 11:20 AM, V1 (Administrator) stated, the rooms that we have waivers for not being the correct size are in the Annual Long Term Care Survey Information book.

Based on observation, interview and record review the facility failed to maintain proper sanitation of serving utensils. This failure has the potential to affect all 36 residents residing in facility. Findings include: Daily Census Report dated 5/15/23 documents 36 residents residing in facility. On 5/15/23 at 7:30 AM Observed the commercial coffee pot dripping brown liquid from the front of the spigot. The Coffee pot was sitting on the kitchen counter directly above an open utensil drawer. Coffee was dripping from the coffee pot directly into the utensil drawer onto the serving utensils. Multiple serving spoons in the drawer of various sizes were covered with small brown dry spots. The bottom of the drawer was splattered with dried brown spots. On 5/15/23 at 7:35 AM V6 Certified Dietary Manager (CDM) stated That coffee pot has been dripping into the utensil drawer ever since they (supplier) moved it to the counter. It used to sit somewhere else so we (staff) could put something under it to catch the drips. Now it just drips all day into the utensil drawers. We (staff) use those utensils all day long. I have seen staff using those utensils to dish out resident's food. I have to come up with a better plan. The facility policy titled 'Kitchen Sanitation' issued October 2014 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan for four of 12 residents (R15, R16, R21, R33) reviewed for care plans in the sample list of 22. Findings include: The facility's Comprehensive Care Planning policy with a revised date of 11/1/17 documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. Components of the CPC (Comprehensive Care Plan) may include: e. Care Plan - Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. 1.) R15's Medication Administration Record (MAR) dated 5/1/23 through 5/31/23 documents diagnoses including Rhabdomyolysis, Cellulitis of Unspecified Part of Limb, Localized Edema, Hypokalemia, Other Specified Infestations, Type 2 Diabetes Mellitus, Essential Hypertension and Hyperlipidemia. This MAR documents an admitted [DATE] (28 days ago) and documents orders for blood glucose monitoring four times a day, oral Diabetic medications (Metformin and Onglyza), Insulin (Basaglar), oral Hyperlipidemia medications (Fenofibrate and Rosuvastatin), BPH (Benign Prostatic Hypertrophy) medication (Tamsulosin), diuretic (Furosemide) and Potassium Chloride. R15's Care Plan with a revision date of 4/27/23 only documents R15 is a high fall risk and R15 had an actual fall. On 5/17/23 at 12:13 PM, V16 Care Plan Coordinator confirmed R15 does not have a comprehensive care plan in place and stated R15 should have a comprehensive care plan in place at this time. 2.) R21's MAR dated 5/1/23 through 5/31/23 documents diagnoses including Dehydration, Muscle Weakness, Need for Assistance with Personal Care and Dysphagia. R21's Registered Dietician Notes dated 3/6/23 by V21 Dietician document a noted significant weight gain of 11% (16 pounds) in three months. This note documents R21 is on a regular, mechanical soft diet. R21's Nurse's Notes dated 5/17/23 document V2 Director of Nursing had a conversation with the family regarding R21's decline in condition. This note documents V2 discussed with R21's family that R21 is now having some swallowing difficulties at times. On 5/17/23 at 2:27 PM, V2 Director of Nursing stated that R21 has had a steady decline lately and hasn't wanted to get out of bed for meals. R21's Care Plan with a revision date of 5/1/23 does not address R21's diet orders or significant weight gain or R21's increased need for assistance during meals. 41970 3.) R16's Physician Progress Note dated 5/3/23 documents Chief complaint/Reason for visit: Wound on Left Knee. Diagnosis: Pressure Ulcer. Assessment and Plan: Recommend bordered foam to area to avoid further pressure. Replace every three days or as needed if soiled. On 05/17/23 at 10:13 AM Observed R16's Left Inner Knee Pressure Ulcer. V13 Licensed Practical Nurse (LPN) completed the dressing change. R16's Left Inner Knee Pressure Ulcer was dark red with three dark yellow dry areas in the center. R16's Left Inner Knee Pressure Ulcer did not have a bandage covering the area. On 5/17/23 at 10:20 AM V13 Licensed Practical Nurse (LPN) stated (R16's) Left inner Knee wound appeared to be a bug bite at first but now they (facility) called it a pressure ulcer. V13 stated I hadn't seen it for about a week because I was off work, but it looks like it has gotten worse. R16's Care Plan does not include a focus area, goal nor interventions for R16's Left Inner Knee Pressure Ulcer. On 05/17/23 at 11:30 AM V16 stated (R16) does have a pressure ulcer on (R16's) Left Inner Knee. (R16's) pressure ulcer should have been included on (R16's) comprehensive careplan and was not. 4.) R33's Nurse Progress Note dated 4/26/23 at 10:41 AM documents Skin Evaluation: Skin Issue: Pressure Ulcer / Injury. Skin issue location: Right Ankle Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 3.0 centimeters (cm) Width: 2.0 cm Depth: 0.1 cm. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful with purulent tan and yellow drainage. This same evaluation did not document measurements. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here. R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it.

Based on interview and record review the facility failed to complete wound treatments for one of four residents (R5) reviewed for wound care in the sample list of 22 residents. Findings include: R5's Medication Administration Record dated 5/1/23 through 5/31/23 documents diagnoses including Age Related Physical Debility, Cerebral Palsy, Functional Urinary Incontinence and Mental Disorder. R5's Nurse's Note dated 4/25/23 at 9:40 AM by V16 Wound Nurse documents R5 has MASD (Moisture Associated Skin Damage) to the buttocks and R5 was seen by the Wound Physician. R5's Minimum Data Set (MDS) dated [DATE] documents R5 had MASD. R5's Wound Assessment and Plan dated 4/4/23 by V22 Wound Nurse Practitioner, documents Wound Type as MASD and a treatment order to cleanse area, pat dry well, Zinc Barrier Cream 20% or greater, apply every shift and as needed and every half day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (disinfectant/antiseptic). R5's Treatment Administration Record (TAR) dated 4/1/23 through 4/30/23 documents an order with a start date of 4/5/23 at 6:00 PM and a discontinue date of 4/8/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing, every shift. This TAR then documents an order with a start date of 4/9/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing. everyday shift -Start Date- 4/08/2023 and a D/C (discontinue) Date- 4/12/2023. This treatment was not signed off as completed on 4/8/23 or 4/12/23. R5's Wound Assessment and Plan dated 4/11/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 4/1/23 through 4/30/23 does not document the 4/11/23 order. There is no treatment documented after 4/11/23. R5's Wound Assessment and Plan dated 4/18/23 by V22 documents the wound type as MASD to the Sacrum and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and every twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (gel forming moisture-retentive dressing), change as indicated and as needed. R5's TAR dated 4/1/23 through 4/30/23 does not document this order as being written or completed. R5's Wound Assessment and Plan dated 4/25/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse with normal saline or sterile water, apply to wound bed and cover with dry clean dressing and as instructed. R5's TAR does not document this order as being written or completed. R5's Wound Assessment and Plan dated 5/16/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, skin barrier cream/ointment, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 5/1/23 through 5/31/23 documents an order with a start date of 5/16/23 to cleanse area. Pat dry well. Skin barrier cream/ointment-apply every shift and as needed for MASD. R5's TAR does not document that this has been completed. There are no signatures on the dates to indicate the treatments were completed. On 5/18/23 at 12:20 PM, V2 Director of Nursing confirmed the orders are not entered correctly according to V22's orders. V16 Wound Nurse confirmed that V22's orders are documenting things that are not getting completed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved.

Based on observation, interview and record review the facility failed to transcribe physician orders and complete wound treatments and pressure risk assessments for one of four residents (R33) reviewed for wound care in a sample list of 22 residents. Findings include: R33's undated Face Sheet documents an admitted [DATE] with medical diagnoses of Displaced Bimalleolar Fracture of Right Lower Leg, Atrial Fibrillation and Congestive Heart Failure. R33's Pressure Ulcer Risk assessment dated [DATE] documents R33 as high risk for skin breakdown. R33's Medical Record does not document any further Pressure Ulcer Risk Assessments after R33's Stage 2 Right Inner Ankle Pressure Ulcer was identified on 4/25/23. R33's Skin Only Evaluation dated 4/26/23 documents a Right Inner Ankle Stage 2 Pressure Ulcer measuring 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. This same evaluation documents R33's Stage 2 Right Inner Ankle Pressure Ulcer was first noted at the Physician office after cast removal. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful purulent tan and yellow drainage. This same evaluation did not have measurements. R33's Nurse Progress Note dated 5/4/23 at 9:26 AM documents (R33) seen by (V17) Wound Physician. New orders to Inner Ankle on Right R33's Nurse Progress Note dated 5/8/23 at 5:18 PM documents (R33) seen by (V18) Family Nurse Practitioner (FNP). FNP would like the dressing to pressure wound on Right Ankle changed daily instead of every other day. R33's Skin Only Evaluation dated 5/11/23 documents a Right Ankle Stage 3 Pressure Ulcer as measuring 2.5 cm long by 1.5 cm wide by no depth documented with full thickness skin loss. R33's Physician Order Sheet (POS) dated April 1-30, 2023, and May 1-31, 2023, does not document physician orders for treatment of R33's Right Inner Ankle Pressure Ulcer. R33's Treatment Administration Records (TAR) dated April 1-30, 2023, and May 1-31, 2023, do not document any treatment orders for R33's Right Ankle Pressure Ulcer. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here (facility). R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. On 05/17/23 at 1:45 PM V2 Director of Nurses (DON) stated any newly admitted resident or established resident that has pressure ulcers documented should have those wounds measured, documented, care planned, and Physician should be notified to obtain wound orders. We (facility) documented that (R33) had a Stage 2 Pressure Ulcer that worsened to a Stage 3 and we (facility) had no orders on the POS or TAR. That is terrible. I have no way to say if the treatments were even getting done. By the documentation, (R33's) Right Inner Ankle Pressure Ulcer was being measured but there was no other follow up. I have been trying to educate all the nurses on how to document a pressure wound. I can't say why the nurses didn't have treatment orders on the POS or TAR, but I do know that they (staff) have been educated on this many times before. It looks like I will have to re-educate again. The undated facility policy titled 'Preventative Skin Care' documents all residents will be assessed using the pressure ulcer risk assessment at the time of admission and weekly for four weeks. Then will be reassessed at least quarterly and/or as needed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved.

Based on observation, interview and record review the facility failed to provide supervision and proper transfer technique during toileting to prevent a fall for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a fractured right humerus resulting in decreased mobility and pain. Findings include: R1's undated care plan documents; admission to the facility on [DATE] for rehabilitation of a pelvic fracture and prior to admission R1 lived at home independently. R1's admission weight is documented as 103.5 pounds and R1's admission care plan documents R1 is to have the assistance of 2 staff with a gait belt used at all times for transfers. R1's admission fall assessment documents R1 as a high fall risk, requiring assistance with activities of daily living and with a history of previous falls. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as cognitively intact and requiring a two person physical assistance for toileting. R1's fall investigation dated 9/21/22 documents that R1 fell while toileting resulting in a broken right humerus. Physician orders dated 9/21/22 document that this fall with fracture required an X-ray, an emergency room visit and the subsequent use of a right arm sling for four weeks. On 10/18/22 at 8:35AM, R1 was sitting in a recliner with the right arm in a sling and propped upon a pillow. R1 stated, I came (to the facility) because I fell at home. When I fell here, I just got dizzy in the bathroom and fell . I didn't have a belt on. Before I fell , I was in a room with a bathroom but when I got back from the hospital, they put me in here with a commode. Upon wincing when moving R1's right arm, R1 stated, The nurse should be coming in to bring me my pain medicine and to help me move this, pointing to her right arm. On 10/18/22 at 9:00AM, V2 Director of Nursing stated, We moved (R1) from her old room to a new one because she really isn't wanting to move much and prefers to just have the girls get her up to a commode. I have gone down and talked to her about the importance of getting up and out of the chair, but since the fall I think that she has been afraid to get up. R1's care plan dated 10/7/22 documents R1 has been incontinent more frequently since the right shoulder fracture. On 10/18/22 at 1:30PM, R1 was sitting in her recliner. R1 stated, I prefer to just sit here. My knee hurts, my arm hurts. It is just better if I don't move. On 10/18/22 at 11:00AM, V3 Physical Therapy Assistant stated, The standard of care is to use a gait belt for transfers. It is too bad that R1 fell because prior to that she was doing really well. On 10/18/22 at 9:41AM, V4 Certified Nursing Assistant stated, I wasn't using a gait belt and I couldn't get to (R1) before she fell . V4 Certified Nursing Assistant's (CNA) disciplinary documentation dated 9/21/22 documents that V4 CNA failed to transfer R1 properly and left R1 unattended resulting in resident safety being jeopardized. On 10/18/22 at 9:55AM, V6 Nurse Practitioner stated, It is possible that if the staff had been using a gait belt, ((R1's) fall) could have been prevented. The facility gait belt and transfer policy revised date 4/10/06 documents, All certified nursing assistants and licensed nursing personnel engaged in the lifting and transferring of residents will use gait belts. Mechanical lifts will be used when the use of gait belts does not provide an adequate margin of safety. The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and employees. After orientation to facility policy and training in the use of gait belts, employees who fail to use them or to use them appropriately should be consider subject to disciplinary measures. Gait belts are mandatory.

Based on observation, interview, and record review the facility failed to implement interventions for known behaviors of a resident (R4) with Dementia. This failure resulted in R1 falling from the bed and sustaining a right [CONDITION(S)]. R1 and R4 are two of four residents reviewed for falls in the sample list of 4. Findings include: The facility's Incident Report Form - IDPH (Illinois Department of Public Health) Notification dated 5/18/22 documents R1 rolled out of bed in the early morning on 5/18/22. R1 later complained of pain and was hospitalized on [DATE] at 12:30 PM. The Final Incident Report-IDPH Notification for R1's 5/18/22 fall investigation documents: R1 was attempting bed mobility and R1's right side is flaccid due to [CONDITION(S)] ([CONDITION(S)].) R1 was unable to stop rolling and landed on R1's right side on the floor. The next morning R1 complained of right hip pain. R1 was transported to the hospital and R1 had a right [CONDITION(S)]. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has functional limitation to one upper and lower extremity and is dependent on two staff for transfers. R1's Care Plan documents R1 has right sided [CONDITION(S)] related to [CONDITION(S)], and R1 uses 1/4 bed rails for bed mobility. R1's Fall Report dated 5/18/22 documents: At 2:30 AM R1 was heard yelling and was found lying on R1's right side on the floor. R1 was yelling that R1's roommate (R4) was trying to get over here to me (R1) and I (R1) fell OOB (out of bed.) R1 had muscle spasms noted to R1's right leg. R1's Nursing Note dated 5/18/22 at 9:40 AM documents R1 complained of pain to the right leg and was not able to bend or move R1's leg as prior to R1's fall. R1's hip and pelvis x-ray report dated 5/18/22 at 12:56 PM documents the reason for the x-ray as Right hip pain from a falling injury, and the x-ray showed an intertrochanteric fracture of the right hip. R1's Hospital Summary dated 5/21/22 documents: R1's hospital discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted to the hospital on 5/18/22 after a fall from bed at local SNF (skilled nursing facility) which resulted in fracture to right hip/surgical repair/nailing. The Resident Notification of Room/Roommate Change forms document the following: R1 and R4 began sharing a room on 3/11/22. R4 was transferred to another room on 5/18/22. R4's MDS dated [DATE] documents R4 has severe cognitive impairment. R4 transfers and walks with setup and supervision. R4's Nursing Notes document: On 4/3/22 at 3:45 PM While roommate (R1) was in shower, resident (R4) (went) over to roommate's side and ate (R1's) snacks and drank (R1's) coke. On 4/10/22 at 5:30 PM R4 was entering other resident rooms and eating their snacks. R4's Care Plan documents R4 has Dementia, is confused, and often wanders. R4's Care Plan and April and May 2022 Behavior Tracking does not address R4's behaviors of going through other resident's belongings and taking food from other residents. On 6/8/22 at 9:47 AM R1 was lying in bed. R1 had difficulty communicating and was only able to respond yes/no to questions. R1 answered yes to having a recent fall and going to the hospital as a result of the fall. R1 was asked if R1 had any injuries from the fall. R1 said yes and pointed to R1's right hip. On 6/8/22 at 11:14 AM V8 Certified Nursing Assistant (CNA) stated one day while R1 was out of R1's room for a shower, R4 ate R1's candy. On 6/8/22 at 11:19 AM V8 entered R1's room (which R4 no longer resides in), and R4 was lying in the bed. On 6/8/22 at 11:53 AM V6 CNA stated: About an hour before R1's fall, V6 heard R1 yelling. V6 went to R1's room, and R4 was going through R1's belongings. V6 assisted R4 back to R4's bed. R4 had previously tried to take R1's candy, and this has happened occasionally over the last month. R4 and R1 just don't get along. At the time of R1's fall, V6 heard R1 yelling. R1 was found lying on R1's right side on the floor between R1's and R4's beds. R4 was trying to help R1. R1 seemed upset and was pointing at R4. R1 can't talk much, so V6 asked R1 if R4 had tried to get into R1's belongings again. R1 said yes. R1 complained of pain and pointed to R1's right leg. On 6/8/22 at 1:00 PM R1's fall investigation was reviewed with V2 Director of Nursing. V2 stated nothing had been reported to V2 that R1 had been upset with R4 previously. V2 confirmed V6's written statement documents at 1:00 AM V5 CNA and V6 had heard R1 yelling out, and R4 was on R1's side of the room. V2 confirmed V4 RN's written statement documents at the time of R1's fall, R1 was attempting to get R4 out of R1's side of the room, and R1 fell out of bed. On 6/8/22 at 1:56 PM V7 CNA stated: R4 wanders into other resident rooms and goes through other resident's belongings. This is not a new behavior for R4. R4 has taken food from other residents during meals in the dining room. R4 doesn't distinguish between what is R4's and what doesn't belong to R4. On 6/8/22 at 2:02 PM V9 Social Services Director stated V9 was not aware that R4 had taken R1's candy or had gone through other resident's belongings. On 6/8/22 at 3:06 PM V6 Registered Nurse stated R4 has dementia and doesn't mean anything by it, but R4 rummages through other resident's belongings and has taken food from other residents before. R4 does that all the time, it is a behavior that R4 has. We try to redirect R4. V6 stated at the time of R1's fall, R1 was found on the floor of R1's room on R1's right side. R1 was yelling get him (R4), get him and R1 was pointing to R4. R4 had been on R1's side of the room prior to the fall. V6 was asked what was the cause of R1's fall. V6 replied I assume that (R1) was upset with (R1's) roommate (R4) being on (R1's) side of the room and was trying to get (R1's) roommate (R4) from R1's side of the room. On 6/8/22 at 3:59 PM V2 Director of Nursing stated the facility does not have a policy on dementia or behaviors. V2 stated staff are to report behaviors to V2, and a care plan for the behavior and interventions is developed. V2 stated V2 wasn't sure that R4 taking food from others would be considered a behavior, since R4 has dementia. V2 stated R4 taking food from others and going through other resident's belongings and interventions were not added to R4's behavior tracking until June 2022.

Based on record review and interview the facility failed to ensure one resident (R18) was safely transferred during toileting by staff not using a gait belt and R18 not wearing footwear during transfer. This failure resulted in R18 slipping in urine and sustaining a right ankle fracture. R18 is one of four residents reviewed for falls in a sample list of 35. Findings include: R18's undated face sheet documents a diagnosis of Non Displaced Oblique Fracture of Right Tibia, Fracture of Lower End of Right Fibula, [CONDITION(S)] and Difficulty in Walking. R18's Cognitive assessment dated [DATE] documents a score of 12 out of a total possible 15 points indicating moderate cognitive impairment. R18's Investigation Report for Falls dated 9/2/20 documents R18 was barefoot during transfer and V27 (Certified Nurse Aide/CNA) did not use gait belt to transfer R18 from toilet to wheelchair. Quality Care Reporting Form dated 9/2/2020 documents R18 was being assisted off of toilet on 9/2/2020 at 4:45 AM. R18 stood barefooted with no gait belt in place, had urinary incontinence episode and slipped in urine. Staff was educated to have R18 wear proper footwear per this form. X-Ray report of R18's right ankle dated 9/7/2020 documents impression 'Acute Non Displaced Distal Fibular Fracture. V15 (Doctor of Podiatric Medicine/DPM) documented in 9/15/2020 progress note Patient (R18) had a known ankle fracture at the start of September 2020. Patient was not placed in a boot. Patient was made partial weight bearing after knowing about her (R18) ankle fracture. Patient has pain with fracture. Final Incident Report to Illinois Department of Public Health documents the root cause of R18's acute Non Displaced Distal Fibular Fracture as the facility feels the only incident that would have possibly caused the fracture was the fall on 9/2/2020. On 4/22/21 at 1:35 PM V13 (Licensed Practical Nurse/LPN) stated she remembers R18's fall on 9/2/20. V13 stated staff should have applied footwear such as no skid socks to R18's feet to help prevent fall. V13 stated staff should always use gait belt when transferring residents to prevent incidents and falls. Using the gait belt and having resident wear shoes or no skid socks is for resident safety. This resident (R18) was not refusing anything that morning. At times she (R18) does refuse, but that morning she (R18) was being compliant. On 4/22/21 at 2:40 PM V2 (Director of Nurses/DON) stated R18 fell on [DATE] with no ankle injuries noted at that time. V2 stated V1 (Administrator) worked the floor on 9/7/20 and documented R18's right ankle was discolored. V2 stated an X-Ray was ordered and obtained which showed an acute right ankle fracture. V2 stated the staff should do everything possible to ensure resident safety including having resident wear footwear and staff should always use their gait belt. The facility policy titled 'Fall Prevention' revised 11/12/18 documents the following: Policy: To provide for resident safety and minimize injuries related to falls. Procedure: All staff must observe residents for safety.

Based on interview and record review the facility failed to follow facility policy and local health department guidance to promptly develop a COVID-19 Unit and move infected residents away from non-infected residents for twelve of twelve residents (R6, R16, R17, R19, R20, R21, R22, R23, R24, R25, R26, R27) reviewed for infection control in the sample of 29 residents. This failure resulted in R6, R23, R24, R25, R26 and R27 being unnecessarily exposed to an infectious disease for an extended period of time. The facility failed to ensure R16, R17, R19, R20, R21, and R22, who tested positive for [DIAGNOSES REDACTED]-CoV-2 or the [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME], were promptly moved to a COVID-19 Unit and away from their roommates, R6, R23, R24, R25, R26 and R27, who were not positive for [DIAGNOSES REDACTED]-CoV-2 or the [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME]. R6, R23, R25, R26 and R27 later tested positive for [DIAGNOSES REDACTED]-CoV-2 or the [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME]. This resulted in an Immediate Jeopardy. While the immediacy was removed on 9/18/20, the facility remained out of compliance at a Severity Level 2. The facility is in the process of implementing re-education components and training related to infection control policies and procedures. Findings include: The COVID-19 Cohorting of Residents policy dated 8/26/20 states: Purpose: To minimize interactions of infectious individuals from non-infected individuals. Identify space within the facility to be dedicated to monitor and care for residents with COVID-19. Ideally this space should be physically separated from other rooms that house residents without confirmed COVID-19. (Separate floor, wing or cluster of rooms) Identify HCP (Health Care Providers) who will be assigned to work only within the dedicated area, when in use. The policy also states, Move resident to COVID-19 designated area if test results are positive for [DIAGNOSES REDACTED]-CoV2. The Floor Plan dated 8/16/20 Original documents R17 and R27 are roommates, R19 and R23 are roommates, R16 and R6 are roommates, R20 and R26 are roommates, R21 and R25 are roommates, and R22 and R24 are roommates. On 9/4/20 at 12:50 PM V1 (Administrator) confirmed the floor plan dated 8/16/20 Original documents resident room assignments through the morning of 8/18/20. The Nurses Note dated 8/14/20 documents R17 has a temperature of 102 degrees Fahrenheit and that R17 was placed on droplet precautions. The Nurses Note dated 8/14/20 at 5:20 PM documents R17's Rapid COVID-19 test is positive. R17's Nurses Notes dated 8/14/20 through 8/16/20 do not document R17 was moved to a COVID-19 Unit or that R17 or R17's roommate R27 were moved to different rooms. R27's (R17's Roommate) Nurses Notes dated 8/14/20 at 5:45 PM document a rapid COVID-19 test was collected for R27 and R27's rapid COVID-19 test was negative. R27's Nurses Notes dated 8/14/20 through 8/16/20 do not document R27 was moved to a different room away from R17. R27's Nurses Notes and vital signs records dated 8/13/20 and 8/14/20 do not document R27 has signs or symptoms of COVID-19. The Nasopharyngeal Swab test results dated as collected 8/16/20 and reported 8/17/20 document R16, R19, R17, R22, R20, R21 and R27 are positive for [DIAGNOSES REDACTED]-CoV-2. The Nasopharyngeal Swab test results dated as collected 8/16/20 and reported 8/17/20 document R6, R23, R24, R25 and R26 are negative for [DIAGNOSES REDACTED]-CoV-2. R6, R23, R24, R25 and R26's nurses' notes and vital signs records dated 8/17/20 and 8/18/20 do not document signs or symptoms of COVID-19. The Laboratory Report dated 8/21/20 documents R25 is positive for the [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] COVID-19. The Nasopharyngeal Swab test results dated as collected 8/24/20 and reported 8/25/20 document R6, R23, and R26 are positive for [DIAGNOSES REDACTED]-CoV-2. On 9/4/20 at 10:00 AM V18 (Assistant Administrator County Public Health Department) stated R17 had a positive rapid COVID-19 test on 8/14/20. V18 stated according to the floor plans V1 sent to the health department, R17 (who was positive for COVID-19 {[MEDICATION NAME]} on 8/14/20), was still in the same room with R27 (who was negative for COVID-19 {[MEDICATION NAME]}, on 8/16/20). V18 stated R17 should have been moved on 8/14/20. On 9/4/20 at 1:30 PM V16 (Registered Nurse) confirmed R17 had a positive rapid COVID-19 test on 8/14/20 and that R17 remained in the same room with R27 all weekend (8/15/20 and 8/16/20). V16 stated R17 went out the Hospital Emergency Department over the weekend and was readmitted back into the same room with R27. On 9/4/20 at 10:00 AM V18 stated health department staff were notified by the facility the morning of 8/18/20 of several additional [DIAGNOSES REDACTED]-CoV-2 positive residents. V18 stated V18 spoke with V1 and V1 wanted to leave [DIAGNOSES REDACTED]-CoV-2 positive residents in the same rooms with [DIAGNOSES REDACTED]-CoV-2 negative residents. V18 stated V18 told V1 that V1 needed to develop a COVID-19 unit for the residents that tested positive and an observation unit for residents who were exposed. V18 stated when V1 was told V1 would have to create a COVID-19 Unit, V1 was not cooperative. V18 stated around 3:00 PM on 8/18/20 a family member (V20) of a [DIAGNOSES REDACTED]-CoV-2 negative resident (R6) came to the health department and complained that R6 was not going to be moved away from R6's [DIAGNOSES REDACTED]-CoV-2 positive roommate (R16) until the next day. V18 stated V18 assured V20 that V18 spoke to V1 and the residents would be moved today (8/18/20). V18 stated V20 returned to the health department at 5:00 PM on 8/18/20 and reported again that R6 was told by facility staff that the residents would not be moved until the next day. V18 stated V18 called V1 and found that V1 had left the facility for the day without moving the infected residents away from the non-infected residents and without setting up the COVID-19 and Observation Units. V18 stated V1 told V18 that V1 was not going to move the residents or set up the COVID-19 unit until the next day. V18 stated V1 was adamant V1 was not going to move the residents and it was a challenge to get (V1) to move the residents. V18 stated V1 told V18 that V1 did not have the staff to move residents today (8/18/20) and V1 thought moving the residents would spread [MEDICAL CONDITION] throughout the building. V18 stated V1 was angry and hostile. V18 stated V1 did not want to go back to the facility and move the residents. V18 stated V18 told V1 the residents had to be moved today (8/18/20). V18 stated V18 received a text message from V1 around 6:15 PM that evening stating the residents were being moved. The electronic mail from V18 dated 9/4/20 documents I (V18) explained again the need to place the COVID positive residents into a COVID unit immediately. (V1) argued this point, saying (V1) had an algorithm from the CDC (Centers for Disease Control and Prevention) that indicated (V1) did not have to separate the positive and negative residents and that (V15) (IDPH Infection Control Consultant) had told (V1's) boss the same thing. I (V18) asked for (V1's) supervisor's contact information (which (V1) refused to give me) and immediately tried to contact (V15). On 9/8/20 at 12:00 PM V15 stated V15 did not tell the facility it was ok to leave COVID-19 positive residents and COVID-19 negative residents together. V15 stated it is wrong to leave COVID-19 positive and negative residents together for an extended period of time. V15 stated the facility was ignoring guidance. On 9/10/20 at 10:30 AM V2 (Director of Nurses and Infection Preventionist) stated they were going by the CDC Algorithm that states to move residents if possible. V2 stated they had no private rooms and thought they could draw the curtain between the COVID-19 positive and negative residents and place the residents on droplet precautions. V2 stated the local public health department trumped their policy by telling facility staff they had to move COVID-19 positive residents together and exposed residents together. V2 stated V2 thought V1 spoke to local public health department staff on 8/18/20. On 9/4/20 at 12:50 PM V1 confirmed the facility received the test results for the positive and negative [DIAGNOSES REDACTED]-CoV-2 residents by fax the morning of 8/18/20 and then V1 left the facility that evening without moving the residents or setting up the COVID-19 Unit. V1 confirmed R16, R19, R22, R21, R20, and R27 tested positive for [DIAGNOSES REDACTED]-CoV-2 on 8/18/20. On 9/10/20 at 11:05 AM V1 was asked if V1 called the local health department to report the positive COVID-19 test results on 8/18/20, and V1 stated they called me, or I called them. I don't remember. V1 was asked what instructions V1 was given by the local health department on 8/18/20 and V1 stated, I don't recall, I don't want to say if I don't remember. On 9/4/20 at 10:00 AM V18 stated the facility started with 4-6 cases and then left [DIAGNOSES REDACTED]-CoV-2 positive residents in rooms with [DIAGNOSES REDACTED]-CoV-2 negative residents for an extended period of time, and [MEDICAL CONDITION] spread throughout the building. The Spreadsheet sent by V1 by electronic mail on 9/4/20 documents 32 residents and 17 staff members have tested positive for [DIAGNOSES REDACTED]-CoV-2. The Resident Roster dated 9/1/20 documents 37 residents reside in the facility. An Immediate Jeopardy situation was identified on 9/16/20. The Immediate Jeopardy was identified to have begun on 8/14/20 when the facility failed to set up a COVID-19 unit and move infected residents out of rooms with non-infected residents. On 9/16/20 at 2:10PM, V1 was notified of the Immediate Jeopardy situation. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 9/21/20 at 10:50 am V1 verified department managers were in-serviced by V22 (Regional Director of Operations) on following recommendations from the Local Health Department and the Illinois Department of Public Health (IDPH), and COVID-19 control measures and cohorting of residents. 2. On 9/21/20 at 10:48 am and 10:49 am R24 and R28 (COVID-19 negative residents) were observed in rooms outside the COVID-19 unit. 3. On 9/21/20 at 10:50 am V1 verified V1 and V2 participated in a conference call with local public health department staff, the IDPH Infection Control Consultant, and V41 (Regional Director of Clinical Operations) on 9/18/20. 4. On 9/21/20 at 10:50 am V1 confirmed that the Quality Assurance Team and Regional team will discuss recommendations and ensure recommendations are implemented.

Based on observation, interview and record review the facility failed to implement new fall interventions after falls for two of seven residents (R5 and R13) reviewed for falls in the sample of eight. These failures resulted in R5's pelvic fracture. Findings include: R5's Physician order [REDACTED]. R5's Minimum Data Set ((MDS) dated [DATE], 9/5/14, 11/5/14 and 2/5/15 document R5's mental status as severe cognitive impairment. The same MDS's documents that R5 requires supervision when ambulating in the room and corridor. R5's Fall Risk assessment dated [DATE] and 9/11/14, documents that R5 was at moderate risk for falls. R5's Fall Risk assessments dated 10/30/15 and 2/8/15 document R5 was at high risk for falls. R5's, Physician Communication and Progress Note for New Symptoms, Signs and Other Changes in Condition (SBAR), along with the Nurses Note and Transfer Form dated 8/5/14 document R5's fall. The same forms document that R5 was found on the floor when R5 complained of right wrist and right hip pain. R5's documented pain level was very, very bad, when R5 was transferred to the local hospital for x-rays which were negative for fracture. R5's, Nurses Note dated 10/27/14 document that R5 was found on the floor and complained of left arm, left hip and back pain at a level of 9/10 (severe). The same note documents that R5 was transferred to the local hospital. The local hospital Radiology Report dated 10/27/14 documents Nondisplaced left inferior pelvic ramus fracture. R5's Nurses Note dated 4/11/15 documents that R5 was found on the floor of her room with no injury documented. R5's Care Plan Conference Participation Logs dated 9/5/14, 11/6/14, 2/8/15 and 5/6/15 document that R5's Care Plan was reviewed but not revised to include any new targeted fall interventions after 7/1/14. On 6/25/15 at 10:28 am, E2, DON stated The only date I'm seeing for (R5's) fall interventions is 7/1/14. Anytime there are changes in a resident's status, the care plan should be updated to include dates of the new intervention when a fall occurs. On 6/25/15 at 9:23, E8, Certified Nursing Assistant stated (R5) stayed in the hall while I went into the bathroom. (R5) waited just outside the bathroom door. I started the shower and rolled up my pant legs. I was behind the curtain then. I didn't see (R5) fall. I should have brought (R5) into the shower room with me. I heard (R5) yell for help. (R5) was lying on her left side when I saw her. (R5) said she did not know what happened. The facility's Physician order [REDACTED]. The facility's Minimum Data Set (MDS) for R13 dated 4/20/15 documents R13 does not ambulate, is dependent upon staff for locomotion in a wheelchair, toileting and eating. This same MDS documents R13 requires extensive assistance of 2 staff members for bed mobility, surface to surface transfers, and dressing. The facility's Fall Risk assessment dated [DATE] documents R13 is a high risk for falls due to confusion, loss of ability to maintain sitting or standing balance, and R13's related medical diagnoses. This same Fall Risk Assessment documents R13 has experienced a fall in each of the two most recent quarters. The facility's Nursing Notes dated 6/1/15 document R13 experienced a fall on 6/1/15 by falling off of the bed. The facility's care plan for R13 documents the most recent care plan review was conducted on 4/20/15. This care plan does not document any targeted interventions related to the fall out of bed on 6/1/15, nor any new or revised interventions since 3/19/14. On 6/23/15 at 4 PM E7, MDS/Care Plan Coordinator acknowledged that the facility's care plans were not individualized nor appropriately revised. On 6/24/15 at 10:30 AM E2, Director of Nursing, acknowledged that there were no new or revised interventions since the date of 3/19/14.