La Bella Of Mascoutah

Based on observation, interview, and record review, the facility failed to provide positioning assistance to 2 of 3 residents (R3, R11), when reviewed for ADL (Activities of Daily Living) care provided to dependent residents in the sample of 12.Findings Include:1.On 2/26/26 at 8:40 AM, R3 was observed in the dining room, up in her reclining wheelchair being assisted with the breakfast meal.On 2/26/26 at 10:35 AM, R3 was observed in her room in her reclining wheelchair.On 2/26/26 from 8:40 AM to 1:00PM, R3 was observed in 15-30-minute increments, R3 was not repositioned during that time.On 2/26/26 at 1:30 PM, R3 was observed being assisted to bed by staff.On 2/26/26 at 1:30 PM, V4, CNA (Certified Nursing Assistant) stated she laid R3 down after breakfast, incontinent care was provided and was repositioned. V4 stated she was unsure of the exact time and did not lay R3 down or reposition her again until 1:30 PM.R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified Skin Changes, Pulmonary Hypertension, Age Related Debility, Urinary Retention, Protein Calorie Malnutrition, HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), Anorexia, and Pain.R3's MDS (Minimum Data Set), dated 1/1/26, documents R3 is dependent with ADLs.R3's Care Plan, dated 9/30/24, documents R3 has an ADL self-care performance deficit and requires staff assistance with care needs. 2. On 2/26/26 at 8:15 AM, R11 was observed in her reclining wheelchair in the dining room. On 2/26/26, from 8:15 AM to 12:45PM, R11 observed in 15-30-minute increments and was in the dining room in her wheelchair and had not been repositioned.On 2/26/26 at 1:50 PM, R11 was observed being assisted to bed with staff.On 2/26/26 at 2:00 PM, V5, CNA, stated she laid R11 down after breakfast, unsure of time, provided incontinent care and got her back up in her reclining wheelchair.On 3/3/26 at 11:38 AM, V1, Administrator, stated the residents that are unable to reposition themselves should be assisted by staff every two hours.The Activities of Daily Living Policy, with a revision date of 3/17/25, documents residents will be provided with care, treatment and services as appropriate to maintain or improve their quality of life. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with their plan of care, including appropriate support and assistance with (in part): mobility.

Based on observation, interview, and record review, the facility failed to implement safety measures to prevent falls in 1 of 5 residents (R11) when reviewed for freedom of accidents in the sample of 12.Findings Include: On 2/27/26 at 9:48 AM, R11 was observed in the dining room in her wheelchair with a clear plastic lap tray in place. The tray is attached to the wheelchair with Velcro straps going from the tray to the wheelchair arm rests. The tray is easily moved and slides up/down very easily. R11's Progress Note, dated 12/19/25 at 10:07 PM: 9:25 PM, documents the following: Resident observed lying on her back/right side in dining room next to her wheelchair. No apparent physical injury; AROM (Active Range of Motion) and PROM (Passive Range of Motion) WNL (Within Normal Limits) for resident. Neuro checks initiated and WNL for resident. VSS (Vital Signs Stable) 120/78, 63, 16, 97.4, 99% RA (Room Air). 9:35 PM, DON (Director of Nurses), Administrator, POA (Power of Attorney), and MD (Medical Doctor) notified. POA would like resident to be sent to the local hospital. 9:50 AM, Transferred from floor to stretcher by 2 EMT's (Emergency Medical Technician), transported via ambulance.R11's Progress Note, dated 12/20/25 at 5:30 AM, documents the following: The nurse at the local hospital called to give report said CT of the head was normal, also did UA (Urinalysis) with reflex to C&S (Culture & Sensitivity). UA was positive sent for C&S, Rocephin 1gm (gram) given at hospital, script for Vantin (Cefpodoxime) sent to pharmacy. Resident returned to facility at 5:15AM, resident transferred from stretcher to bed, no signs or symptoms of pain or discomfort at this time, call light within reach.R11's Face Sheet, undated, documents R11 has the following diagnoses: CP (Cerebral Palsy), Seizures, Dependence on Wheelchair, Disorders of the Muscle, and Intellectual Disability.R11's MDS (Minimum Data Set), dated12/12/25, documents R11 has severe cognitive impairment and is dependent with ADLs (Activities of Daily Living). R11's Care Plan, dated 3/31/25, documents R11 has the potential for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and is unaware of safety needs with an intervention for a lap tray to be used while R11 is up in her chair to prevent falls and ensure resident safety. There were no new interventions implemented for R11's fall on 12/19/26. The Facility Repair Requisition, dated 12/19/26, included in R11's investigation of the fall, documents the following: Specialized chair check and problems apparent. Placed apparent. Placed arm back on chair. Transfer belt to assure resident's safety. There was no name on the requisition.On 2/27/26 at 9:17 AM, V9, CNA (Certified Nursing Assistant) stated she was working on 12/19/26 when R11 fell. V9 stated she was on break and came back and found R11 lying on the floor in the dining room. V9 stated R11 did have her lap tray on but it wasn't secure and the family and facility knew that. V9 stated when R11 moves around in her wheelchair, the tray loosens, lifts and slides off and R11 will slide out of her wheelchair. V9 stated she did not witness R11 fall but is sure that is what caused her to fall.On 3/3/26 at 11:38 AM, V1, Administrator, stated, she understands R11's tray is easily moved/loose and will have maintenance address this. The Fall Reduction Policy, with a revision date of 10/30/24, documents the purpose of the policy is to provide an environment that remains as free of accident hazards as possible and to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a comprehensive assessment and preference for 3 of 3 (R4, R5, R12) residents investigated for activities in a sample of 12.1. R4's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].R4's EMR dated 9/3/25 documents a diagnosis of legal blindness, as defined in USA.R4's EMR dated 9/3/25 documents a diagnosis of anxiety disorder, unspecified.R4's EMR dated 10/3/25 documents a diagnosis of other psychotic disorders not due to a substance or known physiological condition.R4's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents that the resident requires setup or clean-up assistance for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident requires supervision or touching assistance for chair/bed to chair transfer and toilet transfer.R4's Care plan dated 10/24/25 documents, I prefer (Specify: to participate, little participation or no participation) in activity involvement.Care Plan is not done.R4's Activity Assessment (Quarterly or Annually) dated 12/3/25 documents Unedited the form is blank.2. R5's EMR undated documents the resident was admitted to the facility on [DATE].R5's EMR dated 7/24/20 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.R5's EMR dated 10/18/21 documents a diagnosis of morbid (severe) obesity due to excess calories.R5's EMR dated 7/29/20 documents a diagnosis of major depressive disorder, single episode, unspecified.R5's MDS dated [DATE] documents a BIMS score of 15 out of 15. The MDS documents that the resident that the resident requires supervision or touching for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident partial/moderate assistance for chair/bed to chair transfer and toilet transfer.R5's Activities Assessment (Quarterly or Annually) dated 7/26/25 documents Unedited the form is blank.3. R12's EMR undated documents that the resident was admitted to the facility on [DATE].R12's EMR dated 7/13/25 documents a diagnosis of paralytic syndrome, unspecified.R12's EMR dated 10/20/25 documents a diagnosis of acute respiratory failure with hypoxia.R12's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.R12's Activities Assessment (Quarterly or Annually) dated 8/29/25 documents Unedited. Assessment is not done.During this investigation, no observations of R4 and R12 engaging in any activities nor did any activity staff engage with R4 and R12 for 1 on 1 activities. R5 was observed playing bingo one day.On 2/26/26 at 8:20 AM, R4 stated that there are no activities for him except bingo and he only plays bingo to get snacks.On 2/27/26 at 12:17 PM, V8, Activity Director/Social Service Designee stated that activity assessment and social service assessments should be done on admission and quarterly. She stated that care plans for activity and social service should be updated every 3 months.On 2/27/26 at 12:23 PM, V20, MDS/Care Plan Coordinator stated that care plans should be updated quarterly.Facility's Activity Programs policy and procedure dated 11/5/19 documents An ongoing program of activities is designed to meet the needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan in 3 of 4 residents (R3, R4, R12), reviewed for development of the comprehensive care plan in the sample of 12.Findings Include:Findings include:
1. On 2/26/26 at 10:35 AM, R3 was observed in her room in a reclining wheelchair, with the television on. Contractures were observed to the left hand with the fingers completely contracted to the palm of the left hand. There were not any splints/washcloths in place to aid in contracture management.
R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified Skin Changes, Pulmonary Hypertension, Age Related Debility, Urinary Retention, Protein Calorie Malnutrition, HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), Anorexia, and Pain.
R3's MDS (Minimum Data Set), dated 1/1/26, documents R3 has severe cognitive impairment, has impairment in ROM (Range of Motion) in one upper and one lower extremity, is dependent with ADLS (Activities of Daily Living), and is not receiving any ROM programs.
R3's Activity Assessment, dated 4/4/25, documents R3 enjoys listening to music, sitting outside, watching TV and movies, prefers to stay in room, and prefers activity programs in small groups or in room.
R3's Care Plan, dated 9/30/24, failed to document a ROM/Contracture Management or Activities Care Plan.
2. R4's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].
R4's EMR dated 9/3/25 documents a diagnosis of legal blindness, as defined in USA.
R4's EMR dated 9/3/25 documents a diagnosis of anxiety disorder, unspecified.
R4's EMR dated 10/3/25 documents a diagnosis of other psychotic disorders not due to a substance or known physiological condition.
R4's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents that the resident requires setup or clean-up assistance for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident requires supervision or touching assistance for chair/bed to chair transfer and toilet transfer.
R4's Care plan dated 10/24/25 documents I prefer (Specify: to participate, little participation or no participation) in activity involvement.
Care Plan is not done.
R4's Activity Assessment (Quarterly or Annually) dated 12/3/25 documents Unedited the form is blank.
3. R12's EMR undated documents that the resident was admitted to the facility on [DATE].
R12's EMR dated 7/13/25 documents a diagnosis of paralytic syndrome, unspecified.
R12's EMR dated 10/20/25 documents a diagnosis of acute respiratory failure with hypoxia.
R12's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.
R12's Activities Assessment (Quarterly or Annually) dated 8/29/25 documents Unedited. Assessment is not done.
R12 did not have a care plan for the resident's preference for activities.
On 2/27/26 at 12:17 PM, V8, Activity Director/Social Service Designee stated that activity assessment and social service assessments should be done on admission and quarterly. She stated that care plans for activity and social service should be updated every 3 months.
On 2/27/26 at 12:23 PM, V20, MDS/Care Plan Coordinator stated that care plans should be updated quarterly.
On 3/3/26 at 11:38 AM, V1, Administrator, stated she is aware the care plans need to be updated and they are currently in the process of doing this.
The Care Plan Policy, with a revision date of 11/6/19, documents the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment.

Based on interview and record review, the facility failed to develop a comprehensive care plan on 2 of 18 residents, (R20 and R26), reviewed for Comprehensive Resident Centered Care Plan in the sample of 25.Findings Include:1.R20's Face Sheet, undated, documents R20 has a diagnosis, in part, of Severe Calorie Protein Malnutrition.
R20's Care Plan, dated 10/30/24, fails to document a care plan related to her nutritional status/needs.
2.R26's Face Sheet, undated, documents R26, has a diagnosis, in part, of (ESRD) End Stage Renal Disease.
On 12/17/25 at 8:33 AM, R26 stated he receives dialysis.
R26's Care Plan, dated 11/11/25, fails to document a care plan related to his diagnosis of ESRD, which requires hemodialysis.
On 12/19/25 at 8:15 AM, V1 Administrator, stated care plans should be developed for each resident's specific needs and she is working on them.
The Comprehensive Care Plan Policy, with a revision date of 6/25/25, documents the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

Based on observation and interview, the Facility failed to store foods in a manner that prevents foodborne illness and potential contamination. This has the potential to affect all 33 residents living in the Facility.Findings Include:On 12/16/2025 at 10:35 AM in the standing refrigerator there was a clear plastic container covered with plastic wrap labeled sloppy joe and a clear plastic container covered with plastic wrap labeled cheesy broccoli rice, neither container was dated. In the dry good storage area, there was an uncovered, clear plastic container with a plastic bag full of a white powdery substance that appears to be flour with label or date.On 12/17/2025 at 12:30 PM a large plastic container of dry cereal was on the bottom of a three-tier metal rolling cart uncovered with no date. On 12/17/2025 at 3:20 PM V17, Dietary Manager, stated all food stored in the refrigerator should be stored in a covered container and labeled with the date it was cooked. V17 stated food is only good for 3 days once cooked and placed in the refrigerator. V17 stated all dry good including cereal should be in a sealed labeled and dated container. V17 stated when flour is opened, it is placed in a plastic bag and then placed in a closed container and labeled with what it is and dated. The Facility's Food Storage Areas Policy Revised 12/30/2024 documents Prepared food stored in the refrigerator until service shall be dated. Such food will tightly sealed with plastic wrap, foil, or a lid. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 12/16/25 documents there are 33 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to serve palatable food and food cooked at the appropriate temperature when reviewed for Food and Nutrition Services. This failure has the potential to affect all 33 residents residing in the facility.Findings Include:
1. On 12/16/25 at 3:00 PM, R20 was observed and appears thin. R20 stated the food needs perked up, she couldn't eat the meals on Saturday (12/13/25), they were horrible. Sunday (12/14/25) they were a little better, so she ate. R20 stated she has lost weight and needs to gain it back but the food tastes so bad she can't eat it.
R20's MDS (Minimum Data Set), dated 10/10/25, documents R20 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R20 is cognitively intact.
2. On 12/16/25 at 11:20 AM, R27 stated the food tastes horrible. She is hungry but can't eat it. R27 stated they offer substitutes, but they aren't any better. R27 stated she is never offered snacks and doesn't know if they even have any.
R27's MDS, dated [DATE], documents R27 has a BIMS of 15, indicating she is cognitively intact.
3. On 12/16/25 at 11:10 AM, R33 stated he isn't getting enough to eat, they tell him he is getting double portions at meals, but he isn't. When he asks for more, he is told they don't have any food left. R33 stated when he asks for snacks, he is told they don't have any.
R33's MDS, dated [DATE], documents R33 has a BIMS of 14, indicating he is cognitively intact.
4. On 12/18/25 at 11:46 AM, V19, R14's Family, stated the food is horrible. Over the weekend, they served a cheese sandwich on 2 pieces of dry bread and 1 piece of cheese with tater tots that were barely warm. V19 stated almost daily he goes out to get R14 food because it's that bad.
R14's MDS, dated [DATE], documents R14 has a BIMS of 9, indicating she has moderate cognitive impairment.
5. On 12/16/25 at 2:32 PM, R1 stated the food is always cold and there is real a temperature abuse problem going on. R1 stated the food in the facility is not impressive at all. R1 stated the facility doesn't give a crap on what they serve the residents.
R1's Undated Face Sheet documents R1 was admitted to the facility on [DATE].
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.
R1's Physician Order dated 9/30/2025 at 3:07 AM documents R2 is on a Regular Diet.
6. On 12/16/25 at 11:39 AM, R16 stated the food in the facility is terrible and cold.
R16's Undated Face Sheet documents R16 was admitted to the facility on [DATE].
R16's MDS dated [DATE] documents R16 is cognitively intact.
R16's Physician Order dated 11/30/2025 at 1:57 PM documents R16 is on a Low Concentrated Sweets Diet.
7. On 12/16/25 at 11:06 AM, R29 stated the food in the facility is horrible and herself and other residents practically go hungry because the food is awful, cold, and there is not enough at times.
R29's Undated Face Sheet documents R29 was admitted to the facility on [DATE].
R29's MDS dated [DATE] documents R29 is cognitively intact.
R29's Physician Order dated 11/12/2024 at 10:42 AM documents R29 is on a Regular Diet.
8. On 12/17/25 at 11:46 AM, V6, Dietary Cook, removed an industrial sized pan of scalloped potatoes out of the oven and placed them on top of the stove underneath the hood vent. On 12/17/25 at 12:20 PM, V6 placed the industrial sized pan of scalloped potatoes on the steam table and served the residents without taking the temperature before serving.
9. On 12/17/25 at 12:30 PM, after the last resident had been served, food temperatures were taken with a calibrated thermometer on the steam table, and the following food temperature was not within the safety food code guidelines of 135 degrees Fahrenheit (F) or higher: pork loin 123.0 F.
11. On 12/18/25 at 1:00 PM, during the resident council meeting, the following concerns with the food were voiced: R20 stated the food is gross, over the weekend they had some sort of fettucine, the noodles weren't cooked, and it wasn't fit to eat. R20 stated another time she got to the dining room late for lunch because there wasn't enough staff. She asked for a grilled cheese and the cook, told her no they didn't have time. R20 stated she is hungry a lot because the food isn't edible. R1 stated the food [NAME] are small, not even child size portions. R1 stated they started using smaller glasses too. R20 stated he has snacks in his room he can eat but not everyone does. R1 stated it's all due to budget. R30 stated on the weekends they are screwed, the food is bad, they have an alternate menu but it is just as bad. R30 stated he was going to go out and buy some canned sardines and smoked ham so he will have something to eat.
On 12/17/2025 at 3:20 PM V17, Dietary Manager, stated all hot food temperatures should be between 170-190 degrees Fahrenheit and temperatures are taken before food is served to prevent food borne illness.
On 12/18/25 at 3:00 PM, V1, Administrator, stated they do not have a policy on food palatability/taste.
The Facility's Food Temperatures Policy Revised 12/30/2024 documents Food stored hot will be kept at 135 degrees F or above. Food will be cooked to the appropriate internal temperature per regulations.
The Facility's Food Storage Areas Policy Revised 12/30/2024 documents Hot foods or potentially hazardous food will leave the kitchen or steam table at 135 degrees F or above.
The Centers for Medicare and Medicaid Services, Form 671, dated 12/16/25, documents there are 33 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to have a sufficient number of CNAs (Certified Nursing Assistants) to care for their residents when reviewed for Nursing Services. This failure has the potential to affect all 33 residents residing in the facility. Findings Include: On 12/17/25 at 9:06 AM, there were 2 CNAs observed working. On 12/16/25 at 11:10 AM, R33 stated they don't have enough aides, it takes a long time for him to get his call light answered and to get help. On 12/17/25 at 10:55 AM, 10:59 AM, 11:15 AM, and 11:30 AM - R20's call light was on. Staff in hallway were passing by, not answering call light. On 12/17/25 at 11:41AM R20 stated she has had her call light on since 10:30 AM and no one has come into her room to help her. R20 stated, I understand that now they are getting ready for lunch, feeding the residents, but I'm tired of it, tired of waiting, they think oh it's just (R20), she'll understand, but I'm tired of waiting. I want a shower and want to get up for the day. They don't have any aides here today, I haven't even seen any. On 12/17/25 at 11:54 AM - R20's call light remained on. R20 verified no one has come into her room yet. On 12/17/25 12:22 PM R20's call light remained on. R20 verified no one has come into her room to help her.On 12/16/25 at 11:55 AM V5, R31's Family stated this past Sunday 12/14/25, at approximately 1:30 PM, he came into the facility and R31 was still in bed with no brief, she was incontinent of urine. She hadn't been dressed for the day and looked like she hadn't even gotten out of bed. V5 stated they were short staffed on aides and there is a problem with continuity of care with the CNAs. On 12/18/25 at 11:46 AM V19, R14's Family, stated the food is horrible. Over the weekend, they served a cheese sandwich on 2 pieces of dry bread and 1 piece of cheese, with tater tots that were barely warm. V19 stated almost daily he goes out to get R14 food because it's that bad. V19 stated the facility is very short staffed on aides. V19 stated the Administrator and DON (Director of Nurses) come in often to help out but then there isn't anyone to do their jobs. V19 stated they will hire aides and then 2 days later they're gone, they've been fired. V19 stated the ones that are here try but they don't have enough of them. On 12/18/25 at 1:00 PM, during the Resident Council Meeting, R1 and R30 stated they do not have enough CNAs to provide care, they are overworked and tired.12/17/2025 9:30 AM V7, LPN, stated they have enough CNAs most of the time, there are times they are short, but she helps out on the floor. The Resident Council Minutes, dated 4/1/25, documented concerns with being short staffed and the CNAs working too hard. The Resident Council Minutes, dated 7/31/25, documented concerns that more CNAs were needed. The Nursing Staffing Assignments document the following: 12/14/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. 12/17/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. 12/18/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. The Employee Timecards for the CNAs document the following: On 12/14/25, there was 1 CNA working day shift, 2 CNAs working evening shift, and 2 CNAs working night shift. On 12/17/25, there were 2 CNAs working day shift, 2 CNAs working evening shift, and 3 CNAs working night shift. On 12/18/25, there were 4 CNAs working day shift, 2 CNAs working evening shift, and 3 CNAs working night shift. On 12/16/25 at 10:40 AM, V1, Administrator, stated the CNAs think they need 4 CNAs per shift, but with a census of 33, they only need 3 CNAs on day shift, 3 CNAs on evening shift and 2 CNAs on night shift. V1 stated they have had turnover with the CNA staff recently and are actively hiring and recruiting. The Facility Assessment, dated 11/1/25, documents they require 15 full time employees to provide competent resident support and daily care. The Staffing Policy, with a revision date of 2/20/25, documents the following: The facility will provide sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The Centers for Medicare and Medicaid Services, Form 671, dated 12/16/25, documents there are 33 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to give resident showers to 3 of 5 residents (R2, R3, R5) reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 5.Findings Include:1. R2's Face Sheet, undated, documents R2 has a diagnosis, in part, of Quadriplegia.R2's MDS (Minimum Data Set), dated 10/12/25, documents R2 is cognitively intact and is dependent upon staff for showers.R2's Care Plan, dated 6/3/25, documents R2 has an ADL self-care deficit and requires 1-2 assist with showers.R2's Shower Sheets, fails to show any documentation of a shower given/offered from 9/9/25 until 9/22/25 and none documented in 11/2025On 12/2/25 at 10:35 AM, R3 stated they don't have enough CNAs (Certified Nursing Assistant), and when you don't have enough CNAs, you don't get your showers.2. R3's Face Sheet, undated, documents R3 has a diagnosis, in part, of Cerebral Infarction with Hemiparesis/Hemiplegia.R3's MDS, dated [DATE], documents R3 is cognitively intact and requires partial/moderate assist with showers.R3's Care Plan, dated 10/20/21, documents R1 has an ADL self-care performance deficit, requires one staff participation with bathing, and to shower Monday/Thursday on day shift and as needed.R3's Shower Sheets, fails to show any documentation of a shower given/offered from 11/1/25 until 11/12/25 and none documented after 11/19/25.On 12/2/25 at 10:30 AM, R5 stated she is not getting her showers.3. R5's Face Sheet, undated, documents R5 has a diagnosis, in part, of Fibromyalgia and Congestive Heart Failure.R5's MDS, dated [DATE], documents R5 has moderate cognitive impairment and requires set up / clean up assistance with showers.R5's Shower Sheets, fails to show any documentation of a shower given/offered from 10/16/25 until 11/5/25.On 12/4/25 at 8:50 AM, V1, Administrator, stated showers are being given. Some of the residents will be offered a shower on their shower day, refuse and then want it at a different time and they do their best to accommodate. V1 stated she assists with showers. V1 stated V2, DON, interviewed the residents on their preferred date, shift, for showers and made a new shower schedule based on their preferences and it's been working out, it's that some refuse and then want it at a different time, so they might have to wait, but they do get their showers. The Shower Care Policy, dated 11/24/20, documents it is the policy of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to monitor and document pressure ulcer development for 1 (R2) of 3 residents reviewed for pressure ulcers in the sample of 7.Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan dated 10/23/2025 documents R2 currently has an alteration to R2's Integumentary System due to Surgical Incision Right Leg. Non-Blanchable area to right/left buttocks and coccyx. Blister to Left Buttock. On 9/25/25: R2 has a stage 1 to her buttocks/coccyx. Educate R2, Power of Attorney, POA or caregiver as to causes of skin break down, skin tear, or pressure ulcer: transfer/positioning or during ambulating. Encourage resident to do what she /he can do for self. Place nonslip pad in her wheelchair to prevent R2 from sliding down in her wheelchair.On 10/23/2025 at 9:55AM V4, Licensed Practical Nurse, LPN, V5, LPN and V6, Certified Nursing Assistant, CNA, assisted R2 back to bed via mechanical lift. Coccyx/lower buttocks area dressing changed. Coccyx/lower buttocks area has 2 open wounds. One on right side quarter size and one on left side dime size. V4 changed dressing according to orders. R2's Electronic Health Record had no documentation of wound measurements or wound monitoring. R2's Skilled Nursing assessment dated [DATE], Section G Skin/Wound, documents no new changes in skin integrity. Type of wound present - surgical. Other skin issues - none. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - skin shear on buttocks. Notable changes to wound present - skin shear on buttocks.R2's Braden Scale for Predicting Pressure Sore Risk dated 9/13/2025 documents R2 is at risk for pressure sore development. R2's order sheet dated 9/25/2025 documents Cleanse open area to left upper buttocks with normal saline. Apply foam bordered dressing. Change daily and as needed every evening shift for skin management.R2's order sheet dated 10/23/2025 at 4:56PM Cleanse open area to buttocks with NS. apply skin prep. Apply barrier protectant cream. Apply foam bordered dressing. Change daily & PRN.R2's order sheet dated 10/23/2025 at 4:23PM Cleanse open area to left upper buttocks with NS. Apply barrier protectant cream. Apply foam bordered dressing. Change daily and as needed.R2's shower sheets dated 9/29/2025 documents 2 spots with arrow pointing to lower buttocks. and blister burst when peri care was given. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents shear and red 8.3, 8.0, blister 0.1 x 0.4, R 4.0 x 3.0.R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents red with arrow pointing to coccyx area. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented. On 10/23/2025 at 10:20AM V11, Physician, stated, When I visit, I usually see most of the residents out of their bed and in the dining room area. I saw (R2) about two weeks ago and she had a Stage-1 sore on her coccyx that was just red at the time. (R2) always wanted to stay in bed most of the day, so I put in orders, after seeing her wound, for her to get out of bed to wheelchair for all meals and then out of bed for two hours between meals. I was off last week, and I have not seen her wound since then. If her wound has gotten worse than a stage-1 wound, then no one notified me about it. On 10/23/2025 at 3:16PM and 3:30PM Surveyor asked V1 for wound notes and measurements for R2's wounds. Surveyor asked V1 on 10/24/2025 at 8:20AM for R2's wound notes and measurements. V1 stated, The areas on R2's bottom are shearing from her sliding down. We have new orders now and I will send the measurements. On 10/24/2025 at 10:00AM V4, LPN, stated R2 has 2 areas but they aren't really pressure they are kind of connected and are from friction. I measured the area yesterday, but I don't think we had been measuring. On 10/24/2025 at 11:55AM V2, Director of Nursing, DON, stated I saw R2's wounds yesterday. The area that is quarter size did not appear open. It could be called a stage 2. I would expect a wound to be measured, and the resident referred to the wound company that comes in. From what I understand of R2's wound situation is that R2 was referred to the wound company when admitted . The wound company found R2 did not need services at that time. The facility did treatments here. Going forward our nurse manager V18 is going to do measurements and treatments. Facility policy updated 5/2/2022 states, To identify factors that place the residents at risk for the development of pressure ulcers. To implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of existing pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure quality/safe transportation for 1 (R2) of 4 residents reviewed for unsafe transportation in the sample of 7. This failure resulted in R2's fractured right leg coming off R2's foot pedals and R2 dragging fractured right leg on ground. Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan updated currently has an alteration in her mobility and needs assistance due to limited range of motion due to non-weight bearing to right lower to right lower extremity status post-surgery. R2 requires mechanical lift for transfers. Interventions include: Cueing, reorientation as needed. Monitor/document ability to perform ADLs. Encourage/provide gentle range of motion as tolerated with daily care. Report any decline in abilities to Physician. Weight bearing restriction to right lower extremity. R2 uses a wheelchair and requires total dependence of 1 staff for locomotion. Physical/Occupational therapy evaluation and treatment per orders.On 10/23/2025 at 3:30PM V15 stated, On 10/21/2025 the staff got (R2) up right before we were to leave for her appointment. She (R2) was in a lot of pain in the transport van. She was screaming and I couldn't do anything to help her. The van driver and I tried to pull her up, but we couldn't do much. No staff member came with us. When we got to the Doctor's office her leg, the one with the immobilizer on, was dragging the ground because she had slid down that far in the wheelchair. Therapy had put a small mat to connect her foot pedals since the boot she is wearing is so big. The mat had started to come off and that caused her right foot to drag. Her right foot was dragging while I was pushing her. The staff at the Doctor's office pulled her up and then she was better. She had been crying so much the Doctor wanted an Xray. The Doctor's office called an ambulance to take R2 over to the hospital to get an Xray. Then the ambulance took us back over to the Doctor's office and then transferred R2 back to her wheelchair and the transport van took us back to the facility. On 10/23/2025 at 3:30PM R2 stated I was in such pain. I was screaming. I had been looking so forward to getting out of here too. I was afraid to move because I thought I would fall. My leg was dragging and that hurt.On 10/23/2025 at 9:00AM V21, Complainant, stated (V15) was pushing (R2) to the appointment and her broken leg was dragging the ground, and she was crying in pain. It took 5 of us to pull her up. They are very dissatisfied with the facility.On 10/24/2025 at 2:00PM V2 stated, (V15) would have assumed responsibility if he was going to the appointment with (R2). The mat on the foot pedal was probably coming off because (V15) had backed her wheelchair up. He probably needs more education. On 10/23/2025 at 3:30PM V1 stated, The Doctor's office wanted to get (R2) an Xray at the local hospital and we offered to do the Xray here. I knew (R2) would be a difficult transfer so I thought it would be easier to do here. We outsource our transportation right now. We do not have our own van.Facility policy states, It is the policy of this facility to safely transport residents to/from necessary appointments when needed. If the interdisciplinary team (IDT) determines a resident requires assistance, then arrangements must be made to send an appropriate escort to meet that particular need. Examples of residents requiring assistance are residents who need assistance with AOL's, have impaired decision making, are elopement risk or otherwise deemed unsafe to be out alone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to assess, monitor, and provide treatments as ordered and notify a provider of maggots for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. This failure resulted in maggots in R1's foot wound. that R1 described as giving her the heeby jeebies. Using a reasonable person concept, maggots in a wound would cause a person to feel shame, embarrassment, anxiety, and uncleanliness for this profound, disturbing experience of parasites in a wound.1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including paraplegia, acquired absence of right leg above the knee, and pressure ulcer of left heel.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, ambulated via wheelchair, and had three stage 3 pressure ulcers that were present on admission.R1's Care Plan initiated 6/30/24 documents R1 has a wound.R1's Specialized Wound Management Note dated 7/14/25 documents R1 has left dorsal foot pressure ulcer (no stage listed) measuring 3.0 cm (centimeters) x 5.5 cm x 0.3 cm.R1's Progress Note by V5, Licensed Practical Nurse (LPN) on 7/19/25 at 2:05 AM documents, this nurse was completing wound dressing change, when maggots were noticed. maggots removed with normal saline and hydrogen peroxide was applied to wounds. wound were dried and wound dressings applied. (V6), PA (Physician Assistant) was notified and NNO (no new orders) were received.On 8/29/25 at 2:15 PM and 9/3/25 at 11:55 AM, V5 was unavailable by phone.On 8/29/25 at 2:05 PM, V6 was unavailable by phone.On 9/3/25 at 10:55 AM, R1 stated, I've had maggots in my wounds twice here. That (V5) didn't know how to do a dressing (correctly). I told her to cover up my toes good, but she didn't, and that's what happened. They were all over my foot and moving around. I told her to get them out of there. It gave me the heeby jeebies. R1 stated V5 removed the maggots, but did not send her to the hospital. On 9/3/25 at 9:35 AM, V7, Wound Nurse Practitioner (NP), stated she was not aware of R1 having maggots in her wound and would have expected the Facility to notify her, if that were the case. She stated R1 goes out to smoke frequently, and dressing changes can prevent maggots. The general procedure is to remove the maggots and send the resident to the hospital.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture of upper arm muscle, and acquired absence of right and left legs above the knee.R2's MDS dated [DATE] documented R2 was cognitively intact, ambulated by wheelchair, and had one stage two pressure ulcer and one stage three pressure ulcer that were present on admission.R2's Care Plan initiated 6/3/25 documents R2 was admitted with pressure ulcers. The interventions included treatments as ordered by physician.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 2 left buttock pressure ulcer measuring 2.0 cm x 2.0 cm wide x 0.2 cm deep.R2's Physician Order dated 6/17/25 documents cleanse left buttock with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate, and cover with bordered foam dressing every day shift. R2's Treatment Administration Record (TAR) does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, or 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 left posterior thigh pressure ulcer measuring 12.0 cm x 12.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse left posterior thigh with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-6/26/25, 8/1/25, 8/2/25, 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 right posterior thigh pressure ulcer measuring 12.0 cm x 15.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse right posterior thigh with normal saline or wound cleanser apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, 8/6/25.On 9/3/25 at 9:46 AM, V2, Director of Nursing (DON), stated wound treatments should be given as ordered and documented in the TAR, when given. The Facility's Wound Care Policy and Procedure revised 11/9/19 documents, Document treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent resident-to-resident abuse for 1 of 3 residents (R7) reviewed for abuse in the sample of 11.Findings Include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8's Quarterly MDS, dated [DATE], documents R8 is severely cognitively impaired, wanders daily, has disorganized thinking, inattention, altered level of consciousness, physical and verbal behaviors towards others occurred 4-6 days, other behaviors not directed towards others occurred 4-6 days and rejects care 1-3 days.R8's Nursing Progress Note, dated 7/29/2025 at 9:42 PM documented, res noted in another res room. Res confused and disoriented. When res asked him to leave out of room, he grabbed her left arm and held on to it causing a skin tear. Res requested assistance from staff to have him assisted out of room. Res taken to room & placed in bed. All parties have been notified.On 8/12/2025 at 1:35 PM, R7 sat up in her wheelchair in her room and stated a few weeks ago at around 9:30 PM R8 was in her room, when she told R8 to get out of her room he walked up to her grabbed both her forearms, and he squeezed them to death, and it hurt bad. R7 stated she had a large bruise to her left forearm and a skin tear. R7 stated the skin tear bled down her arm. Resident pulled left sleeve up and noted steri- strips on her left forearm, no bruising noted. R7 stated it scared the h*** out of her, but she didn't cry. R7 stated when she sees R8 down her hall now, she has staff redirect him because she doesn't want to get hurt again. R7 stated she knows R8 has Alzheimer's disease but that she wishes staff would redirect him more often because he really scared her that day.On 8/19/2025 at 12:30 R8 was observed sitting in the dining room at the facility. R8 didn't respond to any of the IDPH surveyor's question, R8 just starred straight ahead. On 8/19/2025 at 1:00 PM V20, LPN stated R8 is not alert and has Alzheimer's disease. Staff try to keep an eye on R8 because he often goes in other residents' rooms and lays in empty beds. R7 reported to her one night that while attempting to redirect R8 out of her room, R8 grabbed R7's left forearm which caused a skin tear. On 8/12/2025 at 2:15 PM V1 Administrator, V8 Regional Administrator and V2 Interim DON stated they were not aware of any resident-to-resident altercations on 7/29/2025. V1 stated she would have expected staff to report what occurred so she can start an investigation as soon as possible and put an intervention in place to prevent it from occurring again. V8 stated he didn't view the incident as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. The Facility's Resident Right to Freedom of Abuse, Neglect and Exploitation policy, initiated 10/16/2023, documents the facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include physically aggressive behavior, such as grabbing and verbally aggressive behavior such as intimidating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate a resident-to-resident abuse for 1 (R7) of 3 residents reviewed for abuse in the sample of 11. Findings include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8's Quarterly MDS, dated [DATE], documents R8 is severely cognitively impaired, wanders daily, has disorganized thinking, inattention, altered level of consciousness, physical and verbal behaviors towards others occurred 4-6 days, other behaviors not directed towards others occurred 4-6 days and rejects care 1-3 days.R8's Nursing Progress Note, dated 7/29/2025 at 9:42 PM documented, res noted in another res room. Res confused and disoriented. When res asked him to leave out of room, he grabbed her left arm and held on to it causing a skin tear. Res requested assistance from staff to have him assisted out of room. Res taken to room & placed in bed. All parties have been notified.On 8/12/2025 at 1:35 PM, R7 sat up in her wheelchair in her room and stated a few weeks ago at around 9:30 PM R8 was in her room, when she told R8 to get out of her room he walked up to her grabbed both her forearms, and he squeezed them to death, and it hurt bad. R7 stated she had a large bruise to her left forearm and a skin tear. R7 stated the skin tear bled down her arm. Resident pulled left sleeve up and noted steri- strips on her left forearm, no bruising noted. R7 stated it scared the h*** out of her, but she didn't cry. R7 stated when she sees R8 down her hall now, she has staff redirect him because she doesn't want to get hurt again. R7 stated she knows R8 has Alzheimer's disease but that she wishes staff would redirect him more often because he really scared her that day.On 8/19/2025 at 12:30 R8 was observed sitting in the dining room at the facility. R8 didn't respond to any of the IDPH surveyor's question, R8 just starred straight ahead. On 8/19/2025 at 1:00 PM V20, LPN stated R8 is not alert and has Alzheimer's disease. Staff try to keep an eye on R8 because he often goes in other residents' rooms and lays in empty beds. R7 reported to her one night that while attempting to redirect R8 out of her room, R8 grabbed R7's left forearm which caused a skin tear. V20 stated she reported the incident to V8, Regional Administrator but that she didn't think it was a resident-to-resident altercation, V20 thought it was just a skin incident. V20 didn't ask R7 if she was scared of R8 and didn't note her left forearm was bruised. On 8/12/2025 at 2:15 PM V1 Administrator, V8 Regional Administrator and V2 Interim DON stated they were not aware of any resident-to-resident altercations on 7/29/2025. V1 stated she would have expected staff to report what occurred so she can start an investigation as soon as possible and put an intervention in place to prevent it from occurring again. V8 stated he didn't view the incident as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. V1, V2 and V8 stated they started a resident to resident abuse investigation when it was brought to their attention on 8/12/2025. The Facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy & Procedure, initiated 10/1/2023, documents it is the policy of the facility to empower and enable all owners, operators, employees, agents or contractors of the facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act (EJA) and CMS regulations. Within five working days of the incident, the facility will provide in a follow-up investigation report. This report will contain information from the resident's record, summary of other documents obtained, sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified, who investigated the incident, and who is submitting the report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to order a abdominal ultrasound, urinalysis/culture and sensitivity in a timely manner for 1 (R4) of 3 residents reviewed for timeliness of care in the sample of 3. This failure resulted in a nonverbal resident (R4) being transferred to the emergency room and diagnosed with a impacted stool in the intestine that was digitally removed from her rectum, enema, IV hydration and intramuscular shot for the urinary tract infection and put on oral antibiotics. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during a hospital visit. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy, constipation and GERD.R4's Care Plan, dated 3/31/2025 documents focus bowel and bladder incontinence. Interventions: record bowel movements, frequency, and consistency. Assess any signs of discomfort, burning or itching around anus, loss of appetite, etc. No documentation of R4's diagnosis of constipation was addressed/documented on her care plan. Another focus: R4 has a communication problem, she is nonverbal. Goal: R4 will feel heard and understood, as reflected in her body language and facial expressions. Interventions: encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or respond to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. R4's Annual Minimum Data Set, dated [DATE] documents she is severely cognitively impaired, no constipation present, both sides functional impairment in range of motion, wheelchair for mobility device, doesn't ambulate, dependent on staff for toileting, incontinent of bowel and bladder. R4's Physician's Order Sheet (POS), dated 12/2/2021 MiraLAX 17 grams by mouth every day for constipation. 12/2/2021 Senokot S 8.6 milligrams/50 mg two times a day for constipation and 1/27/2025 Bisacodyl 1 suppository rectally at bedtime every other night for constipation. R4's Medication Administration Record (MAR) dated 8/2025 staff documented physician prescribed medications to treat constipation were administered as ordered. R4's POS, dated 8/4/2025, documents a urinalysis and reflex culture (no reason for order) and an ultrasound abdomen and pelvis indication: mass in lower left quadrant.R4's Bowel and Bladder document, dated 8/3/2025 through 8/14/2025 staff documented R4 had a small bowel movement on 8/3/2025, large bowel movement on 8/9/2025 and 8/11/2025 and a small bowel movement on 8/12/2025. R4's Nursing Progress dated 8/4/2025 through 8/7/2025 no documentation as to why a urinalysis and reflex culture was ordered and no documentation if either test was collected/completed. R4's Nursing Progress Note, dated 8/7/2025 at 1:33 AM, documents attempted to get urine per sterile technique without success. No documentation if the ultrasound abdomen and pelvis was completed. R4's Physician's Progress Note, dated 8/8/2025 at 7:00 AM documents urinalysis and reflex culture sent. R4's Medical Record dated 8/8/2025 through 8/11/2025 showed no urinalysis and reflex culture, or ultrasound abdomen and pelvis results were not uploaded in R4's Medical Record. R4's Physician's Progress Note, dated 8/11/2025 at 7:00 AM, documents the patient is a poor historian due to cerebral palsy and aphasia. The patient history is taken from her family and nursing staff. The patient has been restless and agitation for the past week. There was possible grimacing and complaint of pain witness by her family. Anxiety versus GI/GU (genitourinary/gastrointestinal) symptoms, continuing to await US (ultrasound) and UA (urinalysis)/UC (urine culture.) R4's Medical Record was reviewed for the UA/UC and abdominal/pelvic ultrasound on 8/12/2025 at 12:00 PM. The results were not uploaded in R4's electronic medical record at that time. On 8/12/2025 at 12:10 PM V1, Administrator and V2, Interim Director of Nursing stated he noted a day or so ago that R4's UA/UC was not collected yet and the abdominal/pelvic ultrasound was not completed yet and he had been on the phone with the ultrasound company all morning trying to figure out why it wasn't done yet. V2 stated the ultrasound company informed him that the physician's order verbiage was not correct, and it needed the word limited to be added to it so the ultrasound would be covered by insurance. V2 stated he didn't know why the physician ordered a UA/UC other than to rule out a UTI and the ultrasound abdomen/pelvis was ordered because R4's physician felt a mass in her abdomen. V2 wasn't aware the laboratory and ultrasound tests were not completed until the surveyor requested the test results, that's when he started making calls to see why the tests were not completed. V1 stated when a physician orders a lab test and/or an ultrasound she expects the UA to be collected and sent off to the lab the next day and if it was attempted to be collected and unsuccessful, the nurse should report that to the oncoming nurse and that nurse should attempt to collect the specimen. If there are any issues getting a specimen i.e. urine collected and/or issues with getting an ultrasound completed nurses should notify the resident's physician within 24 hours and update them on why the tests were not done. V1 stated it was a breakdown of communication between nurses as to why these tests were not completed in a timely manner. R4's Nursing Progress Note, dated 8/12/2025 at 2:16 PM staff documented company here to do abd (abdominal) x ray for a mass to left quad. At 2:50 PM, staff documented, attempted to obtain UA sample via straight cath per sterile technique. Attempt was unsuccessful. Evening shift nurse notified that sample is needing to be collected, verbally understood. At 9:21 PM, staff documented x ray results received and faxed to MD (physician.) At 9:34 PM staff documented, urine obtained & in fridge in med room. Lab req filled out & faxed to lab. Lab to p/u (pick up) urine in the AM (morning.)R4's Laboratory Report, dated 8/12/2025 documents urine specimen collected on 8/12/2025. UA results: pending. UC results: Escherichila Coli (E-Coli.) R4's Ultrasound Patient Report, dated 8/14/2025 documents pelvis ultrasound findings: images of the bladder are unremarkable. Left lower quadrant images are unremarkable as well. There is no evidence of mass, cyst or fluid collection. Impression: unremarkable examination. R4's Ultrasound Patient Report, dated 8/14/2025 documents abdomen ultrasound findings: trace amount of ascites is noted in the left lower abdomen/pelvis. Peristalsing bowel loops are noted in the left lower abdomen early in the exam, measuring up to 2.3 centimeters in diameter. No discrete mass is identified. Impression: slightly dilated peristalsing bowel loops in the lower left abdomen. Correlate for enteritis versus small bowel obstruction. R4's After Visit emergency room Summary, dated 8/15/2025 documents, reason for visit: abdominal pain. Diagnoses: impacted stool in intestine, UTI and constipation. Instructions: Evaluated in the emergency department today with primary concern of possible constipation. Your workup was concerning for UTI as well. Fecal disimpactation at bedside. Medications administered: Rocephin 1 gram injection (treatment of UTI), saline enema, sodium chloride 0.9% (intravenous fluid for hydration) and Iodamide. R4's POS, dated 8/15/2025, documents a new physician's order Cephalexin 500 mg twice a day for 7 days to treat UTI. On 8/19/2025 at 10:00 AM V1, Administrator and V2, DON stated R4 is a total care, she is incontinent of bowel and bladder and is dependent with all care and is nonverbal. V2 stated staff are expected to document when a resident has a bowel movement in the electronic medical record so they can ensure residents are not constipated. Staff documented R4 had a small bowel movement on 8/12/2025. R4 was transferred to the emergency room after R4's physician reviewed the abdominal ultrasound results on 8/15/2025 as she wanted to rule out a small bowel obstruction. The emergency room discharge paperwork documents she was impacted, and emergency room staff digitally removed the impaction at bedside. After an enema was administrated R4 had a large bowel movement, and she had another large bowel movement when she was readmitted to the facility. V2 stated R4 was also diagnosed a UTI and was administered an intramuscular shot of antibiotics in the emergency room and is continuing by mouth antibiotics at the facility to treat the UTI. V2 stated R4 didn't have a bowel obstruction and the constipation was resolved immediately after the enema was administered in the emergency room. On 8/19/2025 at 10:40 AM V19, R4's physician stated she ordered the abdominal ultrasound on 8/42025 due to feeling a mass in her abdomen but she was more concerned with her having a UTI at that time. R4 is nonverbal and therefore she can't voice pain but when she assessed her on 8/42025 V19 felt R4 was either in pain or experiencing anxiety so she ordered a UA/C&S and an abdominal ultrasound for the mass felt in her abdomen that day. V19 stated the tests were not done in a timely fashion and stated she comes to the facility on Mondays and Fridays and she expected to have both test results back that Friday, 8/8/2025 but she spoke to the floor nurses who were agency staff and they told her the tests were completed but the results weren't in R4's electronic medical record and the medical records employee was on vacation at that time so she had issues getting the test results. After the abdominal ultrasound was completed, she reviewed the results the next day and stated she sent R4 to the emergency room to rule out a small bowel obstruction and stated she reviewed the emergency room records and it was determined R4 had impacted stool near the rectum which was digitally removed at bedside in the emergency room and R4 received an enema in the emergency room where she had 2 large stools right after. V19 stated it was determined that R4 has a UTI and she received an intramuscular shot of antibiotics in the emergency room and she is on a by mouth antibiotic at the facility to treat that. V19 stated she expected the facility to follow the policies and procedures to ensure physician ordered tests are completed in a timely fashion. On 8/19/2025 at 3:00 PM, V2 stated the facility doesn't have a policy or procedure that documents when a lab or ultrasound timeframe should be done.

Based on interview and record review the facility failed to perform safe mechanical lift transfer for 1 of 3 residents (R3) reviewed for accidents in the sample of 6.
Findings include:
R3's Care Plan, dated 6/13/2025, documents that the resident has potential for falls confusion, deconditioning, Gait/balance problems, incontinence, and poor communication/comprehension, unaware of safety needs. The Care Plan documented Resident had actual falls -6/11/25: Witnessed fall in room out of (full body lift), no injury -1/30/25: Unwitnessed fall in room, no injury. Intervention 6/16/2025 sling with straps for transfers.
R3's Incident Report, dated 6/11/2025 at 7:44 PM, documents that Resident transferring per usual from chair to bed by 2 CNAs (Certified Nurse's Aides) using mechanical full lift. During transfer, CNA moved chair out from under resident to position to place in bed. During chair move, resident self-changed position resulting in her rolling through lift straps and onto floor lying on her right side. Resident assessed for injuries; none noted at this time. ROM (Range of Motion) WNL (Within Normal Limits) for resident; baseline contractures to all extremities. Resident shook her head no when assessing for pain. Neuro checks initiated; mental status and movements at baseline and WNL (with in normal limits) for resident. Resident assisted to bed. It also documents that R3 is oriented to person and place, incontinent with no predisposing environmental and situation factors.
R3's Nursing Progress Note, dated 6/11/2025 at 10:23 PM, documents Resident transferring per usual from chair to bed by 2 CNAs using mechanical full lift. During transfer, CNA moved chair out from under resident to position to place in bed. During chair move, resident self-changed position resulting in her rolling through lift straps and onto floor lying on her right side. Resident assessed for injuries; none noted at this time. ROM WNL for resident; baseline contractures to all extremities. Resident shook her head no when assessing for pain. Neuro checks initiated; mental status and movements at baseline and WNL for resident. Resident assisted to bed. Resident assessed by nurse; neuro checks initiated. Admin (Administrator), DON (Director of Nursing), and POA (Power of Attorney) notified. MD (Medical Doctor) notified, requested Xray of right shoulder and right hip. POA requested monitoring and notify of any changes as he does not want her to be sent out at this time. Resident to have 3 staff present for all transfers; PT (Physical Therapy) to assess for positioning with transfers.
R3's Progress Notes, dated 6/11/2025 at 11:12 PM, documents Orders -Administration Note. Note Text: Tylenol Tablet 325MG (milligrams) Give 2 tablet by mouth every 6 hours as needed for pain.
On 7/2/2025 at 10:00 AM requested transfer and sling assessment. As of 7/8/2025 at 3:00 PM the facility did not provide any assessments.
On 6/30/2025 at 9:10 AM V13, R3's Brother, stated that he is R3's guardian. V13 stated that he has concerns about his sister's care at the facility. V13 stated that R3 flipped out of the chair. V13 stated that his sister has been at the facility for 30 to 40 years. V13 stated that he has put a camera in the room because he can't trust the care being given to his sister. V13 stated that on June 11th his sister fell out of the fully body mechanical lift hitting her head on the floor. V13 stated that he has the fall on video. V13 stated that his sister was slouched and side laying in the wheelchair. V13 stated that they lifted R3 out of the chair that way. V13 stated that they didn't bother to fix her before lifting her out of the chair. V13 stated that when they lifted R3 she fell out of the sling. V13 stated that you can hear the staff yell and R3 yell. V13 stated that R3 does not verbalize yes or no. V13 stated that R3 moans, groans, grunts and moves about.
On 6/30/2025 at 10:00 AM V13 provided a video to view. V13 verified that the person in the video was R3. The video dated 6/11/2025 at 7:31 PM. During video at 7:35 PM R3 is transported in room by wheelchair by V4, Certified Nurse's Aide (CNA). R3 was observed lying on right side in wheelchair. At 7:36 PM V6, CNA, pushes the full body lift into the room. V6 and V4 assisted with the transfer. V4 placed the wheelchair sideways, with R3's right side facing the lift. V4 and V6 attached the sling hooks to the lift. R3 remained on her right side while in the sling. R3 was not in the center of sling. V6, standing behind the lift and operating the controls, lifts R3 in the air. R3 remained in right side lying position. V4 then removes the wheelchair from beneath R3 allowing R3 to hang in sling without support. V4 then moves the wheelchair away from R3. V4 was not in reach of R3. V6 then pulled the lift back causing the sling to jerk forward and back. R3 then falls face forward out the sling. R3 was heard letting out a yell. R3 feet remained in sling. Then feet fell to floor.
On 6/30/2025 at 1:31 PM V4 stated that she was present during the fall with R3 on 6/11/2025. V4 stated that she noticed that R3 was leaning and lying back in chair. V4 stated that R3 was moving in wheelchair and groaning and grunting. V4 stated that this (grunting and groaning) means that R3 is in pain. V4 stated that R3 was uncomfortable and need to lie down. V4 stated that she and V6 assisted R3 with the transfer using the (full body lift). V4 stated that they applied the sling and lifted R3 into the air. V4 stated that once in the air she removed the chair from beneath R3. V4 stated that she did not have a hold of R3 at that time. V4 stated that she was maneuvering the chair and did not see the fall initially. V4 stated that she heard V6 yell and looked up and saw R3 hanging from the lift. V4 stated that she then went to help and R3's body fell to the floor. V4 stated that R3 did hit her head on the legs of the lift. V4 stated that R3 was grimacing, moaning, grunting, and grinding her teeth on the floor. V4 stated that R3 looked in pain. V4 stated that she went and got the nurse, and the nurse took over from there. V4 stated that R3 came out the side hole of the sling. V4 stated that she did not reposition R3 in the chair or sling because she thought R3 was positioned appropriately. V4 stated that she felt the sling was appropriate size. V4 stated that the sling that was used was the one that R3 had under her, not sure of size. V4 stated that she is not sure what determines the size of the lift sling.
On 6/30/2025 at 12:15 PM R4 stated that she was in the room when R3 fell. R4 stated that R3 was slouched down in the chair. R4 stated that the girls attached R3 to the lift. R4 stated that V4 moved the wheelchair back over by R4's bed. R4 stated that V4 was away from R3 and not touching her. R4 stated that she was watching V4 with the wheelchair and then heard a yell and turned. R4 stated then R3 was hanging out the lift with head on legs of lift. R4 stated that the CNAs yelled and V4 was trying to get to R3 and then R3 body fell from lift.
On 6/30/2025 at 2:22 PM V6 stated that she and V4 assisted with R3's transfer on 6/11/2025. V6 stated that she was at the controls and V4 had R3. V6 stated that she and V4 applied the straps. V6 stated that R3 was on her back sitting up right in the lift. V6 stated that she lifted R3 out of the chair. V6 stated that V4 removed the chair from under R3. V6 stated that R3 flipped out the side of the sling, face first, hitting head on the legs of the lift. V6 stated that R3 let out a yell. V6 stated that initially R3's legs were still in the sling and then they came out and her body fell to the floor. V6 stated that she felt R3 was in the right sling and positioned correctly. V6 stated that she assumed V4 had a hold of R3 but not sure if she did.
On 6/30/2025 at 3:16 PM V12, Registered Nurse, RN, stated that she was the nurse on duty at the time of R3's fall on 6/11/2025. V12 stated that when she entered the room R3 was on the floor. V12 stated that she assessed R3. V12 stated that she did not see any bruising or swelling at that time. V12 stated that R3 was in pain on the floor as she should after hitting her head on the legs of the lift from the air. V12 stated that she notified V1, Administrator and V2, Director of Nursing. V12 stated that she also notified the physician, and a zoom call was performed, and it was determined that R3 didn't require hospitalization at that time. V12 stated that she notified V13 as well and notified him of the fall. V12 stated that V13 did not want R3 to go to the emergency room. V12 stated that they monitored R3 and performed neuro checks. V12 stated that she was informed that while in the lift R3 made a jerking movement and fell out of the sling onto the floor hitting her head and body on the legs of the lift and floor.
On 7/2/2025 at 9:20 AM V14, CNA/Shower Aide, stated that she is familiar with R3 and have positioned her. V14 stated that R3 does make jerking movements in her chair and in the lift. V14 stated that you must always have a hold of her during the transfer because she can fall out. V14 stated that at times you need 3 people to help with the transfer. V14 stated that R3 requires the lift sling that crosses between the legs. V14 stated that this is the appropriate lift for her. V14 stated that the brother doesn't like the sling. V14 stated that she uses the sling anyway because it's the safest for her. V14 stated that the resident needs to be sitting up right as much as possible while in the lift. V14 stated that if the resident is not then they are lowered in the chair, repositioned, and then transferred. V14 stated that the slings are determined by size and weight.
On 7/2/2025 at 9:33 AM V16, CNA, stated that she has transferred R3 multiple times. V16 stated that R3 makes these movements. V16 stated that R3 will be stretched out then she will randomly draw her feet up in a jerking movement. V16 stated that R3 will be in the fetal position and then will stretch out. V16 stated that none of these movements are slow. V16 stated that it is scary at times lifting R3. V16 stated that when R3 is moving in the bed or in the chair, V16 stated that she gets a 3rd and sometimes 4th person. V16 stated that its safer because she will have these movements, and it will cause the sling to move, and I am afraid of her falling out of the sling.
On 7/2/2025 at 10:00 AM V1, Administrator, stated that the conclusion of the fall from what was told to him is that R3 was agitated in the wheelchair and during the transfer. V1 stated that the staff lifted the R3 in the air, using the lift. R3 move in the lift and R3 fell to the floor, hitting her head on the legs of the lift. V1 stated that he and V2, Director of Nursing, were notified and performed a zoom call while R3 was on the floor and had the staff describe what happened. V1 stated that he did not ask if the staff was in contact with the resident during the transfer. He assumes that they were.
On 7/2/2025 at 10:15 AM V3, Assistant Director of Nursing (ADON (Assistant Director of Nursing)) stated that R3 is challenging at times in the lift. V3 stated that R3 makes jerking movements and moves in the lift. V3 stated that R3 makes these movements in her chair as well as causing her to slide down in her chair. V3 stated that when R3 is like this it is challenging to transfer R3. V3 stated that the transfer is scary because R3 could fall out of the chair. V3 stated that when R3 is like that they will use a 3rd person. V3 stated that she has transferred R3 and due to her movements, she had to be repositioned in the chair and in the sling prior to transfer. V3 stated that this is to assure R3's safety. V3 stated that is R3 was in a lying position he would expect the staff to reposition R3 in her wheelchair prior to attaching the lift. V3 stated that once in the air of R3 was not positioned appropriate in the sling she would expect the staff to reposition R3. V3 stated that if that was not possible, she would expect the staff to get a 3rd person to assist in the transfer. V3 stated that the staff are aware of these movements with R3 and that they can always add people with the lift and always maintain contact with the resident during the transfer.
On 7/8/2025 at 11:50 AM V19, Therapy Director, stated that R3 was seen after fall. V19 stated that an evaluation was completed, and they work on transfer safety. V19 stated that the staff were in serviced. V19 stated that R3 is to have 3 staff for transfers.
The (Brand name of mechanical lift) PATIENT SLING REFERENCE GUIDE, not dated, documents Patient Sling Guide It is very important to use the correct sized sling and make sure it is fitted properly prior to lifting. This ensures the safety of both the person being lifted and the caregiver. The goal of this guide is to assist those responsible for selecting the correct sling on a patient by patient basis and outlines a few factors that need to be addressed in the selection of the appropriate type of sling for a patient. (Brand name of mechanical lift company) wishes to ensure that the task of moving patients is done in an effective and safe manner. Size & Weight Range Guide (approximately). Please note the following sling guide is a recommendation only. A full risk assessment must be done prior to any sling being selected. This will ensure safety for the patient and caregiver. Small (S) 75- 150. 59 - 64. (The Brand name of mechanical lift company) Owner's Manual, not dated, documents that Transfer From Wheelchair - Grasp the sling at each corner of the U shape of the commode aperture. - The sling should be fitted with the handle on the back section facing outward. - Help the user lean forward slightly, then slide the sling down between the chair and the user's back. - Position the commode aperture where the buttocks meets the seat. - Position the sling equally around both sides of the body. - Draw the leg sections to the front along the length of the user's thigh. - Check the sling's central positioning by comparing the lengths of the leg sections when they are drawn forward. - Reposition the sling if the leg sections are not equal in length. - Feed the leg sections under the thighs. o From between the legs, gently pull the leg section up the inner thigh. - Feed as much material as possible under and between the thighs. - Ensure the leg sections are positioned midway under the thighs to provide good support and greater comfort. - Move the lift slowly towards the user and position the spreader bar over the user's chest. - Attach Loop a of sling to Hook A on Spreader Bar; attach Loop b to Hook B; attach Loop c to Hook C; attach Loop d to Hook D. - Lift patient above the wheelchair by using the hand control. - Pull lift away from wheelchair. Position patient over bed and lower patient onto it.
SAFETY INSTRUCTIONS: Please pay careful attention to the following important information regarding the care, maintenance, and operation of the (Brand name of full body mechanical lift). Carefully read these instructions before assembling the lifter or attempting to lift any user with the device. PLEASE NOTE THE FOLLOWING: - Special care must be taken with users/patients who cannot themselves provide assistance while being lifted. (i.e. patients who are comatose, spastic, agitated, or otherwise severely handicapped.) - While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices, including not wearing a beard net to protect hair from getting into the food, and not covering food items during transportation. This failure has the potential to affect all 38 residents in the facility.
Findings include:
On 6/12/25 at 8:10 AM, V4, Cook, was seen working in the kitchen, preparing residents breakfast meal with no beard net on while having a full beard and mustache.
On 6/12/25 at 9:25 AM, V5, Cook, was seen in the kitchen with a hat on, has a full beard with no beard net on. After V5 was interviewed, he went and got a hairnet and a beard net and put them on.
On 6/12/25 at 9:30 AM, R5 stated she mainly eats in the dining room, the food always has a lid on the plate only, but in her room, there is no lid on her drinks or side dishes. R5 stated she does not see the male cooks wearing anything over their beards.
On 6/12/25 at 9:35 AM, R2 stated he eats both in his room and in dining room and the main plate of food has a lid on it when delivered to his room, but nothing else is covered. R2 stated he doesn't remember seeing anyone with a beard net or something covering their beard.
On 6/12/25 at 10:10 AM, R3 stated that he eats in his room for dinners and in the dining room for breakfast and lunch. R3 stated that the food delivered to his room is always covered, but not the side dishes or drinks. R3 stated that he does occasionally see the men in the kitchen with beards wear a beard net and usually a hat, but he estimates only about 60% of the time. R3 stated he was an inspector for the United States Department of Agriculture (USDA), and he is well aware of what kitchen requirements are and the expectations of the kitchen staff and he watches for things like that, and this facility needs some improvements.
On 6/12/25 at 10:35 AM, R1 stated he is the President of the Resident Council. R1 stated whether he eats in his room or the dining room, the main food always come covered, but the side dishes and drinks are not. R1 stated the kitchen staff don't wear hairnets at all unless the State walks in. R1 stated the guys with the beards (V4, V5) never wear a beard net like they are supposed to.
On 6/12/25 at 11:20 AM, V6, Certified Nursing Assistant (CNA)/Shower Aide, stated that she sees the kitchen staff wear hair nets, but not beard nets. V6 stated only the main plate of food has a lid on it, the sides and drinks never do.
On 6/12/25 at 11:22 AM, V7, CNA, stated she has not seen the guys in the kitchen with beards wear a beard net. V7 stated the plates delivered to resident rooms are always covered, but the side dishes and cups are not covered.
On 6/12/25 at 11:30 AM, lunch trays were being delivered to those residents eating in their rooms. A small two shelf cart that is open to air, has resident meal trays on it, with the main plate of food having a hard cover, while the side dishes and drinks were uncovered.
On 6/12/25 at 12:00 PM, R4 was seen in his room after his lunch tray delivered. There was no lid seen on his bowl of corn or any drink. There was a lid covering the main plate only. R4 stated he always eats in his room and there is never a cover over the side dishes or his drinks.
On 6/12/25 at 12:05 PM, R1 received his lunch tray in his room with a lid over his main plate only. There was no cover on his bowl of corn or drinks. R1 stated there is never a lid on his side dishes or his drinks.
On 6/12/25 at 12:15 PM, V9, CNA, stated they deliver the meal trays to those eating in their rooms on a small cart. V9 stated that only the plate is covered and that the drinks and side dishes are never covered.
On 6/12/25 at 12:20 PM, V10, R5's Daughter, stated she visits R5 several times a week and R5 usually eats in the dining room, but sometimes will eat in her room. V10 stated the main plate of food is usually covered but the side dishes and drinks are never covered. V10 stated she does see the kitchen staff with a hairnet on, just not sure of the beard nets.
On 6/12/25 at 1:30 PM, V1, Administrator, stated I know we have some kitchen problems, and we are hiring and trying to fix the problems. When advised of food being delivered and transported across the building with no lids or covers, V1 stated I will have them ordered and will take care of it. When advised of the kitchen staff not wearing beard nets, V1 stated I know we ordered them, and they have them in there. I will make sure that they always have one going forward. I would expect the kitchen staff to maintain proper sanitation and food handling practices at all times.
The Facility's Transportation of Food Policy, dated 11/5/19, documents Food being transported from the kitchen to other parts of the building must be done in a safe and sanitary manner. 1. All food must be covered during transportation.
The Facility's Dress Code Policy, dated 11/5/19, documents Staff members will dress appropriately, according to their job description. 4. Hair restrains to be worn in the kitchen. 5. [NAME] Guards if facial hair is present.
The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 6/12/2025, documents that the facility has 38 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This failure resulted in R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. This failure also resulted in R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body.
Findings include:
1. R1's admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome as diagnosis.
R1's Care Plan dated, 1/28/2025, documents that the resident has pain. Interventions include Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.
R1's Minimum Data Set, (MDS), dated [DATE], documents that R1 is cognitively intact, dependent on staff for ADLs (activity of daily living). It also documents that R1 experience pain almost constantly that frequently interferes with day-to-day activities. It also documents that R1 receives pain medication routinely and as needed and has experienced pain at level of 7.
R1's Progress Note, dated 4/9/2025 to 4/24/2025, documents that Orders -Administration Note, Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain not in stock.
R1's Controlled Substances Proof of Use, dated 3/25/2025, documents last dose of Xtampza ER 18mg was administered 4/8/2025 at 4 PM.
R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents the first dose of Xtampza ER 18mg administered 4/26/2025 at 10 AM.
R1's Progress Note, dated 4/21/2025, 4/22/2025, documents that Orders -Administration Note, Note Text: oxycodone HCl Oral Tablet 15 MG Give 15 mg by mouth six times a day for pain give 15mg PO q 4 hours routine for pain med out of stock(OOS).
R1's Controlled Substances Proof of Use, dispense date 4/22/2025, documents that the first dose of Oxycodone HCL 15mg tab was administered on 4/23/2025 at 12 AM.
R1's Progress Note, dated 4/28/2025 at 7:27 PM, documents that Orders -Administration Note, Note Text: Lyrica Oral Capsule 100 MG Give 100 mg by mouth every 12 hours for pain take 100 mg PO q12 hours med out of stock.
R1's Medication Administration Record, dated April 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank 4/1 at 4 PM, 4/8 at 12 PM, 4/18 at 8AM, 12PM, and 4 PM. 4/19 at 12 PM and 4 PM, 4/20 at 8AM, 12 PM and 4 PM.
R1's Progress Note, dated 5/6/2025, 5/8/2025, 5/9/2025 documents that Orders -Administration Note Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain OOS.
R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents that the last dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/5/2025 at 4PM.
R1's Controlled Substances Proof of Use, dispense date 5/6/2025, documents that the first dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/7/2025 at 4AM and last dose administered 5/7/2025 at 4 PM.
R1's Medication Administration Record, dated May 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank on 5/3 and 5/4 at 8AM, and 12PM.
On 5/13/2025 at 11:50 AM R1 stated that when he doesn't have his pain medication his pain is ongoing, uncontrolled, and severe. R1 stated that his pain, is rated 9 on pain scale (1 to 10) to left side of his body. R1 stated that the pain gets so high that when he finally gets his medication it takes a while for the pain to lower. R1 stated that they don't do anything different for him he just waits till the medication comes in. R1 stated that he goes out of the facility but that can be difficult because of the pain.
2. R2's admission Record, print date 4/14/2025, documents that R2 was admitted [DATE]. It lists R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy as diagnosis.
R2's Care Plan, dated 4/10/2024, documents [NAME] has potential impairment to skin integrity. It also documents Administer Morphine and Hydrocodone as per orders.
R2's MDS, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 experience pain almost constantly that rates a 10 (1-10) on pain scale and receives routine and as needed pain medication.
R2's Progress Note, dated 3/27/2025 and 3/28/2025, documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain HOLD IF PATIENT IS NODDING OR SHOWING S/S of BEING OVER-MEDICATED med out of stock, insurance issue, pharmacy notified.
R2's Progress Note, dated 3/29/2025, documents that new order for liquid morphine given. Morphine Sulfate ER Oral Tablet Extended Release 60 MG discontinued. Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 4 hours for pain med out of stock, pharmacy notified.
R2's Progress Note, dated 3/30/2025 at 3:15 AM, documents that Health Status, Note Note Text: Resident c/o uncontrollable pain requesting to be sent to ER (emergency room). Call placed to 911 at this time. 0330 Resident leaving facility with (local) Ambulance service at this time. Report giving to (local hospital). At 1:07 PM Health Status Note Note Text: Resident returned to facility via ambulance at 11:15am after being sent out r/t back pain. Hospital treated pain with medications this morning. No new dx or medication orders at this time. Resident is currently in her room sitting up.
R2's Progress Note, dated 4/7/202508:50 Orders -Administration Note, Note Text: Gabapentin Oral Tablet 800MG Give 1 tablet by mouth four times a day for neuropathy MEDICATION CURRENTLY UNAVAILABLE
R2's progress Note, dated 4/12/2025 12:25 PM, documents that Health Status Note, Note Text: Resident was able to find local pharmacy that had previous Morphine script in stock wanted to know if it would be possible to change Morphine script back to Morphine 60mg: 1 tablet by mouth every 12 hours for pain scheduled at 8AM & 8PM. Spoke with (V19's) office asked if she could notify the provider of this and asked if they did approve change if they could send over Morphine ER 60mg to (local pharmacy). (V19's) Morphine 60mg 1 tab every 12 hours was approved and sent to (Local pharmacy) Will update prescription changes in EMR (electronic medical record).
R2's Progress Note, dated 5/11/2025, 5/12/2025, 5/13/2025, and 5/14/2025 documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain med unavailable.
R2's Resident Controlled Substance Record, not dated, documents the last dose of Morphine ER 60mg was administered 5/11/2025 at 8AM.
R2's MAR, dated April 2025, documents blank for Baclofen 10mg on 4/1, 4/14, 4/18, 4/19, 4/20 Baclofen 20mg 4/6 at 6AM, 4/19 at 2Pm and 8 PM, 4/20 at 6AM and 8 pm. Gabapentin 800mg 4/1 at 4pm and 8 pm, 4/14 at 4 8 pm 4/18, 4/19, 4/20 at 4PM and 8 PM.
R2's MAR, dated May 2025, documents Baclofen 10mg at bedtime and 20mg 5/10 blank. Gabapentin 800mg 5/3 and 5/4 at 8AM and 12 PM. 5/10 at 8PM blank.
On 5/12/2025 at 2:30 PM V3, LPN, stated that they have had some issues with medication. V3 stated that more on the other halls. V3 stated that they had a recent change in pharmacy and causes some delays with the change. V3 stated that when there is a blank in a routine medication the system highlights that and it alerts her to verify if the medication was given because at that time it would look as it was not.
On 5/12/2025 at 3:00 PM V2, Director of Nursing, stated that the facility is chaotic. V2 stated that she has been at the facility for about 3 months. V2 stated that prior to the changeover it was difficult to get medications from the pharmacy. Communication was horrible. V2 stated that the medication would be ordered and not delivered. V2 stated that they would have to call the pharmacy and then they were told it was an issue with the script or insurance. V2 stated that the previous pharmacy had emergency boxes in the medication room, but it was no good if you can't access it. V2 stated that it was difficult to care for the residents. V2 stated that then the changeover happened and again there were some challenges with getting medication. V2 stated that there were delays with getting medication. V2 stated that she feels its getting better. V2 stated that she is aware of medications not being delivered. V2 stated that when the medications are administered, they are signed off. V2 stated that the medication being blank would indicate that it wasn't given. V2 stated that she expects the staff to administer medication as ordered. V2 stated that she was aware of R1's medication being out and difficulty with getting the medications. V2 stated that R1 has a lot of pain and withdrawals from not receiving his pain. V2 stated that R1 goes out of the facility and when this happened the medication are to have documentation there shouldn't be an empty space on the MAR. The system is set up to make you document. V2 stated that if it's not documented it's not given. V2 stated that R2 medication is out currently, and they are trying to get it. V2 stated that R2 takes a lot of medication for pain and needs her medication. V2 stated that she likes to stay in her room, but she is different and lays in the bed more. V2 stated that due to R2's pain and the amount of pain medication she takes to manage it when the medication is not administered her pain is horrible and she has withdrawals depending on the length of time she is without. V2 stated r1 and R2 did not received their medication as ordered and did not receive medication from emergency kit or pixis.
On 5/12/2025 at approximately 3:30 PM R2 stated that the pain scale did not cover her pain, the pain is excruciating and continuous. R2 stated that she went to the emergency room for pain relief. R2 stated that she stays in bed due to the pain, it hurts to breathe. R2 stated that due to her diagnosis of spinal muscular atrophy her muscles in her head and face are continuously being pulled downward. The pain is already horrible but without the pain medication it is horrid. R2 stated that she smokes cigarettes but not as much. R2 stated that smoking cigarettes helps with her anxiety which is elevated due to pain, and she doesn't go out to smoke as much because of it. R2 stated that she feels forgotten and the pain gets so bad she wants to die. R2 stated that this is not the first time. R2 stated that she has experienced withdrawal symptoms as well. R2 stated that she is always nauseated and has anxiety but it is more its extreme and she can't stand it.
On 5/14/2025 at 2:16 PM, V17, Pharmacist, stated that the pharmacy took over April 1st. V17 stated that R2's Xtampza is a medication that is not in the pyxis and not available in the facility. V17 stated that 2 doses were sent on 5/6/2025 and then 5/9/2025 a 2 week dosage was sent. V17 stated as soon as they received the request and script the medication was sent out. V17 stated that the were notified of refill needed for R2's Morphine on 5/8/2025. V17 stated that the script was written by a physician that was not Medicaid eligible. V17 stated that the facility was notified about this. V17 stated that they were awaiting a script from another physician. V17 stated that at this time the medication has not been filled. V17 stated that the medications are scheduled medications and would be a significant medication error. V17 stated that R2's medication was not taken from Pixis.
On 5/14/2025 at 2:45 PM V1, Administrator, stated that she was made aware by the pharmacy that there was an issue with script from V20. V1 stated that V19 was notified and requested a script from him for the medication. V1 stated that the medication is now being filled at a local pharmacy and awaiting call from pharmacy for pick up.
On 5/14/2025 at 3:47 PM, V16, CNA, stated that R2 is having pain. Appetite has decreased. V16 stated that R2 usually sits up in her chair and has not been doing that as much.
On 5/13/2025 at 4:00 PM V18, LPN, stated that she gave R2 the last dose. V18 stated that she ordered the morphine at that time. V18 stated that she has been off and today was her first day back.
On 5/15/2025 at 9:40 AM V20, Nurse Practitioner, stated that she was aware that the facility recently went through and change and new pharmacy. V20 stated that there were some problems with getting medication when that transition occurred. V20 stated that she was made aware when a resident is getting low on the medication, and she will get the medication. V20 stated that R1 and R2 not receiving their schedule meds this is a significant medication error. V20 stated that obviously R1 and R2 would experience some discomfort related to not receiving the pain medication. V20 stated that it's obvious if they don't get the medication. V20 stated that she would expect the patients to get there medications as prescribed. V20 stated that she would expect the staff to address the pain with alternate interventions. V20 stated that she has ordered pain management in the past.
On 5/15/2025 at 10:43 AM, V15, Medical Director, stated that he is usually notified of need for refills. V15 stated that he expects medication to be administered as prescribed. V15 stated that it is unfortunate that the medications were not available and administered to the patient as ordered.
As of 5/15/2025 at 4:00 PM observed R2 outside leaning against wall crying. R2 stated that she is in so much pain that she didn't want to live like this and wanted to die. R2 stated that it hurts to sit and hurts to stand. R2 stated that it was miserable. R2 stated that her pain medication has not been delivered and she has not received her medication.
The Administering Medication policy dated October 15, 2023, documents 3. Medications shall be administered according to physician written/verbal orders upon verification the right medication, dose, route, time and positive verification of resident identity when no contraindications are identified, and the medication is labeled according to accepted standards. 8. The individual administering the medication shall sign of the electronic Medication Administration Record date for the specific day before administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This IJ began on 3/30/2025 when R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. R2 described a decrease in her quality of life, along with expressions of feeling forgotten and wanting to die. Additionally, R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body.
This failure resulted in Immediate Jeopardy on 3/30/2024 when R2 was transferred to the emergency room for pain treatment due to not receiving scheduled pain management and experiencing ongoing excruciating pain. R1 experiencing ongoing unrelieved pain. On 5/19/2025 at 8:51 AM V1, Administrator was notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 5/20/2025, after abatement reviews dated 5/19/2025 at 11:43 AM, 2:17 PM, 3:56 PM, 4:09 PM, 5/20 11/59 AM, 12:07 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training.
Findings include:
R1's admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome as diagnosis.
R1's Care Plan dated, 1/28/2025, documents that the resident has pain. Interventions include Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.
R1's Minimum Data Set, (MDS), dated [DATE], documents that R1 is cognitively intact, dependent on staff for ADLs (activity of daily living). It also documents that R1 experience pain almost constantly that frequently interferes with day-to-day activities. It also documents that R1 receives pain medication routinely and as needed and has experienced pain at level of 7.
R1's Progress Note, dated 4/9/2025 to 4/24/2025, documents that Orders -Administration Note, Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain not in stock.
R1's Controlled Substances Proof of Use, dated 3/25/2025, documents last dose of Xtampza ER 18mg was administered 4/8/2025 at 4 PM.
R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents the first dose of Xtampza ER 18mg administered 4/26/2025 at 10 AM.
R1's Progress Note, dated 4/21/2025, 4/22/2025, documents that Orders -Administration Note, Note Text: oxycodone HCl Oral Tablet 15 MG Give 15 mg by mouth six times a day for pain give 15mg PO q 4 hours routine for pain med out of stock(OOS).
R1's Controlled Substances Proof of Use, dispense date 4/22/2025, documents that the first dose of Oxycodone HCL 15mg tab was administered on 4/23/2025 at 12 AM.
R1's Progress Note, dated 4/28/2025 at 7:27 PM, documents that Orders -Administration Note, Note Text: Lyrica Oral Capsule 100 MG Give 100 mg by mouth every 12 hours for pain take 100 mg PO q12 hours med out of stock.
R1's Medication Administration Record, dated April 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank 4/1 at 4 PM, 4/8 at 12 PM, 4/18 at 8AM, 12PM, and 4 PM. 4/19 at 12 PM and 4 PM, 4/20 at 8AM, 12 PM and 4 PM.
R1's Progress Note, dated 5/6/2025, 5/8/2025, 5/9/2025 documents that Orders -Administration Note Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain OOS.
R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents that the last dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/5/2025 at 4PM.
R1's Controlled Substances Proof of Use, dispense date 5/6/2025, documents that the first dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/7/2025 at 4AM and last dose administered 5/7/2025 at 4 PM.
R1's Medication Administration Record, dated May 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank on 5/3 and 5/4 at 8AM, and 12PM.
On 5/13/2025 at 11:50 AM R1 stated that when he doesn't have his pain medication his pain is ongoing, uncontrolled, and severe. R1 stated that his pain, is rated 9 on pain scale (1 to 10) to left side of his body. R1 stated that the pain gets so high that when he finally gets his medication it takes a while for the pain to lower. R1 stated that they don't do anything different for him he just waits till the medication comes in. R1 stated that he goes out of the facility but that can be difficult because of the pain.
2. R2's admission Record, print date 4/14/2025, documents that R2 was admitted [DATE]. It lists R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy as diagnosis.
R2's Care Plan, dated 4/10/2024, documents (R2) has potential impairment to skin integrity. It also documents Administer Morphine and Hydrocodone as per orders.
R2's MDS, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 experience pain almost constantly that rates a 10 (1-10) on pain scale and receives routine and as needed pain medication.
R2's Progress Note, dated 3/27/2025 and 3/28/2025, documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain HOLD IF PATIENT IS NODDING OR SHOWING S/S of BEING OVER-MEDICATED med out of stock, insurance issue, pharmacy notified.
R2's Progress Note, dated 3/29/2025, documents that new order for liquid morphine given. Morphine Sulfate ER Oral Tablet Extended Release 60 MG discontinued. Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 4 hours for pain med out of stock, pharmacy notified.
R2's Progress Note, dated 3/30/2025 at 3:15 AM, documents that Health Status, Note Note Text: Resident c/o uncontrollable pain requesting to be sent to ER (emergency room). Call placed to 911 at this time. 0330 Resident leaving facility with (local) Ambulance service at this time. Report giving to (local hospital). At 1:07 PM Health Status Note Note Text: Resident returned to facility via ambulance at 11:15am after being sent out r/t back pain. Hospital treated pain with medications this morning. No new dx or medication orders at this time. Resident is currently in her room sitting up.
R2's Progress Note, dated 4/7/202508:50 Orders -Administration Note, Note Text: Gabapentin Oral Tablet 800MG Give 1 tablet by mouth four times a day for neuropathy MEDICATION CURRENTLY UNAVAILABLE
R2's progress Note, dated 4/12/2025 12:25 PM, documents that Health Status Note, Note Text: Resident was able to find local pharmacy that had previous Morphine script in stock wanted to know if it would be possible to change Morphine script back to Morphine 60mg: 1 tablet by mouth every 12 hours for pain scheduled at 8AM & 8PM. Spoke with (V19's) office asked if she could notify the provider of this and asked if they did approve change if they could send over Morphine ER 60mg to (local pharmacy). (V19's) Morphine 60mg 1 tab every 12 hours was approved and sent to (Local pharmacy) Will update prescription changes in EMR (electronic medical record).
R2's Progress Note, dated 5/11/2025, 5/12/2025, 5/13/2025, and 5/14/2025 documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain med unavailable.
R2's Resident Controlled Substance Record, not dated, documents the last dose of Morphine ER 60mg was administered 5/11/2025 at 8AM.
R2's MAR, dated April 2025, documents blank for Baclofen 10mg on 4/1, 4/14, 4/18, 4/19, 4/20 Baclofen 20mg 4/6 at 6AM, 4/19 at 2Pm and 8 PM, 4/20 at 6AM and 8 pm. Gabapentin 800mg 4/1 at 4pm and 8 pm, 4/14 at 4 8 pm 4/18, 4/19, 4/20 at 4PM and 8 PM.
R2's MAR, dated May 2025, documents Baclofen 10mg at bedtime and 20mg 5/10 blank. Gabapentin 800mg 5/3 and 5/4 at 8AM and 12 PM. 5/10 at 8PM blank.
On 5/12/2025 at 2:30 PM V3, LPN, stated that they have had some issues with medication. V3 stated that more on the other halls. V3 stated that they had a recent change in pharmacy and causes some delays with the change. V3 stated that when there is a blank in a routine medication the system highlights that and it alerts her to verify if the medication was given because at that time it would look as it was not.
On 5/12/2025 at 3:00 PM V2, Director of Nursing, stated that the facility is chaotic. V2 stated that she has been at the facility for about 3 months. V2 stated that prior to the changeover it was difficult to get medications from the pharmacy. Communication was horrible. V2 stated that the medication would be ordered and not delivered. V2 stated that they would have to call the pharmacy and then they were told it was an issue with the script or insurance. V2 stated that the previous pharmacy had emergency boxes in the medication room, but it was no good if you can't access it. V2 stated that it was difficult to care for the residents. V2 stated that then the changeover happened and again there were some challenges with getting medication. V2 stated that there were delays with getting medication. V2 stated that she feels its getting better. V2 stated that she is aware of medications not being delivered. V2 stated that when the medications are administered, they are signed off. V2 stated that the medication being blank would indicate that it wasn't given. V2 stated that she expects the staff to administer medication as ordered. V2 stated that she was aware of R1's medication being out and difficulty with getting the medications. V2 stated that R1 has a lot of pain and withdrawals from not receiving his pain. V2 stated that R1 goes out of the facility and when this happened the medication are to have documentation there shouldn't be an empty space on the MAR. The system is set up to make you document. V2 stated that if it's not documented it's not given. V2 stated that R2 medication is out currently, and they are trying to get it. V2 stated that R2 takes a lot of medication for pain and needs her medication. V2 stated that she likes to stay in her room, but she is different and lays in the bed more. V2 stated that due to R2's pain and the amount of pain medication she takes to manage it when the medication is not administered her pain is horrible and she has withdrawals depending on the length of time she is without. V2 stated r1 and R2 did not received their medication as ordered and did not receive medication from emergency kit or pixis.
On 5/12/2025 at approximately 3:30 PM R2 stated that the pain scale did not cover her pain, the pain is excruciating and continuous. R2 stated that she went to the emergency room for pain relief. R2 stated that she stays in bed due to the pain, it hurts to breathe. R2 stated that due to her diagnosis of spinal muscular atrophy her muscles in her head and face are continuously being pulled downward. The pain is already horrible but without the pain medication it is horrid. R2 stated that she smokes cigarettes but not as much. R2 stated that smoking cigarettes helps with her anxiety which is elevated due to pain, and she doesn't go out to smoke as much because of it. R2 stated that she feels forgotten and the pain gets so bad she wants to die. R2 stated that this is not the first time. R2 stated that she has experienced withdrawal symptoms as well. R2 stated that she is always nauseated and has anxiety but it is more its extreme and she can't stand it.
On 5/14/2025 at 2:16 PM, V17, Pharmacist, stated that the pharmacy took over April 1st. V17 stated that R2's Xtampza is a medication that is not in the pyxis and not available in the facility. V17 stated that 2 doses were sent on 5/6/2025 and then 5/9/2025 a 2 week dosage was sent. V17 stated as soon as they received the request and script the medication was sent out. V17 stated that the were notified of refill needed for R2's Morphine on 5/8/2025. V17 stated that the script was written by a physician that was not Medicaid eligible. V17 stated that the facility was notified about this. V17 stated that they were awaiting a script from another physician. V17 stated that at this time the medication has not been filled. V17 stated that the medications are scheduled medications and would be a significant medication error. V17 stated that R2's medication was not taken from Pixis.
On 5/14/2025 at 2:45 PM V1, Administrator, stated that she was made aware by the pharmacy that there was an issue with script from V20. V1 stated that V19 was notified and requested a script from him for the medication. V1 stated that the medication is now being filled at a local pharmacy and awaiting call from pharmacy for pick up.
On 5/14/2025 at 3:47 PM, V16, CNA, stated that R2 is having pain. Appetite has decreased. V16 stated that R2 usually sits up in her chair and has not been doing that as much.
On 5/13/2025 at 4:00 PM V18, LPN, stated that she gave R2 the last dose. V18 stated that she ordered the morphine at that time. V18 stated that she has been off and today was her first day back.
On 5/15/2025 at 9:40 AM V20, Nurse Practitioner, stated that she was aware that the facility recently went through and change and new pharmacy. V20 stated that there were some problems with getting medication when that transition occurred. V20 stated that she was made aware when a resident is getting low on the medication, and she will get the medication. V20 stated that R1 and R2 not receiving their schedule meds this is a significant medication error. V20 stated that obviously R1 and R2 would experience some discomfort related to not receiving the pain medication. V20 stated that it's obvious if they don't get the medication. V20 stated that she would expect the patients to get there medications as prescribed. V20 stated that she would expect the staff to address the pain with alternate interventions. V20 stated that she has ordered pain management in the past.
On 5/15/2025 at 10:43 AM, V15, Medical Director, stated that he is usually notified of need for refills. V15 stated that he expects medication to be administered as prescribed. V15 stated that it is unfortunate that the medications were not available and administered to the patient as ordered.
As of 5/15/2025 at 4:00 PM observed R2 outside leaning against wall crying. R2 stated that she is in so much pain that she didn't want to live like this and wanted to die. R2 stated that it hurts to sit and hurts to stand. R2 stated that it was miserable. R2 stated that her pain medication has not been delivered and she has not received her medication.
The facility Pain management policy, dated November 22, 2021, documents Policy Statement: To provide a broad spectrum of treatment for pain management as they apply specifically to older people and with specific recommendations to aid in decision making about pain management of acute or chronic pain.
The Administering Medication policy dated October 15, 2023, documents 3. Medications shall be administered according to physician written/verbal orders upon verification the right medication, dose, route, time and positive verification of resident identity when no contraindications are identified, and the medication is labeled according to accepted standards. 8. The individual administering the medication shall sign of the electronic Medication Administration Record date for the specific day before administering the medication.
The Facility Abatement Plan documents as follows: This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.
1.x The corrective action for the alleged deficient practice has been achieved by the following:
a. Medical Director consulted regarding the availability of pain medication for R1 and R2 on 5/14/25.
b. Medication for R1 and R2 were ordered, received, and administered as prescribed.
c. All medication orders received by pharmacy on 5/14/25, from the physician, for R1 and R2 and delivered STAT to the facility.
d. An audit for all resident medications for pain was completed by the ADON on 5/14/25.
e. Medical Director provided pain medication orders to pharmacy on 5/14/2025.
f. Education provided to nursing staff initiated on 5/15/25 and completed on 5/20/25, by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain. The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift.
2. Residents with active orders of pain medication have the potential to be affected by the alleged deficient practice.
3. The following systematic measures have been implemented to ensure the alleged deficient practice does not recur:
a. Education provided to nursing staff initiated on 5/15/25 and completed on 5/20/25, by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain. The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift.
b. Pain assessment on the MAR/TAR to be completed by nurse every shift and addressed if pain noted.
c. Director of Nursing or designee will conduct audit of pain medication administration 3x a week x 4 weeks, to ensure appropriate knowledge and understanding of narcotics delivery, documentation, and administration practices.
d. The Director of Nursing or designee will address all concerns identified during the audit.
4. The following Quality Assurance Programs have been implemented to achieve and maintain substantial compliance with the alleged deficient Practice:
a. The Director of Nursing or designee will report audit findings to the Quality Assurance and Performance Improvement Committee monthly for at least three months, and thereafter as determined by the QAPI Committee.
Completion Date: 05/20/2025

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to secure cigarettes and lighters; failed to reassess resident's smoking risk; and failed to provide appropriate supervision for residents while smoking for 4 of 5 residents (R1, R2, R5, R6)) reviewed for resident safety while smoking in the sample of 9.
The Findings Include:
1. R1's Facesheet, dated 1/22/25, documents R1 was originally admitted to the facility on [DATE], with a most recent admission of 3/31/24 with diagnosis of Hydronephrosis, Emphysema, Extended-Spectrum Beta-Lactamases (ESBL), Cirrhosis of Liver, Malnutrition, Peripheral Vascular Disease (PVD), Thrombocythemia, Methicillin-Resistant Staphylococcus Aureus (MRSA), Neuromuscular dysfunction of bladder, Bilateral Above Knee Amputation (AKA), COVID, Arteriosclerotic Heart Disease (ASHD), Hypertension (HTN), Benign Prostatic Hyperplasia (BPH), Depressive Disorder, Anemia, Generalized Anxiety disorder, Falls, and Hepatitis C.
R1's Care Plan, dated 11/28/24, documents R1 is a smoker. Interventions: R1 is encouraged to wear smoking apron, but resident refuses most of the time. Smoking apron is located right on the inside of the front entrance door. Smoking materials are kept secured by staff. Smoking per facility protocol. This Care Plan was changed just prior to facility providing a copy of it - as of 1/23/25, the Smoking materials are kept secured by staff was removed (see R1 Care Plan prior to change attachment).
R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a moderate cognitive impairment and requires partial/moderate assistance from staff for Activities of Daily Living (ADLs).
R1's Smoking Assessments were documented as completed on 7/15/21 (non-smoker), 10/4/21 (non-smoker), 1/3/22 (non-smoker), 2/8/22 (non-smoker), 4/4/22 (non-smoker), 7/15/22 (smoker), 10/14/22, 1/10/23 (Does the resident only smoke in designated areas at designated times - No), 3/21/24 (Res clothing free from ashes or burn marks - No), 3/31/24, and 10/18/24 (Smoking Plan: Smoking materials are kept secured by staff, smoking per facility protocol.
On 1/22/25 at 9:55 AM, R1 stated that he is a smoker and the only thing staff told him was that he needed to stay at least 15-feet away from the building. R1 stated he keeps his cigarettes with him and has a Cigarette pack (green pack) with five cigarettes and a lighter inside his pack laying on the bed next to him. R1 stated the staff are usually so busy, they don't ask for them back, so he just keeps them with him. R1 stated there is no smoking times and they can go out anytime they want to. R1 stated he is usually outside by himself, with no staff member out there with him. R1 stated at first, they gave him a cover for his clothes, but normally he does not wear one, and the staff never say anything to him. R1 stated he has burnt his clothes before, all the time.
2. R2's Facesheet, dated 1/22/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, and Insomnia.
R2's Care Plan, dated 11/15/24, documents R2 is a smoker. Interventions: Smoking per facility protocol.
R2's MDS, dated [DATE], documents R2 is cognitively intact and is independent on ADLs.
R2's Smoking Assessments were completed on 5/1/23 (non-smoker), 3/21/24 (smoker), 6/20/24, 8/6/24, and 11/5/24 (Smoking Plan: Smoking per facility protocol.)
On 1/22/25 at 10:10 AM, R2 was seen sitting in a recliner with his walker next to him. R2 stated he is a smoker and keeps his cigarettes with him under his rolling walker seat. R2 showed a pack of cigarettes (white pack) and stated he keeps his lighter in his pocket all the time. R2 stated he does not wear any clothing protector and has no problems with burns. R2 stated he can go outside whenever he wants to smoke and usually it is just the residents out there with no staff.
3. R5's Facesheet, dated 1/22/25, documents R5 was originally admitted to the facility on [DATE] with diagnosis of COPD, Schizophrenia, Asthma, Deep Vein Thrombosis (DVT), Encephalopathy, Pulmonary Hypertension (HTN), Acute Kidney Failure, Atheroembolism of lower extremities, Depression, HTN, Anemia, Bipolar disorder, Personality disorder, Dysthymic disorder, Psychosis.
R5's Care Plan, dated 11/20/24, documents R5 is a smoker. Interventions: Assure smoking material is extinguished prior to leaving smoking area. R5 is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol.
R5's MDS, dated [DATE], documents R5 has a moderate cognitive impairment and is independent for ADLs with substantial/maximal assistance from staff for bathing.
R5's Smoking Assessments were completed on 2/7/22 (non-smoker), 4/9/22 (smoker: Can the resident light a cigarette independently - No, Smoking Care Plan: Resident is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol), 5/10/22 (smoker - Does the resident only smoke in designated areas at designated times - No), 8/10/22, 11/9/22, 2/19/24, and 4/15/24 (smoker - Does the resident only smoke in designated areas at designated times - No).
No Smoking Assessments have been completed since 4/15/24.
On 1/22/25 at 11:45 AM, R5 stated he was a smoker and can go outside the front door whenever he wants to and usually about every two hours. R5 stated the staff usually keeps his cigarettes, but he keeps his lighter with him because after nurse gives him a cigarette, he goes out by himself and uses his lighter to light his cigarette. R5 stated no staff ever goes out with him. R5 stated he does not use a clothing protector.
On 1/22/25 at 12:00 PM, R5 was seen going outside the front door, he lit up a cigarette, and sat in his wheelchair with a coat on smoking the cigarette. At 12:08, R5 was seen using the door combination to get himself back inside the facility and back to dining table for lunch.
On 1/22/25 at 3:55 PM, R5 was seen sitting in his wheelchair, smoking by himself, outside the front door.
4. R6's Facesheet, dated 1/22/25, documents R6 was originally admitted to the facility on [DATE] with diagnosis of Malnutrition, Phantom limb syndrome, Bursopathy, Gout, Congestive Heart Failure, Osteomyelitis, Paraplegia, Hypothyroid, Vascular implants, Suprapubic catheter, Colostomy, Nicotine dependence, Peripheral Neuropathy, Right Above the Knee Amputation (AKA), Anxiety disorder, HTN, and Major Depressive disorder.
R6's Care Plan, dated 10/8/24, documents R6 is a smoker and has been educated about the rules of smoking and verbalizes understanding. Interventions: R6 will be supervised while smoking, Nursing staff to store cigarettes and lighters in a secure location, Smoking assessment to be completed on admission and quarterly.
R6's MDS, dated [DATE], documents R6 is cognitively intact and requires partial/moderate assistance from staff for ADLs.
R6's Smoking Assessments were completed on 6/5/20, 1/17/21, 5/7/21, 6/6/21, 9/10/21, 10/8/21, 12/17/21, 3/9/22, 4/16/22, 6/1/22, 8/12/22, 9/1/22, 10/3/22, 10/21/22, 1/2/23, 2/2/23, 3/16/23, 2/3/24, 4/15/23, 5/31/24, 7/7/24, 10/11/24, 10/18/24, 12/18/24, and 1/11/25 (smoker - Smoking Care Plan: R6 will be supervised while smoking, Nursing staff to store cigarettes and lighters in a secure location, Smoking assessment to be completed on admission and quarterly)
On 1/22/25 at 11:45 AM, R6 was seen outside front doors smoking by herself, R6 was seen pushing codes to get back in door. R6 had her smoking supplies with her in her purse.
On 1/22/25 at 11:50 AM, R6 stated she is a smoker and can smoke whenever she wants to. R6 stated she always carries her cigarettes and lighter with her in her purse and her purse is always on her. R6 stated she goes out by herself with no staff present. R6 stated she does not have to wear a clothing protector.
On 1/22/25 at 10:30 AM, V6, Licensed Practical Nurse (LPN), stated There really is no set times for smoke breaks. The residents can go outside anytime they want to smoke. They usually go out the front door and sit on the benches by themselves.
On 1/22/25 at 4:00 PM, V1, Administrator stated that any resident who is alert and oriented can go outside and smoke whenever they want. V1 stated they all have the code to go in and out the door. V1 stated if they are alert and oriented, they can hold their own cigarettes but should not have their lighters with them.
The Facility's Smoking Policy, dated 2/2021, documents 1. Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance that will be needed to ensure the resident's safety. 2. Based on the assessment findings the resident's plan of care will be revised to reflect the level of assistance and any assistive devices that will be needed by the resident to enable the resident's safety. 3. Residents or their representative must provide all smoking materials (cigarettes, pipes, cigars, lighters etc.). Smoking materials must be secured at the nurse's station when not in use. 4. All residents will be supervised when they smoke. Residents must smoke in designated smoking area. 5. Residents may not use vaping devices or e-cigarettes in the building.

Based on Interview, Observation, and Record Review, the facility failed to provide heat in the Therapy Department for residents getting therapy for 1 of 1 residents (R4) reviewed for sufficient temperature control in the sample of 9.
The Findings Include:
On 1/22/25 at 8:43 AM, the Therapy Department is cold and drafty upon entrance. The room has four large windows going from ceiling to approximately two feet off floor, and double doors leading to the outside. The staff was seen wearing a sweatshirt while working with the residents.
On 1/22/25 at 8:45 AM, V7, Occupational Therapist, stated It is cold in here. They have been working on our heat. It has been out for about a month now. We try to make sure the residents have a blanket or sweatshirt to stay warm.
On 1/22/25 at 10:25 AM, R4 stated he gets therapy at the facility and the room is always cold and you freeze to death. R4 stated he has to bundle up with layers of clothing and then he can't do his therapy correctly.
R4's Physician Order, dated 11/5/24, documents OT (Occupational Therapy) clarification for 11/5/24: Skilled OT to evaluate and tx (treat) 5/week (wk) for 60 days to address OT eval high complexity, therex (therapeutic exercises), NMR (neuromuscular re-education), manual treatments, group treatments, theract (therapeutic activities), self care and w/c (wheelchair) management PRN (as needed).
R4's Physician Order, dated 11/5/24, documents Clarification for PT (Physical Therapy) 11/5/24: Skilled PT to eval and tx 3/wk for 60 days to address PT evaluation, therex, NMR and theract PRN. Order written by (staff) MOTR/L (Masters Occupational Therapy Registered/Licensed) on behalf of (staff) PT.
R4's Physician Order, dated 12/6/24, documents Clarification order: skilled PT to eval and treat 5x/wk x60 days and treatment to include Therex, Theract, NMRE (neuromuscular re-education extremities), Manual Techniques, and Group PRN.
R4's Physician Order, dated 12/5/24, documents 1. Skilled OT to eval. 2. Clarification: Skilled OT tx 5/wk for 60 days for OT eval mod complexity, therex, NMR, manual therapy, theract, self care, w/c management prn.
R4's Physician Order, dated 12/9/24, documents Patient to be seen for skilled ST (Speech Therapy) services 3x/week for 4 weeks to target memory and problem solving / insight.
On 1/22/25 at 12:10 PM, V1, Administrator, stated There is a guy fixing the heaters in the building now and you should be feeling more heat in the dining room and other areas. When asked about the Therapy room, V1 stated I had to get that approved by Corporate and they just approved that for the guy fixing the other heaters, and he will be working on the therapy room next. That room heater has been broken since 1/1/25, almost a month now.
On 1/23/25 at 12:00 PM, V9, Maintenance Director, stated I have been fighting with the heat in this building since I turned it on in October 2024. The Therapy Department's heat never did come on. It was mid-October of 2024 when I told the previous Administrator that it needed fixed. I had to get a bid and then send it to Corporate to approve, which I did. I waited weeks for an answer and heard nothing. Then they said I had to get three different bids and forward to them. I finally did that and now apparently, they approved one. Unfortunately, I have no idea when it will be fixed or how long we have to wait for that company to get it fixed.
The local weather on 1/20/25, documented the high temperature was 19 degrees Farenheight (F.). On 1/21/25 the high temperature was 10 degrees F., and on 1/22/25, the high temperature was 37 degrees F.
The Local Weather was obtained from the website https://www.timeanddate.com/weather.
The Facility provided a list of residents receiving therapy at the facility. This list consisted of nine Residents receiving either PT, OT, or ST.
The Facility's Resident Rights Policy, dated 12/2016, documents Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; jj. equal access to quality care, regardless of source of payment.
The Facility's Resident Rights for People in Long-Term Care Facilities from the State of Illinois Department of Aging, dated 3/2017, documents You have the right to Safety and Good Care: Your facility must provide services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone - physically, verbally, mentally, financially, or sexually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to keep daily temperature logs for refrigerators/freezers, wear hairnets covering all hair, dispose of and store food according to policy and hold food temperatures according to policy. This failure has the potential to affect all 38 residents in the facility.
Findings include:
1. On 1/22/25 at 8:52 AM, both V3(kitchen manager) and V10(dietary aide) had their hair outside of their hair nets in the kitchen while handling food.
On 1/22/25 at 12:00 PM, V10, dietary aide, had hair outside of her net from her ponytail and bangs. V3 told V10 to put all her hair back in the net. V10 put her ponytail in the hair net but her bangs remained outside. V3 did not correct her. V10 picked up her personal cell phone with her left hand's fingers, ungloved, while preparing beverages for the residents, put the cell phone back down on the counter, and then used those same fingers to hold beverages to be served inside the cups with no hand hygiene. V12, dietary staff, did not have any hair net covering on his head or facial hair while working with food. V11, cook in training, did not have his facial hair net over his beard covering his facial hair. V3 did not correct V1 or V12 about their hair net use while preparing lunch in the kitchen.
On 1/23/25 at 8:00 AM, V3, V11, and V12 were not wearing hair nets in the kitchen preparing breakfast. Biscuits were at 109.2 degrees Fahrenheit, and when gravy was placed on top of them, the biscuit and gravy were at 109 degrees Fahrenheit on the plate to be served.
V12 stated the key will be to get the food out to the residents as fast as possible since they are losing heat fast. The food was placed on a tray and prepared to be served to the residents.
R1's MDS dated [DATE] documented R1 to be moderately cognitively impaired. On 1/22/25 at 9:55 AM, R1 stated the food is not good and usually cold; eats in dining room and food is still cold.
R2's MDS dated [DATE] documented R2 to be cognitively intact. On 1/22/25 at 10:10 AM, R2 stated the food is terrible and sometimes cannot identify what it is and is usually cold.
R4's MDS dated [DATE] documented R4 to be cognitively intact. On 1/22/25 at 10:25 AM, R4 stated the food is typical Institutional Food and it has improved the past month but still needs a lot of work. R4 stated he eats in dining room and in his room and food is usually cold, even in the dining room. R4 stated he used to be a Federal Consumer Safety Officer and he is well aware of how to store and cook food. R4 stated they need to watch the temperatures of the food and no one in the kitchen monitors the food temps like they are supposed to.
R7's Minimum Data Set (MDS) dated [DATE] documented him to be cognitively intact. On 1/22/25 at 2:48 PM, R7 stated the food varies in temperature, it is sometimes served warm but sometimes cold you just never know what you're going to get. R7 stated he would like the kitchen staff to wear their hair nets, proper fitted clothing, and use proper hand hygiene before working with the food also.
R9's MDS dated [DATE] documented him to be cognitively intact. On 1/22/25 at 2:45 PM, R9 stated the food is not cold but could be warmer, it varies every day. On 1/23/25 at 9:10 AM, R9 stated the biscuits and gravy for breakfast was not hot, it was room temperature, and he only ate two bites of it; it wasn't good.
Resident Council Meeting Minutes dated 12/30/24 documented the food comes out cold at dinner and food was not good quality.
2. On 1/22/25 at 8:45 AM, the kitchen freezer has 5 bags of frozen breaded chicken labeled Don't cook use for activity with no date. The beverage refrigerator has a gallon of two percent milk 2/3's the way used with a expiration date of 1/17/25.
On 1/22/25 at 8:49 AM, V3, stated the 5 bags of frozen breaded chicken are for the Certified Nursing Assistants (CNA's) to use for activities, they like to have food for the residents sometimes.
On 1/22/25 at 8:50 AM, V3 and V10 stated the beverages in the refrigerator (containing the expired milk) is what they serve the residents.
3. On 1/22/25 at 12:15 PM, no active temperature logs in facility binder since December of 2024 for freezers and refrigerators.
On 1/22/25 at 12:15 PM, V3 stated he was not aware that the freezers and refrigerators needed to having daily temperature checks.
On 1/23/25 at 8:15AM, V1, Administrator, stated she expects the kitchen staff to be wearing hair nets properly, we just got in a whole order of nets for their beards in fact, they should know better. V1 stated we will have to provide more education to the kitchen staff on proper procedures.
The Facility's Food Labeling and Storage Policy dated 3/29/21 documented all foods must be labeled and dated right away when going into the cooler, the expiration date is the most important. The facility's Storeroom/Freezer Food Storage Policy dated 6/22/21 documented all open food items in the freezer must be labeled and dated. The facility's Food Safety Policy undated documented foods or beverages that are past the manufacturer's expiration date should be discarded, foods should be stored at the appropriate temperature to maintain safety: hot foods should be held at 135 degrees or higher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to initiate an investigation of alleged theft for 2 of 5 (R4, R6) residents, reviewed for misappropriation of resident property, in the sample of 7.
Findings Include:
1. R4's admission Record, not dated, documents Major Depressive Disorder, and Essential (Primary) Hypertension.
On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able.
R4's Minimum Data Set, dated [DATE], documents that R4 has moderate cognitive impairment.
On 1/15/2025 at 9:38 AM R4 stated that she had money missing $100. R4 stated that she was in her room counting her money. R4 stated that V14, Certified Nursing Assistant (CNA), was in the room with her and helped her put the money in her drawer. R4 stated that she left the room and when she returned the money was gone. R4 stated that the only person that knew where the money was, was V14. R4 stated that she notified V1 about it.
On 1/15/2025 at 12:12 PM V1, Administrator, stated that she has not had any abuse investigations since taking over as Administrator. V1 stated that if the staff are aware or have heard anything it would be an allegation and have to be investigated and reported. V1 stated staff is expected to report any allegations, including gossip regarding theft or abuse to her or the nurse in charge, which then the nurse in charge would contact her. V1 stated if she was contacted with an allegation of theft she would start an investigation and then contact the police and IDPH. V1 stated even if there was gossip of theft involving a resident, she would start an investigation.
On 1/15/2025 at 1:50 PM V3, Licensed Practical Nurse, stated that R4 is alert and answers questions appropriately.
On 1/15/2025 at 1:55 PM V16, CNA, stated that R4 is alert and oriented and able to make needs known. V16 stated that R4 is not known to make false allegations.
On 1/15/2025 at 3:15 PM V1 stated that R4's incident occurred prior to her being the administrator. V1 stated that although she worked at the facility, she was not in the position to investigate the allegation. V1 stated that she has looked for an investigation related to this and was not able to locate one. V1 stated that now that she is aware she will follow up.
2. R6's admission Record, not dated, documents Acute Respiratory failure, Chronic Venous Hypertension, Major Depressive Disorder.
R2's MDS, dated [DATE], documents that R6 is cognitively intact.
On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able.
On 1/15/2025 at 2:45 PM R6 stated that she had a gift card with $150 on it. R6 stated that she put it in her purse and left it in her room. R6 stated that at a later date she went in her purse and it was gone. R6 stated that she told V13, Previous DON, when it happened and have not heard anything about it. R6 stated that she feels violated.
On 1/15/2025 at 3:15 PM V1 stated that R6's incident occurred prior to her being the administrator. V1 stated that although she worked at the facility, she was not in the position to investigate the allegation. V1 stated that she has looked for an investigation related to this and was not able to locate one. V1 stated that now that she is aware she will follow up.
On 1/16/25 at 7:50 AM, V1, Administrator, stated she was not aware of R6's allegation of theft until 1/15/25. R6 stated there was a $150 gift card inside her purse that was missing. She stated the Facility would be replacing the gift card, but the allegation has not been reported or investigated at this time.
On 1/16/2025 at 1:35 PM V18, Social Service Director stated she did not file a grievance regarding the missing gift card because V1 stated she was doing an investigation. V18 stated she was unsure of who the gift card belonged to and who reported the theft. V18 stated she had heard there was around a total of $300 missing from 2 residents, however she is unsure who the residents are. V18 stated one resident was missing maybe $100-$200 in cash and the other resident was missing a $100-$150 gift card. V18 stated the Administrator told her this was all being investigated, and an in-service was done.
The facility's Abuse, Prevention, and Prohibition Policy revised 10/2022 documents the facility prohibits mistreatment, neglect or abuse or residents. The facility also prohibits misappropriation of resident property. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence. The Prevention of Misappropriation of Resident Property section documents Social Service will educate the resident or family of the need to report any items of significance being brought in or removed so that this can be noted on the inventory in the clinical record. Social Service will educate the resident on how to report suspected occurrences, explaining the need to report, how to report, the investigation process and the facility's response to the allegation. The Social Service Designee, overseen by the Administrator, will investigate all reports or complaints of missing resident property following the policy and procedure. If an item that has been reported as missing cannot be located within a period not to exceed 24 hours the Social Service Designee will notify the Administrator of an allegation of possible misappropriation. The Administrator will make the appropriate notifications and initiate an investigation of the allegation of misappropriation of resident property. Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy. Resolution will be completed and reported to the resident/family. The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to implement their Abuse, Prevention and Prohibition Policy for 2 of 5 (R4, R6) residents, reviewed for misappropriation of resident property, in the sample of 7.
Findings Include:
1. R4's admission Record, not dated, documents Major Depressive Disorder, and Essential (Primary) Hypertension.
On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able.
R4's Minimum Data Set, dated [DATE], documents that R4 has moderate cognitive impairment.
On 1/15/2025 at 9:38 AM R4 stated that she had money missing $100. R4 stated that she was in her room counting her money. R4 stated that V14, Certified Nursing Assistant (CNA), was in the room with her and helped her put the money in her drawer. R4 stated that she left the room and when she returned the money was gone. R4 stated that the only person that knew where the money was, was V14. R4 stated that she notified V1 about it.
On 1/15/2025 at 12:12 PM V1, Administrator, stated that she has not had any abuse investigations since taking over as Administrator. V1 stated that if the staff are aware or have heard anything it would be an allegation and have to be investigated and reported. V1 stated staff is expected to report any allegations, including gossip regarding theft or abuse to her or the nurse in charge, which then the nurse in charge would contact her. V1 stated if she was contacted with an allegation of theft she would start an investigation and then contact the police and IDPH. V1 stated even if there was gossip of theft involving a resident, she would start an investigation.
On 1/15/2025 at 1:50 PM V3, Licensed Practical Nurse, stated that R4 is alert and answers questions appropriately.
On 1/15/2025 at 1:55 PM V16, CNA, stated that R4 is alert and oriented and able to make needs known. V16 stated that R4 is not known to make false allegations.
On 1/15/2025 at 3:15 PM V1 stated that R4's incident occurred prior to her being the administrator. V1 stated that although she worked at the facility, she was not in the position to investigate the allegation. V1 stated that she has looked for an investigation related to this and was not able to locate one. V1 stated that now that she is aware she will follow up.
2. R6's admission Record, not dated, documents Acute Respiratory failure, Chronic Venous Hypertension, Major Depressive Disorder.
R2's MDS, dated [DATE], documents that R6 is cognitively intact.
On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able.
On 1/15/2025 at 2:45 PM R6 stated that she had a gift card with $150 on it. R6 stated that she put it in her purse and left it in her room. R6 stated that at a later date she went in her purse and it was gone. R6 stated that she told V13, Previous Director of Nursing, DON, when it happened and have not heard anything about it. R6 stated that she feels violated.
On 1/15/2025 at 3:15 PM V1 stated that R6's incident occurred prior to her being the administrator. V1 stated that although she worked at the facility, she was not in the position to investigate the allegation. V1 stated that she has looked for an investigation related to this and was not able to locate one. V1 stated that now that she is aware she will follow up.
On 1/16/25 at 7:50 AM, V1, Administrator, stated she was not aware of R6's allegation of theft until 1/15/25. R6 stated there was a $150 gift card inside her purse that was missing. She stated the Facility would be replacing the gift card, but the allegation has not been reported or investigated at this time.
On 1/16/2025 at 1:35 PM V18, Social Service Director stated she was gone for a couple days due to a snowstorm, but she was notified the day after that there was an in-service completed due to a missing gift card. V18 stated she did not file a grievance regarding the missing gift card because V1 stated she was doing an investigation. V18 stated she was unsure of who the gift card belonged to and who reported the theft. V18 stated she had heard there was around a total of $300 missing from 2 residents, however she is unsure who the residents are. V18 stated one resident was missing maybe $100-$200 in cash and the other resident was missing a $100-$150 gift card. V18 stated the Administrator told her this was all being investigated, and an in-service was done.
The facility's Abuse, Prevention, and Prohibition Policy revised 10/2022 documents the facility prohibits mistreatment, neglect or abuse or residents. The facility also prohibits misappropriation of resident property. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence. The Prevention of Misappropriation of Resident Property section documents Social Service will educate the resident or family of the need to report any items of significance being brought in or removed so that this can be noted on the inventory in the clinical record. Social Service will educate the resident on how to report suspected occurrences, explaining the need to report, how to report, the investigation process and the facility's response to the allegation. The Social Service Designee, overseen by the Administrator, will investigate all reports or complaints of missing resident property following the policy and procedure. If an item that has been reported as missing cannot be located within a period not to exceed 24 hours the Social Service Designee will notify the Administrator of an allegation of possible misappropriation. The Administrator will make the appropriate notifications and initiate an investigation of the allegation of misappropriation of resident property. Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy. Resolution will be completed and reported to the resident/family. The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility.

Based on interview and record review the facility failed to provide a licensed Administrator to oversee their Administrator in training, this has the potential to affect all 32 residents living in the facility.
Findings Include:
On 1/15/2024 at 9:00 AM V1, Administrator, stated that the facility's census was 38.
On 1/15/2025 at 12:12 PM V1 stated that she has been at the facility for years. V1 stated that she did Minimum Data Set (MDS) for 3 years and then stepped in as administrator in the last 3 weeks. V1 stated that she started on 12/23 or 12/24. V2 stated that V11, Previous Administrator, had been the administrator for the last year. V2 stated that V11 resigned and left prior to the date of her resignation. V1 stated at that time V12, Infection Control and wound nurse stepped in for 5 days and then quit. V1 stated that she has worked for the last 3 weeks in the administrator position and that last Wednesday she filed for her temporary license. V1 stated that the state of Illinois have all of her stuff and she is waiting on processing.
On 1/15/2024 at 3:28 PM V1 stated that she does not work under anyone's license.
On 1/15/2025 at 3:39 PM V1 stated that they did not have a policy for Administrator and qualifications.
As of 1/16/2025 at 11:00 AM the facility had not provided any documentation of a licensed administrator.

Based on record review and interview, the facility failed to provide a full-time working Director of Nursing (DON) for 18 of 18 days reviewed. This has the ability to affect all 38 residents in the facility.
Findings include:
On 1/15/2025 at 12:12 PM V1, Administrator, stated that the previous DON resigned and left before date provided. V1 stated that V2, Acting DON, was a floor nurse and accepted the DON position. V1 stated that V2 is not here this morning because she works evenings for the RN coverage. V1 stated that she is in the process of hiring a DON and should start next week.
On 1/15/2025 at 3:10 PM V2, Acting DON, stated that she started the position January 1st of 2025. V2 stated that she only works evenings as scheduled. V2 stated that the DON duties that she performs is whatever V1 ask her to. V2 stated that she does not perform any other duties.
The Facility provided V2's time report and documented V2 did not work on the following days for December 2024 and January 2025: 12/1, 12/2, 12/6, 12/9, 12/10, 12/14, 12/15, 12/16, 12/20, 12/21, 12/23, 12/24, 12/28, 12/29, 1/1, 1/5, 1/12, 1/14.
On 1/15/2024 at 9:00 AM V1 stated that the facility census was 38 in facility.
On 1/15/2025 at 3:39 PM V1 stated that they did not have a policy for staffing and DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility to assess and renew whenever necessary psychotropic medications for two of two residents (R19, R21) reviewed for unnecessary medications in the sample of 24.
Findings Include:
1.R19's Electronic Health Record Diagnoses section documents R19 has Alzheimer's Disease late onset, Unspecified Dementia, Panic Disorder, MDDR, and Unspecified Psychosis.
R19's Minimum Data Set (MDS) dated [DATE] documents R19 is severely cognitively impaired.
R19's Physician Order Sheet (POS) dated 8/5/24 documents Alprazolam 1milligram (mg) every 4 hours whenever necessary (PRN). ( this medication was not assessed and reordered after 14 days.)
R19's POS dated 8/11/24 documents Xanax 2 mg twice daily and every 6 hours PRN. ( this medications was not assess or reordered in 14 days)
R19's Care Plan dated 8/5/24 documents ()R19 has depression, anxiety, psychosis and receives psychotropic medication. will exhibit indicators of depression, anxiety or sad mood less than daily by review date,R19's intervention: Monitor/document/report to MD (Medical Doctor) prn ongoing s/sx (signs and symptoms) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons.
R19's Health Status Note dated 9/3/24 documents res (resident R19) was up for AM meal and did eat approx (approximately) 25% with and sips of fluid taken. took meds (medications) without diff (difficulty) gen (generalized) weakness evident.res (resident) moves about on and off in chair. Comfort maintained and hospice care continues.
R19's Health Status Note dated 9/8/24 documents res has been up in chair. T and R Q2 (turned and repositioned every) hours and prn. Res was fed this am and consumed 100% of meal and good fluids taken. Drowsy on and off. comfort maintained. will continue to monitor.
On 9/18/24 at 2:00 PM V25 Licensed Practical Nurse (LPN) stated, we give morphine for breakthrough pain when she is trying to climb out of her chair. If she is still restless trying to climb out of the chair hollering, we give PRN Xanax at 12:00 Noon We try to reposition her we add cushion or give her shakes.
On 9/19/24 at 2:30 PM V2 Director of Nursing stated, (V29) Doctor has never been in our building, and the hospice cannot send over their review, because it has other residents on it they review all 200 hundred of their residents on the same day.
2. R21's Electronic Health Record Diagnoses section documents R21 has diagnoses of Unspecified Psychosis, Bipolar, Major Depression Recurrent, and Anxiety Disorder.
R21's MDS dated [DATE] documents R21 is severely cognitively impaired.
R21's Care plan dated 8/31/24 documents the resident (R21) has behavior problems, (R21's) believes she needs to be taken to the second floor. She (R21) believes that is where her room is. She (R21) yells out at times looking for her mother and husband. Intervention is Room in direct visualization of Nurse's Station.
R21's MDS dated [DATE] documents Haldol 1mg/1milliter (ml) give 1ml every 6 hours PRN.
R21's Health Status Note Dated 9/17/24 documents resident cont on hospice services. no coc (change of condition) noted at this time. no behaviors noted so far this shift. no c/o pain or discomfort at this present time. resident currently resting in bed with nonlabored breathing noted. call light within reach.
R21's Health status Note dated 8/5/24 documents hospice notified at this time of res noted to have increased anxiety this am and yells aloud momma, I can't walk and help me anxiety increased from previous. will continue to monitor. request for med adjustment made.
On 9/19/24 R21's Hospice Notes from 8/8/24 through 9/12/24 and did not find a note where the hospice physician wrote in the patient record to renew the prn Haldol.
On 9/18/24 at 2:00 PM V25 Licensed Practical Nurse (LPN) stated, usually we assess her (R21) she gets Haldol for increased restlessness and hollering. We usually give her a snack or ensure. We try to reposition her, (R21) and if that doesn't help give Haldol.
The facility policy dated 2/2021 documents use of psychotropic medications residents will only receive psychotropic medications when necessary to treat a specific condition. Diagnoses alone do not warrant the use of psychotropic medications.

Based on observation, interview, and record review, the Facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness. This has the potential to affect all 42 residents living in the Facility.
Findings include:
On 9/17/24 at 7:12 AM, in the dry storage area there was a large clear tub with unpackaged, individual tea pods. There was no lid on the tub, leaving the contents open to air. There was a rolling cart with three pitchers of liquid on top. Two of the pitchers contained a clear liquid, and one contained a red liquid. None of the pitchers were labeled or dated. There was a tall rack with bottles of pancake syrup, lemon juice, peanut butter, and white vinegar that were previously opened, but were not dated upon opening.
On 9/17/24 at 7:14 AM, in the standing freezer there was a large plastic bag of donuts and a large bag of garlic bread. Both bags had been opened, and the plastic bags were tied in knots, but neither were labeled or dated.
On 9/17/24 at 7:16 AM, in the standing refrigerator there was a zip lock bag with brown lettuce that was dated 9/9. There was a sealed, unopened bag of lettuce with the commercial label, Best if used by 9/7/24.
On 9/17/24 at 7:20 AM, the second store room refrigerator across from the other refrigerator and freezer contained three gallons of unopened milk with the commercial label, Best by 9/16/24. There was a stainless steel container with beets that was covered with aluminum foil and was not labeled or dated. There was a large stainless steel bowl of chocolate pudding that was covered in plastic wrap and was not labeled or dated. V6, Dietary Aid, brought in a plastic container of fruit cocktail that was not labeled or dated and placed it in the refrigerator. V6 stated that was fruit cocktail, the brown substance was chocolate pudding and she thought the red items looked like beets.
On 9/17/24 at 7:23 AM, there was a portable fan on the sink area that was covered in dust and dirt and was blowing directly toward a bowl of pancake batter next to the cooktop.
On 9/17/24 at 7:24 AM, there was a shelf across from the steam table containing eight one gallon containers of kitchen chemicals within six inches of a rack holding cups. There were two 20 quart containers of dry cereal on a shelf to the left of the steam table that were not labeled or dated.
On 9/17/24 at 7:27 AM, in the standing refrigerator next to the kitchen entrance there was a quart of buttermilk with the commercial label, Best by 16 Sept (September), an opened gallon of 2% milk with the commercial label, Best by 9/16, and an opened jug of apple juice with the hand written date, 9/4, in black marker. There were two cups with milk inside the door that were uncovered and were not labeled or dated. There was an opened carton of prune juice with the hand written date, 3/8, in black marker and the commercial label, Best if used by 20 June 2023. There was a pitcher containing an orange liquid with no label or date. V5, Cook, stated it was Kool-Aid.
On 9/17/24 at 11:50 AM, during lunch service V5, Cook, was not wearing any covering over his beard which measured approximately three inches in length.
On 9/17/24 at 12:29 PM, food temperatures were obtained from steam table using a metal calibrated thermometer after the last resident tray was served. The pineapple measured 68° Fahrenheit (F), the honeydew melon measured 62° F, the peaches measured 73° F, the cottage cheese measured 42° F, the pureed pineapple measured 72° F, and the pureed peaches measured 73° F. The cold items were placed on the steam table, along with the hot items.
On 9/17/24 at 12:40 PM, V5, Cook, stated he thought they used to have beard nets, but may have run out of them. V8, Dietary Manager (DM), stated they do have beard nets, but sometimes they get knocked down when people come in and out of the kitchen, so she will put them back out.
On 9/17/24 at 12:43 PM, V8, Dietary Manager (DM), stated she is going to have staff keep the cold and hot foods separate during meal service to make sure the cold items do not get too warm.
On 9/18/24 at 2:52 PM, V1, Administrator, stated she expects staff to follow their food service policies for storage and labeling and serving temperature.
The Facility's Date Marking for Food Safety Policy revised 4/7/24 documents, The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.
The Facility's Food Labeling and Storage Policy dated 3/29/21 documents drinks should be discarded within a maximum of three days. It documents all foods must be labeled and dated right away when going into the cooler, and the expiration date is the most important. It documents one employee must check all coolers once per day for outdated food.
The Facility's Storeroom/Freezer Food Storage Policy dated 6/22/21 documents, All open food items in the freezer must be labeled and dated. For example, if you open a bag of hash browns and place that open bag into a zip lock or plastic wrap. You must write the use by date from the manufacturer or a 6-month use-by-date on the zip lock bag or plastic wrap.
The Facility's Meal Service Temperature Policy reviewed 8/2024 documents, Foods shall be provided at point of service to support resident/patient satisfaction. Temperatures of hot food shall be supported to promote service temperatures of hot foods to about 120 degrees and cold foods to below 50 degrees.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 9/17/24 documents there are 42 residents living in the Facility.

Based on observation, interview and record review the facility failed to date insulin for 4 of 4 residents (R10, R7, R28 and R196) reviewed for medication storage in the sample of 24.
Findings include:
1. Observation on 9/17/2024 at 9:15 AM the 100/300 medication cart showed R10 Novolog insulin vial was not dated.
R10's Physician's Order Sheet (POS) dated, 9/2024, documents Novolog insulin inject 4 unit subcutaneously before meals.
2. Observation of the 100/300 medication cart showed R7 Lantus insulin vial was not dated.
R7's POS dated, 9/2024, documents Lantus insulin inject 5 units subcutaneously one time a day for diabetes.
3. Observation of the 100/300 medication cart showed R28 Insulin Aspart insulin vial was not dated.
R28's POS dated, 9/2024, documents Insulin Aspart inject 5 units subcutaneously before meals for diabetes.
4. Observation of the 100/300 medication cart showed R196 Toujeo Solostar insulin pen was not dated.
R196's POS dated, 9/2024, documents Toujeo Solostar inject 22 units subcutaneously two times a day for diabetes.
On 9/17/2024 at 9:22 AM V7, Licensed Practical Nurse (LPN) stated insulin vials should be dated the day they are opened.
Review of the facility's Medication Storage In the Facility policy, effective date 6/1/2018, documents when the original seal of a manufacture's container or vial is initially broken, the container or vial will be dated. The nurse shall place a discard date sticker on the medication. (NOTE: the best stickers to affix contain both a date opened and expiration notation line.) The expiration date of the vial will be 30 days unless the manufacturer recommends another date or regulations/guidance require different dating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to to monitor/supervise a resident from wandering into resident rooms at night for 4 of 4 residents (R4, R8, R25, R39) reviewed for resident rights in the sample of 24.
Findings include:
Grievance Report Form dated 7/28/2024, documents R4 stated another resident (R37) wanders in her room looking for a facility owned remote. Actions/recommendations: he should be monitored more closely. Action taken: resident (R37) will be given a sitter.
Grievance Report Form dated 8/25/2024 documents R10 stated another resident (R37) wanders into resident's room in search of a facility owned remote.
On 9/19/2024 at 1:55 PM R4, R8, R25 and R39 stated a resident by the name of (nickname) (R37) wanders into their rooms at night and steals the television remote control. All residents stated they have told the facility time and time again about cowboy doing this but nothing stops him. R25 stated if he comes into my room again I'm going to have to hurt him. R4 stated being a female she doesn't feel comfortable sleeping with (R37) randomly going in her room at night, she said it's freaky.
R37's Undated Face Sheet documents he was initially admitted on [DATE] with diagnosis of schizophrenia.
R37's Quarterly Minimum Data Set (MDS) dated [DATE] documents resident is severely cognitively impaired with diagnoses of Alzheimer's disease, anxiety, insomnia and schizophrenia. No upper or lower extremity impairment and no cane or walker mobility devices.
R37's Progress Note, dated 8/31/2024 at 1:30 PM, documents res (resident) was noted numerous times on the 6 a-2 p shift going into other res's rooms. Res noted down Ash hall several times and was in the breakroom. Res noted with a remote with the initials DK on it. Housekeeping retrieved it and gave it to the nurses, then,it was returned to the res. Other residents advised to close their doors when leaving their rooms. This res was told numerous times to stay on his hall and only go into his room. Res voiced, Okay. A little bit later, res would be noted coming out of another res's room. Staff aware of res's roaming & pacing and entering rooms other than his. Staff tried to keep and eye on res and keep him from entering someone else's room. Res cont to roam halls. Progress Note at 3:36 PM, documents Res noted continuing to go in other res rooms trying to take belongings. Res redirected numerous times by staff.
R37's Progress Note, dated 9/2/2024 at 1:32 PM, documents Res noted going into other res's rooms numerous times this shift & taking belonging. Res redirected out of their rooms and belongings returned. Progress Note at 4:48 PM, documents Resident noted with remote control to another residents room, this nurse redirected resident, and provided education on only using remote control assigned to resident tv in room, resident had blank stare and chuckled. Progress Note at 7:51 PM, documents Resident caught in another resident bathroom, this nurse redirected resident to main dining room, nurse provided education and reminded resident where assigned room was at. Resident shook his head and walked away from this nurse. Resident now pacing hallways, CNA staff walking with resident. will continue to observe.
On 9/19/2024 at 2:30 PM, V1 Administrator stated she is aware the resident (R37) wanders into other residents room but he has a sitter from 4:00 PM - 10:00 PM and she didn't think it was a problem anymore. V1 hired a sitter for (R37) a few months ago and she didn't know it was still an issue. She has consulted with a psychiatrist for medication review and referred (R37) to other, more appropriate facilities but no facility accepted him as a resident. V1 stated she will increase the sitter times with (R37) and have the nurse check on him every two hours while he's asleep to ensure he doesn't wander in other resident rooms.
The facility's resident's rights policy dated revised 1/2024, documents the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Grievances: the resident has a right to and the facility must make prompt effort by the facility to resolve grievances the resident my have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement a resident centered behavior care plan on 1 of 13 residents (R36) reviewed for development/implementation of a comprehensive care plan in the sample of 20.
Findings include:
R36's Face Sheet, undated, documents R36 has a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder.
R36's Minimum Data Set (MDS), dated [DATE], documents R36 has a BIMS (Brief Interview for Mental Status) score of 10, which indicates R36 has moderate cognitive impairment.
R36's Care Plan, dated 9/14/24, documents R36 has a behavior problem, depression and dementia with interventions to give anti-anxiety medications ordered by the physician, monitor/document/report to the physician as needed any ongoing signs or symptoms of depression unaltered by the antidepressant medications and to arrange for psychiatric consult to follow up as needed. The care plan fails to document the behaviors that are exhibited by R36 or resident specific interventions to aid in the management of behaviors. The care plan also fails to document any non-pharmacological interventions to manage the behaviors.
R36's Progress Note, dated 3/25/24 at 5:55 PM, documents the following: Resident sitting next to this nurse at nurses station, very agitated and exit seeking. Resident stated if she didn't get to leave and go home she was going to fall out of the chair. This nurse attempted to redirect resident several times. Behavior continues. Will continue to monitor and observe.
R36's Progress Note, dated 3/27/24 at 1:24 PM, documents the following: Reported by therapy that resident stated that she would rather die than to have to do all of this. This referred to social services at this time and social services is speaking to resident. No distress evident.
R36's Progress Note, dated 4/5/24 at 12:31 PM, documents the following: Social worker observed resident during lunch today. Resident was overheard saying she is not hungry and does not want to eat. COTA (Certified Occupational Therapy Assistant) at lunch table tried to encourage resident to eat with no avail. Resident then stated she did not want to eat because she is depressed. Resident has had an assessment with a score of 12.0, indicating moderate depression. Social worker has contacted psychiatric physician for an evaluation.
R36's Progress Note, dated 5/30/24 at 4:43 PM, documents the following: Resident noted by this nurse, being rude to staff, stating that she does not like her CNA (Certified Nursing Assistant), when asked why, she stated I just don't. This nurse explained to resident that staff was here to help her and that she needed to use her call light for assistance. This nurse asked if CNA had done anything to her and she stated No, I just don't like her, and I don't like you either. Incident reported to social services.
R36's Progress Note, dated 6/27/24 at 11:00 AM, documents the following: Call placed to the physician's office to ask about Lorazepam order being reinstated. Resident has been requesting pill the last 2 days. She is very anxious and says she hasn't slept in 3 days. Awaiting return call at this time.
R36's Progress Note, dated 7/1/24 at 11:09 AM, documents the following: The NP (Nurse Practitioner) here to see resident, new order received for Lorazepam 0.5 mg (milligrams) every 8 hours as needed. Order entered and faxed to pharmacy.
On 9/18/24 at 1:05 PM V18, SSD (Social Services Director), stated the only behavior R36 has is she gets out of bed without asking. V18 stated R36 does not have any kicking, screaming or foul language. V18 stated she is involved in completing the behavior care plans but not on R36.
On 9/18/24 at 1:51 PM V2, DON (Director of Nurses), stated she doesn't see where the interventions are resident specific for R36's behaviors.
The Care Planning Policy, with a review date of 2/2021, documents the following: Every resident will be assessed using the MDS according to the guidelines set forth in the resident assessment instrument manual. The purpose is to assess each resident's strengths, weaknesses, and care needs and to use this assessment to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well being as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to have fall interventions in place and implement progressive interventions in 3 of 7 residents (R6, R19, R36), reviewed for falls in the sample of 24. This failure resulted in R36 sustaining a head injury, requiring emergency room evaluation and treatment including but not limited to glue and adhesive skin closure strips to the right temple area.
Findings include:
1. On 9/17/24 at 9:05 AM, R36 was observed in her room in a low bed with a mat to left side of the bed, the call light was behind the bed, not within reach. R36 had bruising noted to the bilateral eyebrow areas with adhesive closure strips in place to the right eyebrow area. R36 stated she fell recently and that is how she got the bruising. R36 stated she has fallen 3-4 times and has gotten hurt each time. R36 stated she tries to get up on her own and falls, unsure of why she falls, she just does. R36 stated she uses her call button when she needs help and stated it's usually clipped here (reaching on the right side of the bed), but it's not here. Surveyor moved the call light within resident's reach and she pushed it. Staff came into the room to see what R36 needed and R36 stated she was just checking to make sure it worked. R36 stated she had a headache and would like something for it.
R36's Face Sheet, undated, documents R36 has a diagnosis of Dementia, Tremors and Hypertension.
R36's MDS (Minimum Data Set), dated 7/16/24, documents R36 has a BIMS (Brief Interview for Mental Status) score of 10, indicating R36 has moderate cognitive impairment, requires partial/moderate assist with toileting, requires substantial/maximal assist with sitting to standing, requires substantial assist with transfers and has a history of falls.
R36's Care Plan, dated 5/23/24, documents R36 has actual/potential risks for falls with the following interventions: 5/23/24 be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; 8/24/24 continue to educate resident that she needs to be patient and wait for staff to be available to assist; 8/28/24 continue to educate resident to wait for staff to assist her and she will need to ask for assistance; 9/12/24 sent to the emergency room for evaluation and treatment, received 2 adhesive skin closure strips and glue to the right temple and then was sent back to the facility; 9/14/24 continue to educate resident on waiting for staff for transfer needs and encourage her as much as she will allow to stay in high traffic areas. The Care Plan goes on to document R36 has an ADL (Activities of Daily Living) self-care performance deficit with an intervention to encourage her to use the call light and she requires 1-2 staff to assist in all transfers using a mechanical lift. The care plan fails to identify progressive interventions to prevent falls but utilizing the same intervention for multiple falls.
R36's Progress Note, dated 7/11/24 at 9:40 AM, documents the following: Writer called into residents room by CNA. Resident was attempting to transfer herself into bed unassisted, she stood up and slid down the front of her chair onto the fall mat on the floor. Skin assessment completed, no injury or wounds noted. Resident denies any pain or discomfort. Resident assisted up into bed and is now resting quietly in bed with HOB elevated and call light in reach. Fall mat in position and bed in low position, will continue to monitor.
R36's Progress Note, dated 8/24/24 at 12:16 AM, documents the following: Resident roommate summoned this nurse to resident room. Upon entering room resident was found in a sitting position on floor near bed. No internal/external rotation noted. Fall unwitnessed neuro checks initiated at this time. Assisted off floor with the help of two and placed into bed. Resident able to [NAME] WNL. Denies pain or discomfort.
R36's Progress Note, dated 8/29/24 at 9:56 AM, documents the following: Resident noted to be sitting on the floor in the hallway, in front of wheelchair. Resident noted with a 2 cm (centimeter) hematoma to the left side of the forehead. Resident stated I leaned forward to pick something up and fell out of w/c.
R36's Progress Note, dated 9/12/24 at 4:35 PM, documents the following: Resident found on floor in room after this nurse was notified by resident's roommate. BP: 116/66, P: 76 Temp: 98.4, O2: 96, res complaining of head pain, 3 cm laceration noted to right temple, ecchymosis noted to left temple, no other injuries noted. MD and POA notified. EMS (Emergency Medical Services) transported resident to the hospital. report given to ER (Emergency Room) charge nurse.
R36's Progress Note, dated 9/12/24 at 9:46 PM, documents the following: Resident returned to facility from the hospital via EMS. Resident was transferred into bed via 2 EMS attendants. 2 Steri-strips and Dermabond was applied to resident's right eyebrow in hospital. Resident had no complaints of pain or discomfort.
R36's Progress Note, dated 9/14/24 at 9:30 AM, documents the following: This nurse was alerted to resident being on the floor by resident's roommate. I went into room, found resident laying on the floor next to bed, resident was assessed for injuries, no injuries were found, resident's neuro-check was normal & vitals were stable. Once assessment was completed, resident was transferred from the floor to the bed. Resident states she was trying to transfer self from wheelchair to bed & fell, denies any pain or discomfort at this time, will continue to monitor for changes. POA, MD & DON notified.
R36's Hospital After Visit Summary, dated 9/12/24, documents a diagnosis of Fall and Laceration to the Right Eyebrow.
2. R19 Fall Risk Data Collection Form dated 8/24/24 documents R19 is high risk for falls.
R19 Minimum Data Set, dated [DATE] documents for rolling right to left R19 is dependent and going from chair to bed R19 is dependent.
R19's Care Plan dated 8/5/24 documents (R19) is at risk for falls 7/30/24 fall with no injury and 8/9/24 fall with no injury. The resident will be free of minor injury through review date. The resident (R19) will be free of minor injury through review date. Interventions: The resident (R19) will be free of minor injury through review date. Hospice nurse to review medications resident has a floor mat next to bed while in bed. Bed in lowest position. Resident is in a broda chair
R19's Fall Investigation dated 12/2/23 documents resident fell out of wheelchair to floor and hit head.
R19's Fall Investigation dated 1/17/24 documents notified by CNA (Certified Nursing Assistant) that the resident (R19) had fell. Upon entry to the room resident (R19) noted sitting on the floor next to her bed. Sitting on floor on bottom with legs extended forward resident moving all extremities CNA stated resident (R19) fell backward onto floor.
R19's Fall Investigation dated 2/8/24documents resident (R19) found on the floor lying on her left side near the bed. The fall (was) unwitnessed, (and) neuro checks started at this time. The resident (R19) assisted off the floor.
R19's Fall Investigation dated 2/25/24 documents resident (R19) found on the floor near her bed, in her room there was a small goose egg area near the top of her scalp. small amount of blood from a small skin tear. Pressure applied, dry dressing applied, seemed a bit restless PRN tramadol and Ativan was given.
R19's Fall Investigation dated 3/6/24 documents resident (R19) found on floor by her bed.
R19's Fall Investigation dated 6/6/24 found resident (R19) sitting on her buttocks in the doorway resident unable to explain what happen.
R19's Fall investigation dated 6/20/24 resident (R19) noted by staff sliding out of bed onto the floor mat. med review completed floor mat.
R19's Fall investigation dated 7/30/24 resident (R19) taken to room to see if resident needed to be changed. Resident note to be screaming louder resident was noted actively sliding out of bed.
R19's Fall investigation dated 8/3/24 resident (R19) found lying on her left side in the dining room.
R19's untitled Fall Intervention form dated 1/17/24 documents the fall intervention is med review completed continue with med A.
R19's untitled Fall Intervention form dated 2/1/24 documents continue with skilled therapy services for safety transfers.
R19's untitled Fall intervention Form dated 2/8/24 documents care plan meeting held 2/7/24 via phone with POA (power of attorney) discussed hospice for next level of care. R19's untitled Fall Intervention form dated 3/6/24 documents contacted hospice nurse to perform a med (medication review).
R19's untitled Fall intervention form dated 6/6/24 documents hospice nurse updated and came out for a visit will review medications.
R19's untitled Fall intervention form dated 6/20/24 documents floor mat. The untitled Fall Intervention form dated 7/30/24 documents hospice nurse to review medications due to increased anxiety.
R19'sUntitled Fall Intervention form dated 8/5/24 documents spoke with hospice nurse to review different medication for anxiety regimen. R19's POS (Physician Order sheet) Dated 8/5/24 documents Alprazolam 1mg every four hours when ever needed for anxiety.
R19's untitled Fall Intervention form dated 8/24/24 documents resident is in a Broda chair.
0n 9/18/24 at 4:20 PM V3 Minimum Data Set (MDS) coordinator stated, she has had a lot of falls, and we have to reuse some of the interventions. We resolve them and use them again.
3. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness, unsteadiness on feet, and need for assistance with personal care.
R6's Minimum Data Set (MDS) dated [DATE] documented R6 was severely cognitively impaired, independent with bed mobility and transfer, and used wheelchair.
R6's Care Plan initiated 8/3/19 documents R6 is at risk for falls related to history of falls, need for assistance with activities of daily living, incontinence of bowel and bladder, and diagnosis of dementia with poor safety awareness.
R6's Care Plan Intervention initiated 8/3/19 documents R6 will have anti-tippers to wheelchair at all times.
On 9/18/24 at 11:30 AM, R6 was sitting in her wheelchair in the dining room with other residents. There were no anti-tippers on the wheelchair.
On 9/19/24 at 12:40 PM, R6 was sitting in her wheelchair in the dining room feeding herself lunch. There were no anti-tippers on the wheelchair.
R6's Fall Risk assessment dated [DATE] documented R6 was at risk for falls.
R6's Unwitnessed Fall Report dated 5/10/24 documents, CNA came to the nurse saying res (resident) had blood all over her & was all over the floor beside the bed. Upon entering room, this nurse noted res's (resident's) face to be covered with dried blood and blood droplets were noted on the floor beside the res's WC (wheelchair). As CNA was wiping the dried blood off the res, a 2cm (centimeter) x 1cm hematoma with a 1cm gash in the middle was noted over the res's L (left) eyebrow. Resident Unable to give Description.
R6's After Visit Summary from (Local) emergency room documents R6 was seen for a fall with the diagnoses forehead cut, head injury, and laceration repair with glue.
R6's Care Plan Intervention updated 5/10/24 documented, Resident educated to ensure w/c (wheelchair) brakes are locked. (R6's 4/11/24 MDS documented R6 was severely cognitively impaired.)
R6's Unwitnessed Fall Report dated 6/3/24 documents resident was found on the floor in her room sitting on bedside mat, and R6 was unable to explain what she was trying to do.
R6's Care Plan Intervention updated 6/3/24 documents, (R6) will continue to work with Med B therapy services on strengthening. No new interventions were added following R6's 6/3/24 fall.
R6's Unwitnessed Fall Report dated 6/13/24 documents Resident Unable to give Description. There was no Nursing Description, and there were no details of the fall or potential causative factors.
R6's 6/13/24 Care Plan Intervention documents, Continue with therapy services. No new interventions were added following R6's 6/13/24 fall.
On 9/18/24 at 1:12 PM, V17, Certified Nursing Assistant (CNA), stated most of R6's falls happened because she would forget to put on her wheelchair brakes when she was self-transferring.
On 9/18/24 at 2:40 PM, V19, CNA, stated R6 does not let staff know when she needs to transfer, so they often do not know she needs help until she is already done.
On 9/18/24 at 3:17 PM, V26, Occupational Therapist (OT), stated R6 has a tendency to do things herself and is unlikely to ask for help due to cognitive deficits, so they requested increased supervision by staff.
On 9/19/24 at 12:10 PM, V16, Licensed Practical Nurse (LPN)/Wound Nurse, stated R6 forgets her limitations and can take herself to the bathroom, but sometimes she rushes, and that is the problem. She stated interventions have been put in place, but there have been no changes in her level of supervision. She was unsure if R6 ever had anti-tippers on her wheelchair.
On 9/20/24 at 9:18 AM, V21, CNA, stated she does not think R6 has ever had anti-tippers on her wheelchair.
On 9/19/24 at 1:44 PM, V1, Administrator, stated she will have to check into R6's anti-tippers. She stated she expects progressive interventions to be implemented after each fall and followed.
The Facility's Fall Policy reviewed 9/2024 documents, The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both Staff and residents. The Facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be recorded and potential causal factors identified and investigated. Interventions will be implemented and Care Plan Updated.
The Falls and Fall Risk, Managing Policy, dated 12/2007, documents the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to administer medications per Physician Orders in 3 of 5 residents (R2, R10, R11) reviewed for medications in the sample of 17.
Findings include:
1-R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses, including unspecified systolic (congestive) heart failure, essential (primary) hypertension, low back pain, dependence on supplemental oxygen, type 2 diabetes mellitus with diabetic chronic kidney disease, anemia in chronic kidney disease, major depressive disorder, chronic obstructive pulmonary disease (COPD), altered mental status, repeated falls, peripheral vascular disease, hyperlipidemia, and type 2 diabetes mellitus with diabetic neuropathy.
R2's Order Summary Report, printed 11/03/23 documents, order for Symbicort Inhalation Aerosol 80-4.5 MCG/ACT, (Microgram Per Actuation), 2 puffs inhaled orally two times a day for COPD. The start date was 08/22/23, and there was no end date.
R2's Medication Administration Record, (MAR), for the month of September 2023 documents, only 34 of the 36 ordered doses of Symbicort Inhalation Aerosol 80-4.5 MCG/ACT were given.
R2's Order Summary Report, printed 11/03/23 documents, order for Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT, 2 puffs inhaled orally two times a day for COPD with acute exacerbation. The start date was 09/27/23, and there was no end date.
R2's MARs for the months of September and October 2023, document, only 30 of the 42 ordered doses of Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT were given.
R2's Order Summary Report, printed 11/03/23 documents, order for Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT, 1 puff inhaled orally two times a day for COPD with acute exacerbation. One order for this was started on 07/21/23 with no end date, and the other order was started on 09/27/23 with no end date.
R2's MARs for the months of September and October 2023 document, only 60 of the 78 doses of Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT were given.
R2's Progress Notes for September and October 2023 do not provide rationale for any of these medications not being given.
2-R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including epilepsy, diabetes mellitus type 2, hemiplegia, hypertension, and traumatic hemorrhage to cerebrum.
R10's Order Summary Report, printed 11/03/23 documents, order for Atorvastatin 40 mg, (milligrams); give 40 mg at bedtime for hypertension with start date of 9/22/23 and no end date.
R10's MAR for October 2023 documents, only 17 of the 31 ordered doses of Atorvastatin were given.
R10's Order Summary Report printed 11/03/23 documents, order for Keppra 1000 mg; give 1000 mg by mouth two times a day for seizures with start date of 09/22/23 and no end date.
R10's MAR for October 2023 documents, only 46 of the 62 ordered doses of Keppra were given.
R10's Order Summary Report printed 11/03/23 documents, order for Insulin Aspart Injection Solution; inject 4 units subcutaneously before meals along with sliding scale. The start date was 09/22/23 with no end date.
R10's MAR for the month of October 2023 documents, only 72 of the 93 ordered doses of Aspart were given.
R10's Order Summary Report printed 11/03/23 documents, order for Lantus Subcutaneous Solution; inject 20 units subcutaneously at bedtime for diabetes. The start date was 09/22/23 with no end date.
R10's MAR for the month of October 2023 documents, only 17 of the 31 ordered doses of Lantus were given.
R10's Order Summary Report printed 11/03/23 documents, order for Phenytoin Sodium Extended Oral Capsule, give 100 mg by mouth two times a day with start date of 09/22/23 and no end date.
R10's MAR for the month of October 2023 documents, only 47 of the 62 ordered doses of Phenytoin were given.
R10's Progress Notes for October 2023 do not provide rationale for any of these medications not being given.
3-R11's Face Sheet documents R11 was admitted to the facility on [DATE] with diagnoses including essential primary hypertension, generalized anxiety disorder, major depressive disorder and gastroesophageal reflux disease without esophagitis.
R11's Order Summary Report printed 11/07/23 documents, order for Amlodipine Besylate Oral Tablet 5 mg; give one tablet by mouth one time a day for heart with start date of 09/28/23 and no end date.
R11's MAR for the month of October 2023 documents, R11 only received 28 of the 31 ordered doses of Amlodipine.
R11's Order Summary Report printed 11/07/23 documents, order for Hydrochlorothiazide Oral Tablet 25 mg; give one tablet by mouth one time a day for diuretic/b/p, (blood pressure), take 25 mg po, (by mouth), q, (every), d, (day), with start date of 9/28/23 and no end date.
R11's MAR for the month of October 2023 documents, R11 only received 28 of the 31 ordered doses of Hydrochlorothiazide.
R11's Order Summary Report printed 11/07/23 documents, order for Omeprazole Oral Tablet Delayed Release; give 40 mg by mouth at bedtime for acid indigestion, take 40 mg po q hs, (bedtime), with start date of 09/27/23 and no end date.
R11's MAR for the month of October 2023 documents, R11 only received 15 of the 31 ordered doses of Omeprazole.
R11's Progress Notes for October 2023 do not provide rationale for these medications not being given.
On 11/3/23 at 9:57 AM, V1, Administrator, stated, A blank (space) on the MAR means they did not sign it out. She would expect nursing staff to give medications as ordered and document, when medications are given.
The Facility's Administration of Medications Policy revised 12/21 documents, Immediately after a drug is ingested, it should be recorded on the MAR: 1. If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure residents received nutritional supplements and proper portion sizes in 1 of 4 residents reviewed for nutritional status in the sample of 25. This failure resulted in R1 losing significant weight of 12% loss over three months.
Findings include:
R1's Face Sheet documents R1 has diagnoses including cerebral palsy, dependence on wheelchair, gastro-esophageal reflux disease (GERD) without esophagitis, constipation, vitamin B12 deficiency anemia due to intrinsic factor deficiency, anemia, hypothyroidism, oropharyngeal phase dysphagia (difficulty swallowing), age-related osteoporosis without current pathological fracture, and unspecified intellectual disabilities.
R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, required total dependence with two or more-person physical assistance, and required total dependence with one-person physical assistance for eating.
R1's Care Plan documents, (R1) has potential for nutritional problem r/t cerebral palsy, PVD (peripheral vascular disease), seizure d/o (disorder), hyperlipidemia, vitamin B deficiency, intellectual disabilities, vitamin D deficiency, anemia, GERD, hypothyroidism, dysphagia, osteoporosis. (R1) has anemia r/t (related to) vitamin B12 deficiency. (R1) has osteoporosis. (R1) has GERD.
R1's Monthly Weight Report documents R1 weighed 139.8 pounds on 6/23/23 and 123.0 pounds on 9/20/23. This is a 16.8-pound weight loss or 12% weight loss over 3 months.
R1's Order Summary Report printed 9/28/23 documents order for Regular Diet with Pureed Texture and 90 cc (cubic centimeters or milliliters) Med Pass PO (by mouth).
R1's Progress Note by V20, Registered Dietitian (RD), on 7/27/23 at 8:15 PM documents, Diet Order: Pureed with 90mL (milliliters) Med Pass Supplement BID (twice per day).
R1's Progress Note by V19, RD, dated 9/17/23 at 8:44 AM documents, Diet is pureed with 90ml (mL) Med Pass Supplement BID. Regimen continues to provide supportive nutrition. Goal remains for stable weight pattern. Will monitor.
R1's Medication Administration Records (MAR) from 6/1/23 through 9/27/23 were reviewed and do not list Med Pass Supplement or document the Med Pass Supplement was given.
On 9/27/23 at 3:25 PM, V2, Director of Nursing (DON), stated there is no documentation that R1 received the Med Pass supplement.
On 9/27/23 at 3:51 PM, V1, Administrator, stated, the Med Pass was on the POS, (Physician Order Sheet), but not the MAR, (Medication Administration Record).
The Facility's Dietary Order Listing Report printed 9/28/23 documents, R1 has been on a Regular Diet with Pureed Texture since 4/6/23.
R1's Dietary Card from 9/26/23 Lunch documents, R1 was on a Puree Diet with Double Portions.
The Facility's Week 1 Tuesday Pureed Lunch documents, entrée was ½ c, (cup), Pureed Ham with Pureed Bread and ½ c Pureed Mixed Vegetables with Pureed Bread.
On 9/26/23 at 12:19 PM, V9, Cook, used a Number 16 Scoop to plate two scoops of Pureed Ham and Bread and two scoops of Pureed Vegetables and Bread on R1's plate.
On 9/28/23 at 11:44 AM, V20, Registered Dietitian, (RD), stated, That's not right. They shouldn't be using the blue scoop for lunch or dinner meals. I set up the menus that way to make sure the portions are correct. The blue scoop is only used for breakfast. If they got what was listed on the menu, they should not be losing weight.
On 9/28/23 at 2:03 PM, V1, Administrator, stated, she expects dietary staff to use scoop sizes listed on the menu and follow their food service policies.
On 9/29/23 at 9:00 AM, V23, Nurse Practitioner, (NP), stated, she expects Facility staff to follow dietary orders and provide appropriate serving sizes.
The Facility's Serving Utensils Portion Guide documents, the size of a Number 16 scoop is ¼ cup. The Facility's Week 1 Tuesday Lunch portion for Mechanical Soft and Pureed Diets is ½ cup.
The Facility's Therapeutic Diet Orders Policy revised 7/5/23 documents, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.
The Facility's Nutritional Management revised 7/5/23 documents, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.

Based on observation, interview, and record review, the Facility failed to ensure resident menus and appropriate serving sizes were followed in 4 of 4 residents reviewed for therapeutic diets in the sample of 25.
Findings include:
1-The Facility's Dietary Order Listing Report printed 9/28/23 documents, R16 has been on a Regular Diet with Mechanical Soft Texture and Nectar Thick Liquid Consistency since 12/29/22.
R16's Dietary Card from 9/26/23 Lunch documents, R16 was on a Mechanical Soft Diet with Nectar Thick Liquids.
The Facility's Week 1 Tuesday Mechanical Soft Lunch documents, the entrée was ½ c, (cup), Ground BBQ, (Barbecue), Pork Steak with ½ c Creamed Corn.
On 9/26/23 at 12:05 PM V9, Cook, used a Number 16 Scoop to place one scoop of Ground BBQ Pork Steak and one scoop of Creamed Corn on R16's plate. V9 stated she did not know the scoop number or the portion size.
2-The Facility's Dietary Order Listing Report printed, 9/28/23 does not list R9 as having a diet ordered.
R9's Dietary Card from 9/26/23 Lunch documents, R9 was on a Mechanical Soft Diet.
The Facility's Week 1 Tuesday Mechanical Soft Lunch documents, the entrée was ½ c Ground BBQ Pork Steak.
On 9/26/23 at 12:10 PM, V9, Cook, used a Number 16 Scoop to place one scoop of Ground BBQ Pork Steak on R9's plate.
3-The Facility's Dietary Order Listing Report printed 9/28/23 documents, R26 has been on a Regular Diet since 11/28/22.
R26's Dietary Card from 9/26/23 Lunch documents, R26 was on a Mechanical Soft Diet.
The Facility's Week 1 Tuesday Mechanical Soft Lunch documents, the entrée was ½ c Ground BBQ Pork Steak.
On 9/26/23 at 12:17 PM, V9, Cook, used a Number 16 Scoop to plate one scoop of Ground BBQ Pork Steak on R26's plate.
4-The Facility's Dietary Order Listing Report printed 9/28/23 documents, R1 has been on a Regular Diet with Pureed Texture since 4/6/23.
R1's Dietary Card from 9/26/23 Lunch documents, R1 was on a Puree Diet with Double Portions.
The Facility's Week 1 Tuesday Pureed Lunch documents, entrée was ½ c Pureed Ham with Pureed Bread and ½ c Pureed Mixed Vegetables with Pureed Bread.
On 9/26/23 at 12:19 PM, V9, Cook, used a Number 16 Scoop to plate two scoops of Pureed Ham and Bread and two scoops of Pureed Vegetables and Bread on R1's plate.
On 9/26/23 at 12:25 PM, V7, Dietary Manager, stated, she would have to call the company to see what the Number 16 Scoop measures. She stated, It does look small, so we would probably need two scoops.
On 9/28/23 at 11:44 AM, V20, Registered Dietitian, (RD), stated, That's not right. They shouldn't be using the blue scoop for lunch or dinner meals. I set up the menus that way to make sure the portions are correct. The blue scoop is only used for breakfast.
On 9/29/23 at 9:00 AM, V23, Nurse Practitioner, (NP), stated, she expects facility staff to follow diet orders and recommended serving sizes.
On 9/28/23 at 2:03 PM, V1, Administrator, stated, she expects dietary staff to use scoop sizes listed on the menu and follow their food service policies.
The Facility's Serving Utensils Portion Guide documents, the size of a Number 16 scoop is ¼ cup. The Facility's Week 1 Tuesday Lunch portion for Mechanical Soft and Pureed Diets is ½ cup.
The Facility's Therapeutic Diet Orders Policy revised 7/5/23 documents, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a Physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, interview, and record review, the facility failed to reconcile controlled medications to enable an accurate accounting of controlled medications in a timely manner for 1 of 1 resident in the sample of 25.
R2's Face sheet documents admission date of 4/24/2023. Diagnosis includes Chronic Obstructive Pulmonary Disease, Vitamin D deficiency, Insomnia.
R2's Minimum Data Set, MDS, documents R2 has no cognitive deficits and is independent with Activities of Daily Living, ADLs.
R2's Care Plan dated 8/14/2023 documents R2 has pain. Interventions include Anticipate R2's need for pain relief.
R2's Order Sheet dated 6/8/2023 documents Tramadol HCL 50mg. Give 1 tablet by mouth every 8 hours as needed for back pain until 6/15/2023.
Facility Incident Report dated 6/12/2023 documents, June 11th, 2023, at approximately 10:00PM, V2, Director of Nursing, DON, was notified by V14, Licensed Practical Nurse, LPN, that R2's card of 18 Tramadol was missing. June 12th all Nurse Managers looked for medications and medication could not be accounted for. Mascoutah Police notified of missing medication, (report number 23-1363). Investigation initiated.
All Nurses have been interviewed twice. The medications were not accounted for. A report has been made with the Mascoutah Police and they have interviewed a few of the Nurses. An in service was completed on 6/14/2023 at 10:00AM with the nurses on medication storage, medication delivery and abuse. V24 the Pharmacy rep came out on 6/14/2023 and did a medication audit and watched Nurses do medication pass. On 6/14/2023 V15, LPN, received the stat safe medications and left them on the Nurse' Station desk. She did not count the medication with another staff member or put away the medications away per facility policy. V15 has been terminated from employment with facility, related to not following policy and procedure.
On 6/12/2023 Mascoutah Police Department Offense/Incident Report documents, a call was received from V1, Administrator, regarding stolen property. V16 Police Officer, and V17 Police Officer, investigated and interviewed staff. According to Police Report as of 7/24/2023 the Mascoutah Police Department, had failed to be provided with the requested information from V1 regarding this investigation. Due to a lack of information, this investigation is closed.
On 9/28/2023 at 2:00PM V1, Administrator, stated, I expect the nurse and the courier to both count, complete the forms, and put the meds away.
On 9/28/2023 at 11:00AM V2, DON stated, when the meds came in from Pharmacy on 6/11/2023 V15, LPN, signed the meds in. Then V15 allegedly took the card of Tramadol and the manifest. Because the manifest was gone too, no one knew to look for the Tramadol. On Monday 6/12/2023 R2 was out of Tramadol. We called the Pharmacy and Pharmacy said, it was already sent. We then began searching all over for the missing Tramadol. That's how we realized the Tramadol had been taken. V15 is who had access to the Tramadol and the manifest. She was let go then.
On 9/28/2023 at 1:55PM V14 stated, when the courier brings the meds, we make sure they match up with the manifest. The courier and one of the nurses both counts. We sign in the narcotics first. Two nurses sign for the narcotics.
Facility medication policy with a date of 12/2021 states On a routine basis, the Consultant Pharmacist and Consultant Nurse will verify the quantities on hand and the usage of all Schedule II medications in the facility. If a discrepancy is discovered, the Consultant will immediately notify the Director of Nursing and the Administrator. The Pharmacist will assist them in implementing a control procedure. The Controlled Substance Proof of Use Form will also be signed by two nurses at shift change, after they both have physically counted the amount remaining. Both signatures will go in the name of person giving column and the date and time filled in. Schedule II controlled substances shall be stored in such a manner so that two separate locks, using two different keys, must be unlocked to obtain these substances. This may be accomplished by using a locked cabinet within a locked room.