Galena Stauss Nursing Home

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident's (R1) allegation of sexual abuse to Illinois Department of Public Health (IDPH) and local law enforcement. This applies to 1 of 3 residents reviewed for abuse reporting in the sample of 3.The findings include:R1's electronic face sheet printed on 3/26/26 showed R1 has diagnoses including but not limited to congestive heart failure, type 2 diabetes, Alzheimer's disease, dementia with behaviors, major depressive disorder, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 refused to have her cognitive status assessed. During interview with R1 on 3/26/26, surveyor determined R1 is alert and oriented to person, place, and time.R1's care plan dated 12/18/25 showed, (R1) does have an Alzheimer's dementia diagnosis and does report experiencing visual hallucinations as well as long held delusions. (R1) does experience agitation and has displayed combative behaviors; however, her behaviors have improved greatly over the past quarter.R1's progress notes dated 3/19/26 showed, A few minutes after 0600-CNA came up to this nurse to report what (R1) had told her just now. (R1) said she only got changed once during the night. This is untrue, nurse knows she was changed at least twice by night shift CNA (Certified Nursing Assistant). (R1) then stated that (V9-CNA) isn't allowed in her room because she molested me .On 3/26/26 at 9:40AM, R1 stated, There was a girl who didn't want to answer my call light but she's fine now. I'm not going to tell you who it was because she has been really good and taking care of me. It wasn't a big deal; I just wanted you guys to know when it was happening. She molested me too . Surveyor attempted to talk to resident about including Ombudsman with her concerns but resident declined further discussion.On 3/26/26 at 10:41AM, V6 (Social Services) stated, From what I was told, (V9) and the other aide were toileting (R1) and when she was getting up from being cleaned up (V9) pinned her against the wall and was looking at her while cleaning her up. We did do an investigation and there were no findings. It depends on the day with (R1) and if she is getting along with us or not if she is going to make any accusations or not.The facility's investigation dated 3/19/26 showed, Accusation: (V9) molested (R1). This was voiced by the resident. Actions Taken: Spoke with (V9) and (V8-CNA) who are the aides on that shift. They gave their statements/reports. Based off of this, the claims made against (V9) have been unfounded and non-credible . No documentation was present in the facility's investigation showing that local police or IDPH were notified of R1's allegations.On 3/26/26 at 12:14PM, V9 stated, The first time (R1) alleged I did something was in February, I think. I made a statement and the facility has it. I was just told I shouldn't take care of her anymore. I don't think there was any investigation or anything like that. I haven't had contact with (R1) since that time. I do not go in her room even with other staff.On 3/26/26 at 12:49PM, V1 (Administrator) stated, I am the abuse coordinator for the facility. Normally this would be something I would report but this has been an ongoing situation that we weren't sure was a new allegation or something from her previous allegations she made. (R1) initially made the allegations back in January but then she said something again last week, so we weren't sure if this was a new allegation or still something from before. We did not report anything in January either. If we reported everything (R1) alleged against staff, you guys would be here all the time.The facility's undated policy titled, Abuse Prevention Policy & Procedure showed, It is the policy of the facility that all residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. It is our mission to ensure the maximum safety, sense of security, and quality of life for each of our residents. The abuse coordinator and abuse prevention committee members are responsible for the implementation of this policy to ensure the safety of each of our residents .Reporting of Abuse: It is our policy to report all incidents of abuse. If the reporter is unsure an incident meets the definition of abuse, our policy is to report .All abuse incidents shall be reported to the state no later than 24 hours after the incident occurs .A full completed investigation shall be reported within 5 days of the incident .Sexually Based Incidents: All sexually based abuse incidents shall be investigated. If the resident lacks decision making or the committee suspects lack of decision-making ability, the incident shall be investigated as an abuse incident to determine the victim and alleged perpetrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to schedule a follow up dental visit for a resident (R1) experiencing oral pain. This applies to 1 of 3 residents reviewed for quality of care in the sample of 6. The findings include:R1's electronic face sheet printed on 3/11/26 showed R1 has diagnoses including but not limited to congestive heart failure, Type 2 diabetes, Alzheimer's disease, major depressive disorder, hypertension, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and experiences delusions.On 3/10/26 at 12:56PM, R1 stated, I went to the dentist last month and they said I need 4 teeth extracted on the top of my mouth. They didn't do any x-rays or cleaning. Ibuprofen helps with the pain and takes it all away. When I went to the hospital they gave me antibiotics but I had a reaction to it. They said maybe I had an infection and that's why it was hurting so they ordered an antibiotic to cover it. I had a follow up appointment scheduled last week, but the facility turned the transportation away because I didn't have anyone to go with me. I don't feel like I need anyone to go with me. I don't know what the plan is to get me to the dentist.R1's medication administration notes dated 2/1/26-3/11/26 showed R1 utilized Ibuprofen and Tylenol 15 times for oral pain. 10 of the 15 occurrences were between 2/20/26 and 3/11/26.R1's dental visit note dated 2/19/26 showed, Patient presents for limited exam for upper anterior tooth pain. Took PA (periapical) for #10 per doctor. Doctor noted #10 all surface decay with PARL (Periapical Radiolucency). Doctor recommends #10 be extracted with oral surgeon. Patient noted she would like sedation and referred to (local oral surgeon). Patient accepted referral. Doctor recommends to return for full exam as other teeth need to be addressed .Advised patient seek comprehensive care and return for evaluation of other areas as soon as possible .On 3/10/26 at 10:13AM, V5 and V6 (Registered Nurses) stated, We use (local transportation company) if a resident doesn't have family to escort them to appointments. The company requires either family or staff to ride to all appointments so if there isn't family or a staff member to escort the resident, we have to reschedule the appointment. That has happened a few times but nothing major. (R1) does not currently have any follow up dental appointments. V5 stated, I worked last week and nobody told me (R1) had an appointment. The morning of her appointment we asked (V4-Transportation) who was riding with her. She said nobody could go with her alone because she accuses staff of things. I asked why 2 people couldn't ride with her but in the meantime, someone said her appointment was cancelled. (R1) was looking for transportation and ended up calling 911 to see if the ambulance can take her. She can't ride alone because she has Dementia. The ambulance ended up showing up and taking her and (V1-Administrator) said she was being sent out for a psychiatric evaluation, but the hospital didn't do one. They just gave her an antibiotic because of her mouth pain.On 3/10/26 at 10:47AM, V4 (Transportation) stated, I get notified by the nurses or family or whoever makes the appointments that a resident either needs transportation or if family is taking them. If they come back with any follow up appointments I set up transportation and sometimes family will cancel transportation and take the resident on their own. (Transportation company) requires someone to ride with the resident and that can be a struggle if family can't ride with. I do a lot of ride alongs with residents. From what I understand, (R1) called and set up a dental appointment and set up transportation on her own. The day of the appointment we didn't have anyone that could ride along with her. We had to cancel but the week prior she went to an appointment with a friend. I had set up transportation for her and then her friend was going to ride with, but when they showed up she had already left with her friend in her personal car. We called the dentist because she had been gone all day and didn't return until about 4pm. She did make it to the appointment. Last week would have been a follow up from that prior appointment. They were going to follow up on her sore tooth and have a cleaning. Last week she called 911 to take her to the dentist but they took her to the hospital. They wanted a psychiatric evaluation done because they said she shouldn't be calling 911. I don't remember who said it but it was someone in administration here. There is no plan to reschedule that visit because she didn't give us any paperwork when she came back from the 2/19 appointment, so we aren't sure what even really needs to be done.On 3/10/26 at 12:46PM, V3 (Social Service Director) stated, (R1) was supposed to take arranged transportation to her dentist appointment on 2/19 but left with her friend without taking any paperwork and then came back with nothing. We don't know what was done or what follow up was needed because she refused to take the paperwork. I'm not aware of any further appointments that she has.On 3/10/26 at 1:32PM, V1 (Administrator) stated, I'm not sure what is happening with (R1's) dental appointment. I think it was just for a cleaning so I don't think it needs to be rescheduled. She left with her friend and came back with no paperwork on the 19th and then all of a sudden transportation showed up here on the 4th to transport her, but we had no staff members to ride with her. The appointment has not been rescheduled and to my knowledge it won't be.On 3/10/26 at 3:25PM, V7 (Dentist office scheduler) stated, (R1) came in on February 19th for an urgent care appointment. We did tell her she needed oral surgery. We took a PAN (Panoramic x-ray) of the tooth and the dentist noted decay. We gave her a referral for oral surgery because the teeth need to come out. She was a no-show for her appointment on March 4th and we haven't heard anything from her or the facility about rescheduling.On 3/11/26 at 11:12AM, V2 (Director of Nursing) stated, If a resident returns to the facility after an appointment without paperwork, I would expect the nurses to call and follow up on the appointment and see if there were any orders or follow up appointments needed. If (R1) had a follow up appointment scheduled and we weren't able to get her transported there then we should have rescheduled that appointment.The facility's undated policy titled, Resident Appointments showed no guidance on what staff members should be doing if a resident returns from an appointment without paperwork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample 3.
The findings include:
The facility's Incident Report dated 10/13/24 documents R1 was groping R2's breast. V7 (Agency CNA-Certified Nursing Assistant) witnessed R1 groping R2's breast in the dining room.
R1's face sheet shows he is an [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, atrial fibrillation, major depressive disorder and metabolic encephalopathy.
R2's face sheet shows she is a [AGE] year-old female with diagnoses including ischemia cardiomyopathy, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, heart failure, aphasia, and dementia.
On 10/16/24 at 9:38 AM, R1 was observed in his room lying in bed. He was alert to self, he was confused to the month and year. R1 could not recall the incident with R2.
On 10/16/24 at 10:07 AM, R2 was observed in the sunroom sitting in her wheelchair with a flat affect. She responded to her name but could not answer questions.
On 10/16/24 at 2:55 PM, V7 said she was entering the dining room. R1 and R2 were both in their wheelchair's sitting next to each other. R1's hand was groping R2's right breast, he was touching and squeezing her breast. R2 sat there and did not say anything. R2 was not wearing a bra under her shirt and is well endowed. R1 was definitely foundling R2's breast. She told R1 not to touch other residents and removed him from the table. She reported the incident to V4 (LPN-Licensed Practical Nurse).
On 10/16/24 at 12:15 PM, V4 (LPN) said she was in the dining room preparing medications around 4:30 PM to 5:00 PM. R1 was in the dining room in his wheelchair. She saw R1 using both feet self-propelling towards R2 with a purpose. R2's back was facing her and R1 was positioned next to R2. She continued to prepare her medications and saw V7 leaning towards R1 and removing him from the table. V7 then reported R1 was groping R2's breast. R1 and R2 knew each other from the community and knows R1 recognizes R2. R1 is alert to self, forgetful, he had a stroke and has limitations to his left side. He is on hospice and has declined. R2 is aphasic and does not communicate her needs, she seemed hesitant after the incident.
On 10/16/24 at 10:30 AM, V10 (CNA) said R1 is forgetful and normally has no issues. She has seen R1 sit next to R2 talking to her in the past. They are both from this area and not sure if they know each other from the community.
On 0/16/24 at 12:05 PM, V1 (Administrator) said she was notified about the incident that evening. V7 witnessed R1 groping R2's breast and reported the incident. She was surprised because it was unusual behavior for R1, none the less it was inexcusable. I don't think it's intentional abuse.
R2's care plan dated April 2024 shows she has impaired cognitive function, has difficulty making decisions, following direction, has expressive aphasia related to a stroke. R2 is dependent on staff for meeting her emotional, intellectual, physical and social needs related cognitive deficits and physical limitations.
The facility's Abuse Prevention Policy states, It is the policy of this facility that all residents will be free from abuse, neglect .sexual abuse of a resident by a staff member, another resident, or a visitor. Sexual abuse includes but is not limited to sexual penetration, intentional sexual touching without permission or ability to consent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident (R40) from a significant medication error. This applies to 1 of 8 residents observed in the medication pass.
The findings include:
R40's electronic face sheet printed on 10/2/24 showed R40 has diagnoses including but not limited to type 2 diabetes, venous insufficiency, chronic kidney disease, and acute embolism and thrombosis of left lower extremity.
R40's facility assessment dated [DATE] showed R40 has no cognitive impairment, has diabetes, and receives insulin.
R40's care plan dated 6/11/24 showed, (R40) does have a diagnosis of diabetes mellitus. Diabetes medications as ordered by doctor.
R40's physician's orders dated 9/21/24 showed, Lantus Subcutaneous Solution (Insulin Glargine) Inject as per sliding scale: If 100-280= 10 units morning and bedtime; 281-500= 25 units morning and bedtime. Follow same orders for noon and evening blood sugar.
On 10/1/24 at 11:56AM, V5 (Licensed Practical Nurse-LPN) stated, (R40's) blood sugar is 238 so she has asked me to give her 15 units of her Lantus insulin. She chooses what amount of insulin she gets; she always has when she has been in the facility. We have an order for sliding scale, but she won't follow it, so we allow her to choose her dose. (R40 should have received 10 units of insulin with this blood sugar reading).
On 10/1/24 at 2:00PM, R40's MAR (medication administration record) had no documentation that R40 had received 15 units of insulin, nor was there any area for staff to be able to document the medication administration.
On 10/1/24 at 2:04PM, V5 (LPN) stated, (R40) came from home & she's always done this where she decides what dose of insulin she gets. Under the order it doesn't give you the option to chart on the noon and evening dose so that isn't documented anywhere. The dose I gave earlier isn't documented, but I guess I should enter a progress note so that it's documented how many units she received. She used to have an order for her to be able to get a total of 20 units sliding scale every day, but the doctor discontinued that. We have still been working off the discontinued order, but we just don't have a spot to document it in. That is definitely a problem because she could get too much insulin if we don't keep track of how much she has had. She's pretty with it though so she would probably tell us. I called her physician last week and told him about her refusing to comply with the dose, but I don't call him every time to get approval to give her the dose she wants.
On 10/2/24 at 12:32PM, V2 (Director of Nursing) stated, (R40's) physician knows her history and knows she refuses the sliding scale the way it's supposed to be given. I wouldn't expect the nurses to call the doctor every time she refuses the sliding scale, they should just give it the way she wants it. Technically, we should have an order but that's how she does it at home, so we let her do it the same way. If the nurse's give any medications and there is nowhere to document it on the medication administration record then they should at least enter a progress note. It is not my expectation for them to just not document anything because then we don't know how much insulin she is receiving.
The facility's undated policy titled, Medication Administration/Control of Medications showed, Objectives: 2. To identify policies for storage, dispensing and disposal of medication and controlled substances. 3. To establish safe and accurate nursing procedures for dispensing medications to residents .Procedure: 1. The nursing facility will comply with federal and state laws and regulations relating to the procurement, storage, dispensing, administration, and disposal of medications .15. If for any reason a physician's medication order cannot be followed, a notation shall be made on the resident's record describing the circumstances. The physician shall be notified .
The facility's undated policy titled, Insulin Injection Administration showed, Procedure: 1. Check prescriber's order .6. Prepare injection as follows: a. Determine correct amount of insulin to be withdrawn. b. Read MAR again and compare with label on medication .i. Check medication label with MAR a third time .17. Document administration on MAR. 18. If resident refuses medication, indicate on MAR by initialing in appropriate space and circling initial .

Based on interview and record review the facility failed to have licensed staff administer medicated powder. The applies to 1 of 1 residents (R10) reviewed for pharmacy services in the sample of 13.
The findings include:
R10's 7/11/24 Physician Communication note from 2:09 PM showed Situation: resident red/yeasty groin.
R10's Order Summary Report (Physician Order Sheet) showed an order for Nystatin Powder, apply to groin topically as needed for excoriated areas in groin. The order was started 7/11/24.
R10's 7/16/24 skin/wound note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam dressing]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor.
R10's 7/20/24 skin/wound note from 10:51 AM showed, AM CNA (Certified Nursing Assistant) put treatment powder to [R10's] buttocks. This RN (Registered Nurse) unable to view as he is in the recliner chair. Will attempt to look at it when he is toileted if I am not with another resident.
On 10/02/24 at 2:07 PM, V2 Director of Nursing stated nystatin powder is used to treat fungal infections. V2 stated the warm moist environments, such as the groin and skin folds are prone to fungal infections. V2 stated nystatin is a medication and only nurses are allowed to administer nystatin powders. V2 stated the fungal powder should not be used to treat MASD (Moisture Associated Skin Damage] or pressure injuries. V2 stated based on the note a CNA administered the medicated powder and applied it the buttock wound instead of the groin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident oxygen tubing was replaced monthly for 2 of 4 residents (R7, R24) reviewed for oxygen in the sample of 13.
The findings include:
1. R7's face sheet showed an [AGE] year-old female with diagnosis of obstructive sleep apnea, osteoporosis, heart failure, chronic kidney disease stage 3, fibromyalgia, and hypertension.
On 10/01/24 at 09:26 AM, R7 was seated in her room. R7 had an oxygen tubing in her nostrils. The oxygen was administered at 3 liters (l) per hour per nasal cannula (nc) via concentrator. There was no date on the tubing to indicate how long it was in use.
On 10/1/24 at 9:26 AM, R7 said she wears her oxygen all the time.
On 10/02/24 at 11:41 AM, V3 Infection Preventionist said it is important to change oxygen tubing monthly to avoid moisture and bacteria buildup. There should be a physician order on the care and maintenance of the tubing, so it populates to the resident treatment or administration record. We can't ensure the tubing was changed if there's no documentation. If oxygen tubing is not changed, you risk compromising equipment by overuse, can cause respiratory issues for the resident and other adverse effects.
The facility's undated Oxygen Administration & Respiratory Therapy Equipment Policy showed nasal cannulas and masks are changed on the last day of the month of each month, sooner if soiled, clogged or defective.
R7's September treatment administration record showed no documentation the oxygen tubing was changed.
R7's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment.
R7's POS showed a 9/4/23 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%.
R7 had no oxygen use care plan.
2. R24's face sheet showed a [AGE] year-old female with diagnosis of obstructive sleep apnea, anxiety disorder, chronic kidney disease, heart failure, hypertension, type 2 diabetes, and atrial fibrillation.
On 10/1/24 at 10:27 AM, R24 was seated in a recliner in her room. R24 had oxygen tubing in her nose and the concentrator was running at 2 liters per nasal cannula. There was no date on the tubing to indicate how long it was in use.
On 10/01/24 at 10:27 AM, R24 said her oxygen is on all the time except when showering or toileting.
R24's September 2024 treatment administration record (TAR) showed no documentation the oxygen tubing was changed.
R24's physician order sheet (POS) showed no current orders for changing or maintain the oxygen equipment.
R24 's POS showed a 1/26/24 order to administer oxygen at 2 liters as needed to keep oxygen saturation greater than 90%.
R24 had no oxygen use care plan.

Based on observation, interview, and record review the facility failed to assess a pressure injury, failed to treat a pressure injury, and failed to notify the physician of a pressure injury. This applies to 1 of 2 residents (R10) reviewed for pressure injuries in the sample of 13.
The findings include:
On 10/02/24 at 10:15 AM, V4 Registered Nurse (RN) removed R10's adult brief exposing an approximately 1-centimeter (cm) round, non-draining, wound to his right, upper, inner buttock. The area surrounding the wound appeared friable and inflamed. V4 provided a wound treatment and covered the wound with a 4-inch foam dressing.
R10's 8/6/24 Skin/Wound Note from 6:58 PM showed, New [foam dressing] placed on upper gluteal crease. Dated for today. Area of concern is clean, no drainage, looks to be a stage 2 [pressure injury].
R10's 8/6/24 Skin/Wound Note from 7:02 PM showed, Wound measures: 0.8cm x 0.4cm, depth is approximately 2mm (millimeter).
R10's 8/9/24 Skin/Wound Note from 8:49 PM showed, [Foam dressing] changed to upper gluteal crease. One open area remains, 0.5cm in diameter, 0.2cm in depth.
R10's next documented skin/wound note assessment with wound measurements showed on 8/20/24 at 1:17 PM, (11 days after 8/9/24 assessment) Assessed [R10's] pressure injury while he was laying on his right side in bed. Pressure injury to the top of the gluteal crease on the right side: Measurements: 4mm long, 3mm wide and 1mm deep. Scant amount of yellowish drainage on the [foam dressing] placed by [Licensed Practical Nurse] today 8/20. Wound bed with granulation tissue at the edges, is filling in nicely. Cleansed with sterile normal saline and placed a new [foam dressing] on; dated and initialed. I thanked [R10] for laying in bed.
R10 8/23/24 Skin/wound note from 2:16 PM showed, With the patient lying on his right side in bed, I donned a gown and put gloves on after washing my hands. I undid his brief. The area of concern is on the right upper inner buttock just off the gluteal fold. The area is improved since the last time this writer has seen it. Wound Measurements: 1.0cm long, 0.4cm wide and 0.1cm deep. The edges appear to be macerated and I can see granulation tissue in the small wound bed. I cleansed it with sterile normal saline and placed a new dated/initialed [foam dressing] on the area. I left the resident on his right side and he said he was going to nap. (Documented wound improved despite wound size increasing.)
R10's 8/26/24 skin/wound note from 2:14 PM showed, Had to encourage [R10] to lay down in bed on his side to offload from his pressure ulcer. I then was able to perform wound care/assessment. Wound to the right upper inner buttock about 3 centimeters above the anus: Wound now measures 1cm long x 0.4cm wide and about 0.1cm deep. The edges of the wound are macerated, the wound bed is granulation tissue. No drainage, no odor. Area cleansed with sterile normal saline. Then applied a larger [foam dressing] to the buttock and I dated/initialed it. Around this wound is several reddened areas 1cm round. No open areas. This [foam dressing] covers all the areas.
R10's next documented wound assessment was on 9/4/24 a 1:20 PM (9 days later). The note showed the wound was completely healed and no new open areas.
R10's August and September 2024 Medication Administration record, Treatment Administration Record, and physician orders sheet showed there were no physician prescribed treatments for R10 pressure injury and no documented treatments were applied.
On 10/02/24 at 2:07 PM, V2 Director of Nursing stated wound assessments should be done weekly and should include measurements, wound bed descriptions, and drainage descriptions. V2 said the purpose of wound assessments are to track the progression of a wound and to determine if treatments are effective. V2 said the purpose of physician prescribed treatments are to promote wound healing and prevent infection. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 said there were not documented wound treatments apart from foam gauze treatments in the R10's progress notes. V2 said R10's provider and family should have been notified of the wounds when they were identified.
R10's Skin/wound note from 9/11/24 showed (A new wound following the 9/4/24 note when R10's wound was healed), Assessed [R10's] buttocks while on the sit-to-stand (mechanically assisted sit-to-stand lift) from the toilet. On the left upper inner buttock, he has 2 areas of concern: Wound measurements (rough measurement as I had little time to properly measure): Wound #1 0.3cm in diameter, depth approximately 0.1 cm, wound bed beefy red, shallow. Wound #2 is next to it and measures approximately 0.2cm, depth approximately 0.1cm, wound bed beefy red. Wound beds are clean, no drainage. Applied [a gauze foam] after cleansing the area with sterile saline, initialed and dated it. Discussed with the resident [R10] about getting off of his buttocks in the afternoon and laying in bed. He was not happy about that but does verbalize understanding. (No documented provider or family notification.)
R10's 9/17/24 skin/wound note from 10:47 AM showed, I assessed [R10's] skin in the shower room. His wound on the right upper inner buttock is healing nicely. It is down to one area, approximate measurements (the resident was on the sit-to-stand) was: 0.4cm in diameter and depth less than 0.1cm. The wound bed is almost healed over. [foam dressing] place, dated and initialed.
R10's next documented wound assessment, following the 9/17/24, was documented on the 10/2/24 at 10:45 AM (17 days later). The skin/wound note showed, above observation, on 10/2/24 AM at. The skin/wound note showed, the wound care was observed by the state surveyor and R10's spouse. The note showed, .Wound: #1 Area measures 0.5cm in diameter and is approximately 0.1cm deep, . The wound bed was pink, no drainage. Just above this wound was unopened wounds #2 and #3, they are at the 11 o'clock position and at the 11:30 position and about 1cm from wound #1. These are healed over .
R10's Order Summary Report (Physician Order Sheet) showed an order for [Foam] pad. Apply to coccyx/buttock topically as needed for MASD (Moisture Associated Skin Damage) to area on coccyx/buttock change every 2-3 days as needed. This was ordered and started on 9/27/24.
R10's September 2024 Medication Administration Record (MAR) showed no documented wound care on 9/27/24, 9/28/24, 9/29/24, or 9/30/24. R10's MAR dressing change was listed only under the as needed section of the MAR.
R10's progress notes from 9/27/24 through 10/1/24 showed no documented dressing changes.
On 10/02/24 at 2:07 PM, V2 Director of Nursing stated there are no documented assessments for R10 following the 9/17/24 assessment and before the 10/2/24 assessment. V2 stated R10's pressure wound should have been assessed during this time period. V2 stated it is the floor nurses' responsibility to assess wounds and it appears as only one nurse was doing R10's assessments. V2 stated the physician and family should be notified whenever a wound develops, and orders should be obtained. V2 said R10 did not have any physician orders for wound treatment until 9/27/24. V2 stated R10's pressure ulcer dressing change order was poorly written and reads as if it should only be changed as needed instead of being completed every 2 to 3 days and as needed. V2 stated the order was listed under the as needed section of the MAR and there are not documented dressing changes from 9/27/24 until 10/2/24.
The facility's undated Prevention and Intervention of Skin Breakdown policy showed, .3. If the resident has a pressure ulcer, the nurse shall complete the Wound Assessment initially in [the electronic charting]; notification of physician and family, along with treatment order/s and monitor wound in Treatment Book until healed. 4. The treatment of a pressure ulcer or wound should be determined by stage, size, location, drainage, presence of necrotic tissue, and infection status based on facility's wound care protocol and physician approval. 5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up .

Based on observation, interview, and record review the facility failed to store 2 residents (R9,R12) controlled medications under a double lock system. This applies to 2 of 2 residents outside of the sample reviewed for controlled medication storage.
The findings include:
R9's physician's orders dated 9/23/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for agitation .
R12's physician's orders dated 9/21/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for anxiety .
On 10/3/24 at 10:00AM, V6 (Licensed Practical Nurse) unlocked the medication room and opened the medication refrigerator that had no lock on it. Inside of the medication refrigerator were 1 unopened and 1 partially used bottle of lorazepam with R9's name on them. Another partially used bottle was in the refrigerator with R12's name on it. R9 and R12's lorazepam bottles were not under any additional locks in the medication refrigerator.
On 10/3/24 at 10:05AM, V6 stated, Lorazepam has always been stored in this refrigerator and we have never had a double lock on it. I don't think we need to have it double locked, but I could be wrong.
On 10/3/24 at 11:34AM, V3 (Infection Preventionist) stated, All controlled medications in the medication room are to under a double lock system. There should either be a lock on the medication refrigerator door or the controlled substances could be in a locked container in the refrigerator. We do not have either of these and I guess I never thought about it until you asked. This will help prevent diversion of these medications and ensure only the residents that they are ordered for are who receives them.
The facility's undated policy titled, Storage of Medications showed, Objective: The facility stores all drugs and biologicals in a safe and secure and orderly manner .12. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Security access to controlled medication is separate from access to non-controlled medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess non-pressure wounds, failed to have treatments in place for wounds, and failed to notify the physician of new wounds. This applies to 2 of 2 residents (R10 & R41) reviewed for wound care in the sample of 13.
The findings include:
1. R10's admission Record (Face Sheet) showed he was admitted to the facility on [DATE].
R10's 7/11/24 Skin/Wound Note from 6:45 PM showed, Dime size areas noted on coccyx (tail bone area) with cares. Area cleansed and [protective ointment] applied for MASD (Moisture Associated Skin Damage). (The note does not document a wound bed description, measurements, or if any notifications made.)
R10's 7/16/24 Skin/Wound Note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam bandage]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. (Five days after wound was first identified.)
R10's 7/20/24 Skin/Wound Note from 6:49 PM showed the wound was closed.
R10's 7/21/24 Skin note from 8:00 PM showed, Resident with open area in the crease of buttock.
R10's July, August, and September 2024 Medication Administration Record and Treatment Administration Record showed no treatment orders for his buttock/coccyx area until 9/27/24.
On 10/02/24 at 2:07 PM, V2 Interim Director of Nursing stated when wounds are identified, the floor nurse will assess the wound, which includes measurements of the wound, drainage description, and wound bed description. V2 said the floor nurse will then apply a treatment and notify the resident's provider and family. V2 said the nurse should inform them of what was identified and request orders from the provider. V2 said the purpose of assessments are to track the progression of the wound to determine if the wound is improving or declining. V2 said the purpose of wound treatments is to prevent infection and promote healing. V2 said R10's wound charting is poor and difficult to follow. V2 said the provider was notified of the wound on 7/16/24; however, he/she did not respond, and the nurse did not follow up. V2 said the provider should have been notified on 7/11/24. V2 said R10 did not have treatment orders until 9/27/24.
The facility's undated Prevention and Intervention of Skin Breakdown policy showed, .3. If a skin tear or breakdown occurs, an assessment shall be completed under symptom assessment in [the electronic charting]; notification of physician and family, along with any treatment order/s and monitor wound in Treatment Book until healed .5. Measurements of the pressure sore/wound shall be assessed at least once a week and documented in [the electronic charting] under Wound Assessment, follow-up .
2. R41's 7/13/24 Skin/Wound Note from 9:00 PM showed, A 2 cm (centimeter) x 2 cm open area showing the dermis (inner layer of skin) of the skin on the right buttock and there is a 1 cm x 1 cm open area showing the dermis of the skin on the left buttock. These areas show no signs of infection. [foam dressing] dressings applied for protection to these areas. Resident and staff instructed to reposition resident at least 2 hours to prevent future skin breakdown. This writer will notify the day nurse on 7-13-24 to notify [the physician] to obtain an order for dressing changes to buttocks and to notify resident's healthcare POA (Power of Attorney) of the information in this note.
R41's 8/3/24 Skin/Wound Note from 1:29 PM, showed, .The [foam dressing] is not intact to the bottom of the area .The area is completely healed, inspected his buttocks and could not find an open wound. I did replace the [foam dressing] and placed zinc oxide cream to the rest of the buttocks.
R41's electronic health records showed no documented assessments on or before 7/20/24 and 7/27/24.
On 10/02/24 at 2:07 PM, V2 Interim Director of Nursing stated wound assessments are important for tracking the progression of wounds. V2 said assessments will allow the nursing staff to identify if current treatments are effective. V2 said nursing staff should have assessed R41's wound on or before 7/20/24 and 7/27/24. V2 stated there were no documented assessments during this time period.

Based on interview and record review, the facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ).
This failure has the potential to affect all residents in the facility.
The findings include:
The facility's roster dated 10/1/24 showed 44 residents residing in the building.
The facility's PBJ report dated April 1-June 30, 2024 showed, Failed to submit data for the quarter.
On 10/2/24 at 10:03AM, V1 (Administrator) stated, I was made aware that this data was not submitted and there is no reason why. Our corporate staff usually submit it but for some reason they just didn't. We have already received our notification in the mail from IDPH (Illinois Department of Public Health) regarding this so I already knew about the issue. We don't have any policy regarding the PBJ reporting.

Based on interview and record review, the facility failed to implement their policy regarding Legionella management. This failure has the potential to affect all residents in the building.
The findings include:
The resident census report dated 10/1/24 showed 44 residents currently residing in the building.
On 10/3/24 at 9:38AM, V1 (Administrator) stated, I have been working with (hospital infection preventionist) on our policy but we don't have any plan set yet. We don't have any of the water management program done yet, just the hospital one. We have no diagrams, surveillance process, or testing process completed or initiated yet. If we had a Legionella outbreak, we would probably not have any idea of where to even start looking as we haven't implemented anything yet.
On 10/3/24 at 10:37AM, V3 (Infection Preventionist) stated, We have not done anything with legionella that I am aware of. I believe the plan is in process, but we haven't implemented anything yet.
The facility's undated policy titled, Legionella and Waterborne Pathogens Policy showed, Objective: I. To establish a water management program which reduces the risk of Legionnaire's Disease, Pontiac Fever, and other infections due to waterborne pathogens associated with the hospital water system. II. To establish a surveillance process and criteria for defining hospital acquired Legionella and other infections due to waterborne pathogens.

Based on observation, interview, and record review the facility failed to safely transfer a resident with a hoist mechanical lift, which resulted in the resident falling from the hoist and sustaining a cervical spine (neck) fracture. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of the 3.
The findings include:
R1's admission Record (Face Sheet) showed an original admission date of 1/31/23 with diagnoses to include partial left and right leg amputation; 2 diabetes; and mild cognitive impairment.
R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS showed R1 was depenedent upon staff for transfers from the bed to chair.
On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain.
On 9/3/24 at 9:05 AM, R1 was in her geri-chair with a cervical (neck) brace in place. R1's left temple had a faint blue/purple color similar to a nearly faded bruise.
R1's Serious Injury Incident Report submitted on 8/21/24 showed, CNA (Certified Nursing Assistant) report (V3) 8/12/24 - When transferring resident to the chair from bed with mechanical lift, resident leaned too far to the left and started to slip out. This CNA tried to brace the fall, but she still fell down .physician (V6 R1's physician) here to assess resident, 8/21/24, ordered x-ray at [local area hospital] hospital confirmed fx (fracture) of neck .
R1's 8/12/24 Fall During Staff Assist form (Authored by V7 Registered Nurse) from 11:22 AM showed, CNA [V3] came out of [R1's] room to have me come in. I found [R1] laying on her back on the floor. The floor was dry, her geri-chair (high-back reclining chair) was upright with the cushion in it.
R1's 8/13/22 Incident Note from 3:22 AM showed, .Resident states her neck was stiff. PRN (As needed) pain medication administered with HS (evening) pills. (Pills administered the evening of 8/12/24) .
On 9/3/24 at 1:06 PM, V3 CNA stated herself and V9 CNA were transferring R1 from the bed to her geri-chair on 8/12/24. V3 stated she was monitoring/handling R1 during the transfer and V9 was operating the hoist mechanical lift. V3 said R1 was partially suspended over the seat of her geri-chair and as she pulled R1 towards the back of the chair R1 fell out the left side sling and hit her head, neck, and shoulder on the floor. V3 said the mechanical lift sling has a strap at each of the four corners of the sling; two at the head and two at the legs, which are the attachment points for the sling to the hoist. V3 said R1 fell out the left side of the sling between the head and leg straps. V3 said, Nothing like this has happened before .I don't know if the sling was not positioned correctly. I don't know if she was leaning to the left because the sling was not positioned well. I don't think she was trying to lean and grab something . V3 said R1 began complaining of pain the next day after the fall.
On 9/3/24 at 11:30 AM, V9 CNA stated she was controlling the hoist mechanical lift for R1 on 8/12/24.She fell over the left arm rest and on to the floor. She went through the gap between the head strap and the leg strap, through that hole, over the left arm rest and onto the floor. She hit her head, shoulder, and neck area first . V9 said she did not work with R1 for a couple of days after the fall. V9 said the next time she worked with R1 she was complaining of neck pain with movement.
R1's 8/13/24 Incident Note from 11:08 AM showed R1 was reporting neck pain.
R1's 8/14/24 Incident note from 12:41 PM, showed R1 was reporting a sore neck.
R1's 8/18/24 Health Status Note showed R1 continued to experience neck pain with her hoist mechanical lift.
R1's 8/21/24 Leave of Absence note from 9:30 AM showed R1 left the facility for a neck X-ray.
R1's CT cervical spine scan from 8/21/24 showed, Impression: Acute (recent onset) nondisplaced fracture of the odontoid process (a specific appendage of the cervical spine) .
On 9/3/24 at 2:20 PM, V6 R1's Physician stated, Cervical fractures present as pain. I was concerned about a fracture, which is why I shot over there right away. They said the pain was moderate in nature .My concern with the neck pain, was that she had a cervical fracture as a result of her fall, which was the reason I had her sent out. She did have a cervical fracture . V3 said his expectation is the facility should be able to perform safe mechanical transfers. V3 said R1 has no diagnoses that would prevent her from being safely transferred with a hoist mechanical lift.
On 9/3/24 at 2:00 PM, V8 CNA stated R1 is a stable and safe transfer resident. V8 stated she could not think of any reason, other than improper sling placement, which would cause R1 to fall out of the sling.
On 9/3/24 at 3:05 PM, V5 Registered Nurse (RN)/MDS/Falls Program stated, regarding R1's fall on 8/12/24, .My understanding is she (V3) was assisting with a transfer, and she (R1) was not properly placed in the sling If the [hoist mechanical lift] is used correctly it is our safest way to transfer her. If all the policies and procedures were followed correctly and she was positioned correctly, she (R1) should be able to be transferred without falling out of the [hoist mechanical lift]. The fall from the [hoist mechanical lift] caused the cervical fracture .
On 9/3/24 at 2:45 PM, V2 Director of Nursing stated, .If the CNAs are doing are everything correctly, there is no reason that [R1] should have fallen out of the sling. The only thing I can think of is that she was not positioned correctly. They way she fell out of the sling, as you describe it, is she was not positioned correctly in the sling. I have assisted with her transfers before, and she is generally very good during transfers and will follow our commands. Some days she may be more a little more confused. The sling and lift should be able to accommodate any movements she might make during the transfer
The facility's undated Safe Resident Handling and Transfer policy showed, .Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training .The sling is placed under the patient appropriately and the straps are hooked upon the spreader bar

Based on interview and record review the facility failed to notify R1's physician of new-onset neck pain following a fall from a hoist mechanical lift. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3.
The findings include:
R1's admission Record (Face Sheet) showed an original admission date of 1/31/23 with diagnoses to include partial left and right leg amputation; type 2 diabetes; and mild cognitive impairment.
R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.
On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain. R1 stated it took at least a week before she was sent out for X-rays following her fall. R1 stated she believed the facility should have notified her provider of the neck pain sooner than they did.
R1's Serious Injury Incident Report submitted on 8/21/24 showed, CNA (Certified Nursing Assistant) report (V3) 8/12/24 - When transferring resident to the chair from bed with mechanical lift, resident leaned too far to the left and started to slip out. This CNA tried to brace the fall, but she still fell down .physician (V6 R1's physician) here to assess resident, 8/21/24, ordered x-ray at [local area hospital] hospital confirmed fx (fracture) of neck .
R1's 8/13/22 Incident Note from 3:22 AM showed, .Resident states her neck was stiff. PRN (As needed) pain medication administered with HS (evening) pills. (Pills administered the evening of 8/12/24) .
On 9/3/24 at 1:06 PM, V3 CNA stated herself and V9 CNA were transferring R1 from the bed to her geri-chair (a high back reclining chair) on 8/12/24. V3 stated she was monitoring/handling R1 during the transfer and V9 was operating the hoist mechanical lift. V3 said R1 was partially suspended over the seat of her geri-chair and as she (V3) pulled R1 towards the back of the chair R1 fell out the left side sling and hit her head, neck, and shoulder on the floor. V3 said R1 began complaining of neck pain the following day (8/13/24).
On 9/3/24 at 11:30 AM, V9 CNA stated she was controlling the hoist mechanical lift for R1 on 8/12/24. V9 said she did not work with R1 for a couple of days after the fall. V9 said the next time she worked with R1, R1 was complaining of neck pain with movement.
R1's 8/13/24 Incident Note from 11:08 AM showed R1 was reporting neck pain.
R1's 8/14/24 Incident note from 12:41 PM, showed R1 was reporting a sore neck.
R1's 8/18/24 Health Status Note showed R1 continued to experience neck pain with her hoist mechanical lift.
R1's 8/21/24 Leave of Absence note from 9:30 AM showed R1 left the facility for a neck X-ray.
R1's CT scan of the cervical spine from 8/21/24 showed, Impression: Acute (recent onset) nondisplaced (a fracture where the bone did not move) fracture of the odontoid process (a specific appendage of the cervical spine) .
On 9/3/24 at 2:20 PM, V6 R1's Physician stated, Cervical fractures present as pain. I was concerned about a fracture, which is why I shot over there right away. They said the pain was moderate in nature .My concern with the neck pain, was that she had a cervical fracture as a result of her fall, which was the reason I had her sent out. She did have a cervical fracture . V3 said the facility should have notified him of R1's neck pain on 8/13/24, when it first presented. V3 stated, if he was notified of R1's neck pain on 8/13/24, he would have sent R1 out for imaging at that time. V3 stated, in R1's case, the delay in imaging and treatment did not negatively impact R1's prognosis and the delay did not change the type of treatment that was provided.
The facility's 72 Hour Fall Protocol showed, .Notify physician of any change in assessment .
The facility's Symptom Pursuit Charting policy (not dated) showed, 1. At the time a change is noted in a resident's condition, the nurse in charge shall utilize the Symptom Assessment Charting with [electronic health charting] to accurately assess and document the resident's change/s. 2. The nurse shall complete the Symptom Assessment that correlates with the resident's symptoms. 3. The attending physician and significant other shall be notified of the change. If the physician and significant other are not notified, the nurse assessing the resident is to indicate why no notification was made within the record .

Based on interview and record review the facility failed to ensure a staff member immediately reported an alleged abuse the the administrator for 1 of 1 resident (R1) reviewed for abuse reporting in the sample of 6.
The findings include:
On 4/30/24 at 10:01 AM, V4 (Registered Nurse-RN) said that on Thursday 4/25/24 around 7 or 8 PM, she was doing a narcotic count with V3 (RN) and V5 (Licensed Practical Nurse-LPN). V4 said that R1 was sitting near the nurse's station as she usually does. V4 said that she had her back to R1 when she heard a commotion so she turned around and she saw V3 grab an ice cream out of R1's hand and throw it away. V3 then took a tissue and angrily gave it to R1 and said, Clean yourself up and then said, We are not doing this sh** tonight. V4 said that she is not sure what provoked the response because R1 was having a good day. V4 said that she didn't want to make it worse for anyone so she did not say or do anything and continued with narcotic count with V3 and V5 and left. V4 said that she thought about the incident over the weekend and decided to email V1 (Administrator) because she didn't want anything to happen to R1 or any other resident again. V4 said that she knows that she should have reported it immediately after it happened but she did not.
On 4/30/24 at 2:00 PM, V2 (Interim DON) said that V4 came up to her on Monday morning around 7:30 AM and said that she witnessed V3 yell at R1 and take her ice cream away and throw it in the garbage. V2 said that she immediately went to V1 and notified her and they immediately started an investigation.
On 4/30/24 at 2:44 PM, V1 (Administrator) said that all allegations should be reported to her immediately so an investigation can be started and an initial report sent to the state survey agency. V1 said that V4 should have called her and let her know what had happened immediately after it happened.
The facility's Alleged Abuse Report shows that the alleged incident happened on 4/25/24 and the report was dated 4/29/24. There was an email attached to the report that shows that V4 emailed V1 on 4/28/24 at 9:30 AM about the incident that happened on 4/25/24. The email from V4 documents, I printed the abuse policy and there are things that I did wrong such as waiting too long to report. I did not work on Friday and chose not to call any of you over the weekend.
The facility's undated Abuse Prevention Policy and Procedure shows, It is our policy to report all incidents of abuse. If the reporter is unsure an incident meets the definition of abuse, our policy is to report. All abuse incidents shall be reported to the state no later than 24 hours of the incident or sooner.

Based on interview and record review the facility failed to implement their abuse policy by not immediately protecting a resident from the alleged perpetrator after an alleged abuse for 1 of 6 residents (R1) reviewed for abuse in the sample of 6.
The findings include:
On 4/30/24 at 10:01 AM, V4 (Registered Nurse-RN) said that on Thursday 4/25/24 around 7 or 8 PM, she was doing a narcotic count with V3 (RN) and V5 (Licensed Practical Nurse-LPN). V4 said that R1 was sitting near the nurse's station as she usually does. V4 said that she had her back to R1 when she heard a commotion so she turned around and she saw V3 grab an ice cream out of R1's hand and throw it away. V3 then took a tissue and angrily gave it to R1 and said, Clean yourself up and then said, We are not doing this sh** tonight. V4 said that she is not sure what provoked the response because R1 was having a good day. V4 said that she didn't want to make it worse for anyone so she did not say or do anything and continued with narcotic count with V3 and V5 and left. V4 said that she thought about the incident over the weekend and decided to email V1 (Administrator) because she didn't want anything to happen to R1 or any other resident again. On 4/30/24 at 11:26 AM, V3 said that she worked from 7 PM to 7 AM on 4/25/24 and received a call on Monday morning that she was suspend while an abuse investigation was performed.
On 4/30/24 at 2:44 PM, V1 (Administrator) said that all allegation of abuse should be reported to her immediately. V1 said that if the allegation was reported to her when it happened, she would have sent V3 home and immediately started an abuse investigation. V1 said that since it was not reported, V3 worked her shift and was notified on Monday that she was suspended due to an allegation of abuse.
The Facility's undated Abuse Prevention Policy and Procedure shows, It is our policy to immediately remove the perpetrator from the facility. It is the responsibility of the Abuse Prevention team and/or shift supervisor to escort and/or ensure that the perpetrator has left the facility within minutes of the alleged incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for 2 of 5 residents (R2 and R3) reviewed for resident rights in the sample of 5.
The findings include:
1. On 4/30/24 at 11:20 AM, R2 said that she had an issue with V3 (Registered Nurse) two Sundays ago. R2 said that the new person in the room next to her was having her family bring in a rug and she didn't feel that that was appropriate due to being a trip hazard. R2 said that V3 came to give her with evening medications and she questioned her about the rug and V3 turned bright red, put her hand up in my face to gesture stop and said very loudly, I don't know who gave them permission, it's not your concern. She was not speaking to me in a very dignified manner and I didn't appreciate it. All she had to say is I'm not sure but I will look into it and move on.
R2's Minimum Data Set assessment dated [DATE] shows that her cognition is intact.
2. On 4/30/24 at 12:15 PM, R3 said that she has had issue with V3 in the past but she has gotten better. R3 said that V3 had came into her room and asked her a question and she responded, No. V3 then said to her in a very loud voice, Don't talk to me that way. R3 said that V3 was just not very nice and did not treat her with respect. R3 said, She (V3) turns really quickly and I don't know why.
R3's Minimum Data Set assessment dated [DATE] shows that her cognition is intact.
On 4/30/24 at 2:44 PM, V1 (Administrator) said that all residents should be treated with dignity and respect at all times.
The Facility's Resident's Rights for People in Long-Term Care Brochure that is provided to the upon admission shows, You have the right to safety and good care .The facility must provide services to keep your physical and mental health and sense of satisfaction.

Based on interview and record review the facility failed to ensure the safety and supervision of a resident who went through alarmed doors and eloped from a facility on the night shift for 1 of 3 residents reviewed (R1) for safety and supervision in the sample of 4.
The findings include:
The Incident Note dated 10/12/23 at 11:05 for R1 showed, Resident exited facility, getting outside and fell, which was witnessed by CNA (Certified Nursing Assistant) responding to alarm but unable to reach resident before he fell. Minor injuries-cuts and abrasions. Moves all extremities without difficulty and/or pain. Assisted up and into facility by CNA and this nurse. Neuro's and Vitals assessed. See vitals documentation. Wound care to injuries.
The facility's Incident Report for R1 dated 10/13/23 to Illinois Department of Public Health showed, CNA Post Fall Investigation Report for R1 for the incident date of 10/12/23. The description of the event on the report showed, Just finished rounds down shining star hallway. I went to the dining room to find the nurse. As we were talking a door alarm went off. I looked at the board and saw it was the old hallway door. I looked down the old hospital hallway and then outside to see someone with bare legs and incontinence brief running and then fall on the road. I radioed the nurse and grabbed a wheelchair and went to the resident. Upon getting to the resident, found out it was R1. When the nurse came a few minutes later we transferred R1 into the wheelchair and then took him inside.
The facility's final Incident Report for R1 dated 10/20/23 to Illinois Department of Public Health showed, We spoke to the family and learned that the resident had a habit of wandering at home, unbeknownst to us. We have a wander device on R1 to keep him safe. We have also added more signage to the alert system that allows staff to know which alarm is going off because at times it is hard to identify the alarmed door. This way we can head to the door quicker. Finally, as a team we are working together to make sure there is one staff at the nurse's station all hours of the night.
On 10/31/23 at 10:00 AM, V1 (Administrator) stated, on Thursday, October 12 (2023) at 11:00 PM, R1 left the building. V1 stated there were three staff working, 2 CNA's and 1 LPN (Licensed Practical Nurse). The CNA's were down different halls. V1 stated the door alarm by the conference room went off. V1 stated R1's room was on the opposite hall at the farthest end of the hall. V1 stated R1 walks with a walker, walked down his hall, past the nurses station, down another hall and went out the door and was not noticed. V1 stated V3 LPN saw the lights went off behind the nurse's station and did not check the alarm right away. Staff said they were used to the alarm going off at night and thought it was R4 because he likes to go out at night. V1 stated when she interviewed the staff they were just too relaxed about it. V1 stated the staff should have checked right away to see if anyone got out. V1 stated someone checked the alarm but didn't see anyone at the doors. V6 CNA went out the door of the facility by the conference room and out the front door. V6 said she saw a resident running. V1 stated she didn't know how R1 could have been running when he walks with a walker and it didn't make sense R1 got that far away in the time frame the staff stated. V1 stated R1 was wearing a baseball hat, T-shirt, incontinence briefs and gym shoes. V1 stated V6 told her she could see someone outside but didn't know who it was until she got to R1. V6 then called for the nurse on her walkie talkie. V1 stated staff should have called her right away; she received an email stating R1 had a fall but it was more than that, it was an elopement. V1 stated all the staff should have immediately went and checked the doors for this reason alone. It needs to be done for residents safety.
On 10/31/23 at 10:13 AM, V3 LPN stated she was in the kitchen getting coffee for a resident when the alarm went off. V6 CNA heard the alarm and left. V3 said she went over to look at the alarm light on the wall and it said it was the front door. V3 stated she then went down the hall and V6 had used a walkie talkie radio to tell her it was a different resident that got out. Then the CNA radioed back that it was R1 that got out. V3 stated by the time she got to the door of the facility V6 was holding R1 who had been running to the street and fell. V6 stated she went and assessed R1 and V6 went to get a wheelchair and brought it back. V3 stated they put R1 in a wheelchair and brought him back to the facility. V3 stated R1's blood pressure was a little elevated, he had a cut to his hand, by his eye and lip that she put a steristrip on and abrasions to his knees. V3 stated V5 CNA and V6 CNA were at the nurse's station when she went to the kitchen. V5 then went to do checks on residents and she didn't know where V6 had been.
On 10/31/23 at 12:49 PM, R1 was laying on his back in bed. R1 was fully dressed and had his gym shoes on. R1 had a wheeled walker next to him. R1 stated he remembered leaving; he stated, I got up and left. I wanted to go home. My home is about 1 mile from here. I fell outside. R1 stated he didn't tell anyone he was leaving. R1 stated he heard an alarm go off when he left. R1 stated he fell and face-planted but he had gotten pretty far from the facility. R1 stated he did not know how long it took to get help.
On 10/31/23 at 1:43 PM, V6 CNA stated she was the CNA on the hall that R1 left on; she was not his CNA for the night. V6 stated she had been doing rounds and the last resident she had checked was a lady whose catheter was leaking. V6 stated she went to tell V3 LPN about the catheter and an alarm went off. V6 stated that R4 was a resident that usually goes out at night and it was usual for the alarm to go off. V6 stated when she went to the panel she saw the light was on for her hall door. V6 stated she went out her hall door, had to check the old hospital hallway to the left and offices to the right. V6 said she looked out the door into the parking lot and didn't see anything. V6 stated she then looked again out into the parking lot and saw bare legs and an incontinence brief. V6 stated she saw R1 running. V6 stated she couldn't really tell if R1 was running because he meant to or if it was the momentum and he fell; he face-planted. V6 stated when alarms go off the staff is supposed to check them immediately to see what has happened. V6 walked down the hall to the door R1 used to exit, put in a code to open the door. V6 exited the door of the extended care facility in the building but was still in the building. There was a hall to the left that went to the old hospital. A short hall to the right that had offices. Then walked towards the foyer area where there is an office to the left and right as well as a sitting area. V6 went to the exterior door and opened the door. V6 stated the exterior door is not alarmed or locked. V6 pointed down the road to a large tree and stated R1 had went across the parking lot, the street and over to the ditch on the other side of the road in front of the large tree. She stated that is where she saw him.
On 10/31/23 at 2:13 PM, V5 CNA stated R1 was a resident on the hall she had been working on that night. V5 stated she was doing checks on residents, went into a different residents room and he was not in bed; he was on the toilet. She waited for that resident to finish on the toilet and helped him to bed. V5 stated she then checked on that resident's room mate. V5 stated she heard the alarm go off at some point but was in a room helping those residents. V5 stated that there was also R4 that goes out onto the patio nightly so she thought it was him that set the alarm off. V5 said she didn't check the alarm right away because she was busy. V5 stated she didn't remember when the alarm was shut off because she was still in that room. V5 said that since the alarm was shut off she figured everything was okay and went to check another resident in a different room. V5 said when she was in the second room V6's voice came over the radio saying she thought a person was outside and for the nurse to come outside. V5 said she then heard V6 yell into the radio that it was R1 and she told V5 to get out there. V5 said she didn't know which door they had went out. V6 said she ran to the door she saw propped open. V6 said she saw V3 and V6 pushing R1 in a wheelchair.
On 10/31/23 at 2:50 PM, R4 stated he is a night owl and stays up at night. R4 stated that he goes outside anywhere from 10:00 PM - 2:00 AM for some fresh air. R4 stated he doesn't tell anyone that he is going outside, he puts the code in and leaves. R4 stated he goes out onto the patio and the front door by parking lot. R4 stated he has a hard time seeing the keypad to put the numbers in when he comes inside because of a glare so he opens the door, sets off the alarm and enters the code into the keypad once he is inside. R4 stated the staff don't respond because they know it is him. R4 stated if the alarm goes off for a long time then the staff should know it is not him. R4 stated the staff should then check because there are crazy wanderers here that wander day and night.
The Face Sheet dated 10/31/23 for R1 showed medical diagnoses including parkinson's disease, osteoarthritis, actinic keratosis, neurocognitive disorder with lewy bodies, hypertension, tinea unguium, and other specified mental disorders due to known physiological condition.
The Restorative Note dated 8/18/23 for R1 showed, R1 is a new admission to the nursing home. He has a diagnosis of Parkinson's disease. His gait is mildly unsteady and he walks with a shuffling gait. He participates in the restorative program daily. He rides the recumbent bike for 20 minutes, AROM (active range of motion) group exercises, and he is on a walk to dine program. He is ambulatory using a FWW (front wheeled walker) and limited assist of 1. He is limited assist for most ADLs (acitivities of daily living). He does require extensive assistance for lower body dressing, toileting, and bathing. He does not have any functional limitations in ROM (range of motion) to both upper and lower extremities. He is frequently incontinent of bladder and bowel mostly due to not being able to make it to the bathroom in a timely manner. He is able to recognize the urge to urinate. He is able to make his needs known. He scored a 10/15 (moderate cognitive impairment) on his BIMS (brief interview of mental status).
The MDS (Minimum Data Set) dated 8/15/23 for R1 showed moderate cognitive impairment; limited assistance needed for bed mobility, transfers, walking, toilet use and personal hygiene; extensive assistance needed for dressing and bathing.
The facility's Resident Elopement policy (no date) showed, Objective: 1) To protect resident health and safety; 2) To establish a system for immediate location and return of a resident to the facility. Any resident leaving the facility without staff acknowledgement is recognized as elopement. All exit doors to the facility have door alarms in place 24 hours per day and alarm when a person enters or exits the unit without entering the correct code in the keypad. When the alarm sounds, the charge nurse will determine which alarm has sounded. Any available nursing home staff shall immediately check the door that has alarmed for a resident or patient who may have gone out the door. All available staff from all departments shall respond to the closest nurses' station to assist with the search.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 10/10/23 at 1:18 PM, R27's CPAP machine, tubing, head strap and face mask was sitting on the tall heat register in his room. The CPAP face mask was not covered.
The Physician Orders dated October 2023 for R27 showed, Clean CPAP equipment monthly with soap, water, and sanitizer. CPAP on at bedtime and off in the AM for obstructive sleep apnea.
The Care Plan dated 8/16/23 for R27 did not show a plan in place for the use and maintenance of CPAP for his obstructive sleep apnea.
On 10/11/23 at 10:01 AM, V2 DON (Director of Nursing) stated the cleanliness of the mask is on the treatment administration record. V2 stated CPAP machines should be on their designated table for CPAP. V2 stated it was not okay to have the CPAP machine on the register. V2 stated they don't cover the masks they just leave them out and not on the floor. V2 stated they don't cover the masks to prevent contamination.
The Diagnosis Report dated 10/11/23 for R27 showed diagnoses including alzheimer's disease, sleep apnea, morbid obesity, hypertension, fecal incontinence, weakness, major depressive disorder, atherosclerotic heart disease, and arthritis.
The MDS (Minimum Data Set) dated 8/8/23 for R27 showed severe cognitive impairment.
The facility's Care of CPAP Machine policy (no date) showed, the objective was to keep CPAP machines free and clear of debris and potential infectious materials. Clean the mask and tubing weekly by using mild soap with warm water. Hang the mask and equipment in a designated and clean area of the resident's room when not in use.
Based on observation, interview, and record review, the facility failed to obtain physician's orders for a resident (R8) to utilize a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain physician's orders for 3 resident's (R8,R23,R33) CPAP pressure settings, failed to perform routine respiratory assessments for 3 resident's (R8,R23,R33) who utilize a CPAP machine, failed to store 4 resident's (R8,R23,R27,R33) CPAP machines in a manner to prevent contamination. These failures apply to 4 of 5 resident's reviewed for CPAP therapy in the sample of 14.
The findings include:
1) R8's electronic face sheet printed on 10/11/23 showed R8 has diagnose including but not limited to Diagnosis: unspecified cirrhosis of liver, type 2 diabetes, ascites, obstructive sleep apnea, and herpes viral ocular disease.
R8's facility assessment dated [DATE] showed R8 has no cognitive impairment and requires the use of a non-invasive mechanical ventilator (CPAP).
R8's physician's orders dated 10/11/23 showed, Clean CPAP mask and tubing weekly with soap and water. No physician's orders were present for previous dates for R8's mask and tubing to be cleaned.
R8's physician's orders for October 2023 showed no orders present for R8 to utilize a CPAP machine.
R8's electronic medical record had no routine respiratory assessments documented.
On 10/10/23 at 9:46AM, R8 stated, The facility doesn't do anything with my CPAP machine. I'm the one that handles it and makes sure it's cleaned and set to the right settings. They probably don't even know how often it's supposed to be cleaned or what my settings are. I don't use it all the time but I have been better about wearing it the past few months. (R8's CPAP mask was hanging over the side of R8's bedside table and was uncovered).
On 10/12/23 at 9:53AM, V1 (Administrator) stated, We do not have a policy regarding the management of a CPAP machine, only a policy showing how often to clean the machines. We now know this is something we need to work on and ensure that we have a policy and the care for residents with a CPAP machine are completed. (V2-Director of Nursing) advised me that we do not perform routine respiratory assessments on our residents unless we have a concern with them. Having a CPAP does not cause a concern for the nurse's.
2) R23's electronic face sheet printed on 10/12/23 showed R23 has diagnoses including but not limited to atherosclerotic heart disease, hypertension, hyperlipidemia, depression, and gastroesophageal reflux disease.
R23's facility assessment dated [DATE] showed R23 has no cognitive impairment and utilizes a CPAP machine.
R23's October 2023 physician's orders showed, 10/20/22 CPAP. Keep CPAP machine at bedside to wear at night. (No physician's orders were present showing the ordered pressure for R23's CPAP machine).
R23's October 2023 physician's orders showed, 4/21/23 Clean CPAP equipment monthly with soap, water, and sanitizer. 10/11/23 Clean CPAP tubing and mask with soap and water weekly. (The facility's policy showed CPAP equipment is to be cleaned on a weekly basis).
On 10/10/23 at 9:51AM, R23 stated, They usually just lay my mask wherever there is room. It's never covered or in a drawer or anything. It doesn't have a designate space, just where it can fit. They don't clean it often but I know it's supposed to be done at least once a week.
3) R33's electronic face sheet printed on 10/11/23 showed R33 has diagnoses including but not limited to atrial fibrillation, type 2 diabetes, hyperparathyroidism, hypertension, heart failure, obstructive sleep apnea, anxiety disorder, and spinal stenosis.
R33's facility assessment dated [DATE] showed R33 has not cognitive impairment and requires the use of a CPAP machine.
R33's physician's orders dated 4/21/23 showed, Clan C-PAP equipment monthly with soap, water, and sanitizer.
R33's care plan dated 8/29/23 showed, (R33) has altered respiratory status/difficulty breathing related positive COVID-19 diagnosis on 3/4/23 . CPAP SETTINGS: full face mask every night at HS
On 10/12/23 at 8:45AM, R33 stated, I had a sleep study done a few years ago and that's how my settings were determined. I just got this new machine a few weeks ago and they just use the old settings with oxygen bled in every night. They don't assess my respiratory status unless I ask them to or if there is a concern with my breathing.
On 10/12/23 at 10:21AM, V3 (Infection Preventionist-Registered Nurse) stated, The ordered pressure for all CPAP's should be located within the physician's orders. You need to make sure it is put there so that the nurse's know which pressure to check for. It is important to make sure it is set at the correct pressure because that is what prevents the resident from becoming apneic while sleeping. We clean the masks and tubing weekly, at least that's what our protocol is so I hope that's what is happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 1 residents (R36) reviewed for medication errors in the sample of 14.
The findings include:
R36's electronic face sheet printed on 10/12/23 showed R36 has diagnoses including but not limited to Alzheimer's disease, hypertension, major depressive disorder, hyperlipidemia, type 2 diabetes, anxiety disorder, and mood disorder.
R36's facility assessment dated [DATE] showed R36 has severe cognitive impairment.
R36's physician's orders showed R36 had Amlodipine 5mg daily ordered on 11/16/22 and was discontinued on 9/30/23.
R36's nursing progress notes dated 9/28/23 showed, (R36) was eating her supper meal when suddenly she became warm, clammy, and unresponsive for a short period of time. Blood pressure 70/46 .Staff escorted (R36) to her room and laid her down in bed. Notified primary physician regarding the incident. He diagnosed the incident as postprandial hypotension. He recommended to monitor her this evening. Hold blood pressure medication in the morning .
R36's nursing progress notes dated 9/30/23 showed, Primary physician here this morning and discontinued amlodipine.
R36's nursing progress notes dated 10/3/23 showed, Situation: Medication error; Amlodipine was discontinued on 9/30/23, however medication was not pulled from October medications and was administered in error on 10/1 and 10/2 .BP results on 10/1/23: 104/62 10/2/23: 162/89.
Card was removed from medication cart on 10/3/23.
On 10/12/23 at 10:21AM, V3 (Infection Preventionis-Registered Nurse) stated, All medications are given per physician's orders. The nurse's pull up the resident's medication administration records that will show what medications are due, pull the medications out of the drawer, and compare the medications with the medication list. The nurse then administers the medications and confirms in the medication administration record that the resident took the ordered medications. (R36) experienced a hypotensive episode and then was given atenolol after it was discontinued. We were monitoring her blood pressure during that time so I can't say it was a significant medication error. If it was significant then she would have had an adverse outcome but she didn't. She could have, but she didn't.
The facility's undated policy titled, Medication Administration/Control of Medications showed, Objectives: 3. To establish safe and accurate nursing procedures for dispensing medications to residents .13. Medication administration records (MARs) for all medications and treatments shall be reviewed at least monthly by a licensed nurse. MARs shall be checked with the previous month's MAR for accuracy, paying particular attention to any changes in orders .22. Each dose administered is properly recorded on the MAR by the person who administered the dose .

Based on interview and record review, the facility failed to develop and maintain a facility assessment. This failure has the potential to affect all residents in the facility.
The findings include:
The Resident Census and Condition Report dated 10/10/23 showed 44 residents residing in the building.
On 10/11/23 at 10:46AM, V1 (Administrator) stated, We do not have a facility assessment; I know we are supposed to have one and I am learning how to do it. We are doing research on exactly what we need to be doing so we can ensure we have the correct number of staff and that those staff are trained on any specialized needs our resident's might have.

Based on observation, interview, and record review the facility failed to ensure a dignity bag was in place over an indwelling urinary catheter drainage bag for 1 of 1 residents (R6) reviewed for dignity in the sample of 14.
The findings include:
On 10/10/23 at 11:57 AM, R6 was in the dining room in her wheelchair with a indwelling urinary catheter drainage bag attached under her wheelchair. The drainage bag was half full of urine and there wasn't a dignity bag in place over the drainage bag during the lunch time meal service.
On 10/11/23 at 9:50 AM, V4 LPN (Licensed Practical Nurse) stated catheter drainage bags should have dignity bags over them whenever the resident with a catheter leaves their room.
On 10/11/23 at 10:01 AM, V2 DON (Director of Nursing) stated the facility has catheter drainage bag covers that are to be used all of the time when a resident is out of their room and out in the facility. V2 stated the drainage bag covers are used to maintain the dignity of the resident.
The Diagnosis Report dated 10/11/23 for R6 showed medical diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, anemia, hyperlipidemia, hematuria, urinary tract infection, and diverticulitis.
The Physician's Orders dated 10/11/23 for R6 showed she has a 22 french indwelling urinary catheter.
The current Care Plan dated 9/7/23 for R6 showed she has an indwelling urinary catheter due to a neurogenic bladder. The care plan did not show how the resident's dignity would be maintained related to her catheter.
The facility's Care of Urinary Catheters/Procedure for use and disinfection of a leg urinary drainage bag policy (no date) stated a leg urinary drainage bag would be used to allow the resident more mobility and protect dignity by eliminating embarrassment of a visible drainage bag. The policy did not show that a cover would be used over a drainage bag that was not a leg urinary drainage bag for the dignity of a resident.
The facility's Policies Governing Resident's Rights (no date) showed, residents shall be treated with consideration, respect and absence of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative programs including ROM (range of motion) were being provided regularly for 2 of 5 residents (R6 & R33) reviewed for range of motion in the sample of 14.
The findings include:
1. On 10/10/23 at 9:41 AM, R6 was sitting in a custom wheelchair in her room with a mechanical lift sling under her. R6 had a positioning device on the left side of her upper body and a neck pillow in place. R6 stated she doesn't get ROM exercises anymore because there isn't enough staff to do it. R6 stated she used to go to the therapy room and use the hand pulleys to exercise her arms. R6 stated she used to go to the group exercises but that stopped too. R6 stated the programs stopped about a month ago.
The Diagnosis Report dated 10/11/23 for R6 showed medical diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, anemia, hyperlipidemia, hematuria, urinary tract infection, and diverticulitis.
The MDS (Minimum Data Set) assessment dated [DATE] showed no cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.
The September 2023 Restorative documentation for R6 showed for R6's group exercise program and arm pulley restorative program it was provided on 13 out of 30 days. The October 2023 Restorative documentation from 10/1/23 - 10/11/23 showed for R6's group exercise program and arm pulley restorative program it was provided on once.
The Care Plan dated 9/7/23 for R6 showed she has limited physical mobility related to the disease process of multiple sclerosis. Provide gentle range of motion as tolerated with daily care. Restorative - Active ROM Program #1 Group. Restorative - Active ROM Program #2 pulleys. The resident has multiple sclerosis affecting all of her extremities. R6 is chair bound at this time and is dependent on staff for transfers and toileting. R6 is able to self propel her chair, she is able to adjust her position in bed and she remains able to feed herself with adaptive dishware.
On 10/11/23 at 11:35 AM, V2 DON (Director of Nursing) stated the CNA's (certified nursing assistant) on the daily ROM programs when they are done. V2 stated she documents the quarterly ROM/Restorative notes. V2 stated restorative programs are only being done a couple of times per week because she is the only person in the therapy room. V2 stated they had 2 restorative CNA's but they had to pull them to the floor so they would have enough staff to provide care. V2 stated it was the one program that she felt they could cut in order to have staff on the floor to provide care. V2 stated she knows the residents miss it. V2 stated she is not able to provide the restorative programs right now.
The Restorative Nursing Care policy 5/11/21 showed, nursing personnel are trained in restorative care, and our facility has an active program or restorative nursing care which is developed and coordinated through the resident's care plan. The facility's restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Restorative nursing care is performed daily for those residents who require such services.
2) R33's electronic face sheet printed on 10/11/23 showed R33 has diagnoses including but not limited to atrial fibrillation, type 2 diabetes, hyperparathyroidism, hypertension, heart failure, obstructive sleep apnea, anxiety disorder, and spinal stenosis.
R33's facility assessment dated [DATE] showed R33 has no cognitive impairment and receives restorative therapy.
R33's care plan dated 8/29/23 showed, (R33) has limited physical mobility related to weakness.
On 10/11/23 at 9:44AM, R33 stated, Someone is supposed to come in and do exercises with me; however, since the shortage of certified nursing assistants has occurred, the exercises aren't offered on a regular basis, only when they have enough time. I do them on my own as much as I can but I can't lift my legs very well so I need someone to do that part for me. I use a stand lift for all transfers so I would like to keep my leg and arm strength as long as I can so I don't have to use a full lift for transfers.
R33's undated restorative program showed R33 is to have Active Range of Motion- Seated Exercises in Room. R33's restorative program task showed R33 only received restorative therapy 8 times within the past 30 days. All other days for R33 were marked as Not Applicable.

Based on observation, interview, and record review the facility failed to document and record negative COVID testing for staff. This failure has the potential to affect all residents in the facility.
The findings include:
The CMS 672 dated 1/4/22 showed 44 residents reside in the facility.
On 1/04/23 at 11:14 AM, the most recent COVID test log was requested. The facility provided POC (Point of Care) Test Tracking log. The log showed a column for Name; Date Test Performed; Test Result; and Was Individual Symptomatic. The log showed the last documented test was on 10/8/22 (nearly 3 months prior.) The log sheet showed from 9/29/22 to 10/8/22 five tests were conducted for symptomatic individuals. (After 10/8/22 no other symptom tracking or COVID tests.)
On 1/4/23 at 12:51 PM there was a POC COVID testing box containing 22 tests. The box originally contained 40 tests. There was no log sheet with the box.
On 1/04/23 at 12:51 PM, V6 Registered Nurse stated there should be a sheet with POC box for documenting symptoms and test results. V6 said staff and resident POC COVID tests are used from the same box. V6 was unable to find the sheet and stated, Staff must not be documenting their tests.
On 1/04/23 at 9:56 AM, V8 Medical Records states she self-tests for COVID frequently whether for symptoms or personal reasons. V8 said the facility is no longer recording her negative COVID tests.
On 1/04/23 at 9:27 AM, V2 Director of Nursing stated she had not been tracking negative COVID test results for staff and/or their symptoms since October 2022. V2 stated it was her understanding she was not required to do so.
The facility's COVID testing policy was requested. The facility's Return to work protocols/COVID-19 Testing Requirements Policy (dated 8/4/22) was provided and showed no guidance for documentation or tracking of symptomatic staff and their negative tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have an Infection Control program and system in place to track or trend illnesses, failed to have a process to identify contagious residents, and failed to implement transmission based precautions for residents exhibiting infectious illness. This applies to all residents residing in the facility.
These failures resulted in 19 residents (R1,R3,R5,R6,R8,R9,R11,R13,R14,R16,R18,R21,R23,R25,R29,R30, R35,R39,R42) experiencing gastrointestinal and respiratory illness.
The Immediate Jeopardy began on 12/26/22 when R13 and R14 began having symptoms of being tired and rundown, and sore throat, congestion, and cough with green sputum. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/5/23 at 1:32PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/6/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The findings include:
A review of electronic medical records showed: On 12/26/22, R13 reported being very tired and rundown and R14 experienced increased sore throat, congestion, and cough with green sputum. On 12/28/22, R23 experienced nausea and vomiting. On 12/31/22, R1, R3, R25, and R42 experienced nausea and vomiting while R18 and R35 experienced cough, sore throat, and congestion. On 1/1/23, R6 experienced coughing and wheezing. R21 experienced vomiting and R30 experienced a sore throat and cough. On 1/2/23, R5 experienced loose stools and R39 experienced sore throat and congested cough. R13 began experiencing a sore throat, green sputum, and congestion. On 1/3/23, R11 and R16 experienced several episodes of diarrhea. On 1/4/23, R29 experienced fatigue, cough, and congestion.
On 1/4/23 at 1:19PM, V2 (Director of Nursing) stated, There were several residents over the weekend with a gastrointestinal illness but I would have to look at every single resident's progress notes to figure out who they were. I didn't track them because it was the weekend. At 1:30PM, V2 then provided the facility's document titled, Respiratory Symptom Pursuit for 9 residents in the building. V2 stated these were all of the residents who have been ill and no new residents have displayed any symptoms. At this time, surveyors had identified 17 residents who had become ill with respiratory or gastrointestinal symptoms.
On 1/4/23 at 3:05PM, V1 (Administrator) stated, We don't exactly have an infection control program. I know (V2) looks at infections but we don't do anything with the documentation. We just don't have the resources to dedicate someone to just look at infections. I'm not sure how often our policies are updated and reviewed but I know they are current with the standard of practice. I heard about the illnesses over the weekend but to my knowledge everyone is doing fine and better. We don't have a contact at the local health department and we did not reach out to them about this outbreak. I guess I didn't realize we had to or should have.
As of 1/4/23 at 3:15PM, none of the above residents had been placed on transmission-based precautions for their symptoms, no contact had been made between the facility and the local health department regarding an illness outbreak, and no infection tracking had been initiated for an outbreak of a potentially contagious illness.
On 1/5/23, R9 experienced congestion, productive cough with yellow and green sputum. R8 began experiencing a cough with yellow sputum.
On 1/5/23, R9 was sent to a local hospital due to her respiratory symptoms. R9's medical records showed, Patient here with complaint of shortness of breath, cough, generalized weakness and fatigue, increasing lethargy over the past 2 days. Patient was noted to be hypoxic to the high 80s on room air at facility, sent to the emergency room for further evaluation. She is on 3 liters nasal cannula. She does sound wheezy on lung exam, crackles to bilateral bases, my concern is for infectious process including pneumonia R9's diagnostic radiology report dated 1/5/23 showed, Impression: 1. Small bilateral pleural effusions with nonspecific bibasilar opacity, which can be seen with atelectasis or consolidation. Infection is not excluded if there is clinical suspicion.
On 1/5/23 at 10:22AM. V2 stated, I have a book of other infections other than COVID. I print a spreadsheet and put it in the book but we don't do anything with it really. We discuss COVID in our Quality Assurance Performance Improvement (QAPI) meetings but don't necessarily discuss any other infections. We don't have an actual infection control program but we are working on it. Over this past weekend I was called for two residents that were sick with diarrhea and vomiting and there were a few that had respiratory symptoms. I told the staff just to try and keep those residents in their rooms and bring meal trays to them. I didn't see it as an outbreak necessarily because we didn't have a large group of residents that were ill. None of the residents that have been experiencing symptoms have been placed on transmission based precautions. We had one resident (R13) that has been tested for influenza but it was negative. No other residents were tested for influenza. I'm guessing we would report all illnesses to the health department. We did not call the health department for this illness. I didn't really think about it. It was the weekend and nobody was there so I don't even know who I would call. We have not identified any new residents other than the 9 resident symptom pursuit sheets I gave you. There are no new residents other than the initial 9 I gave you. It's like nothing ever happened. The only symptoms the residents had were vomiting and diarrhea so I don't even know what we do for them besides keep them comfortable, hydrated, and give an antiemetic if needed. The symptom tracker sheet is the main way we keep track of these illnesses. Residents are assessed every shift for 72 hours or until symptom free. If a resident is not getting better after 72 hours or the resident has increased symptoms then we would reach out to the physician again for further orders. I did have the nurses start a symptom pursuit form for the 9 residents to keep track of their illness. It is more of a visual aide and reminder for them to check on the residents. At this time, the facility had only identified symptoms for R1,R11,R13,R16,R18,R21,R25,R30, and R35.
On 1/5/23 at 11:05AM, V21 (Director of Clinical Services-Health Department) stated, If there is an outbreak within a facility I am usually in contact with the Director of Nursing or the Administrator. Each facility should have a list of illnesses or symptoms that should be reported to the health department and when they should be reported. I have not received any communication from the facility regarding any recent outbreak of illnesses. If the facility is having any outbreak of a potentially infectious disease I would say 2 or more residents is an outbreak that should be reported to us. The facility has access to my phone number and I am available 24/7 so I can be reached any time. If the facility would have contacted me I would have asked for further information regarding what is going on and ask as many questions as I can. I would go through the Illinois Department of Public Health (IDPH) for specific pathogen guidance if we know the organism. It's on the IDPH web portal for them also but I would go over that and share the guidance with them. I would link them up with people at the state if it was more than I could handle. If the cases seem like they are all linked, I would wonder if its food borne or viral illness. I would have suggested they contact the physician and get an order to do stool testing done to see if we could find exactly what we were dealing with. If we suspected it was food borne illness we would go one route and viral another route. If it was something we thought could be food borne we would get our environmental health on board and get a kitchen inspection going, contact IDPH and go from there to determine what the pathogen is. There are so many avenues to this and so much tracking and documentation I would need to see to start making recommendations. They should have jumped into action within the first few cases to prevent an outbreak of this illness. Now they are behind on testing residents stool and testing for possible influenza. If it was a foodborne illness then it may be too late to try to get that information because they did not report it to me immediately. The purpose of the facility reaching out to us is so we can provide them guidance for infection control, find out what is going on, and stop it as soon as possible. They should contact us early when there is a small amount of cases and we could help them determine the cause and prevent further exposure and spread.
On 1/6/23 at 11:33AM, V2 stated, In the residents electronic medical record program there is an infection control section that you can monitor infections. It's called a symptom pursuit and that's similar to what we use on paper and document in the system. The symptom pursuits go on the communication board on the dash board within the electronic charting program. I go over that every day. I guess I didn't see the new symptom pursuits for the additional residents you identified. I use the [NAME] Criteria for Infection Surveillance.
The facility's undated policy titled, Communicable Disease Reporting showed, Objective: To establish policy in compliance with Illinois law for mandatory reporting of communicable diseases; as indicated per the IDPH rule and guidelines for reporting of communicable diseases .4. Suspected clusters of diseases, which may not be reportable at the time, may also be recorded on a log, and shall be reviewed and monitored per infection control officer, or designee .11. Per IDPH: Certain infectious disease with public health significance shall be reportable by phone, as soon as possible within 3 hours, to the appropriate local health department .b. Any unusual case or cluster of cases that may indicate a public health hazard.
On 1/5/23, V2 provided surveyors with the Revised McGeer Criteria for Infection Surveillance Checklist that she uses for guidance on monitoring and reporting purposes. The undated criteria showed, Gastroenteritis: In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens.
The facility's undated policy titled, Infection Control and Standard/Isolation Precautions showed, Objectives: To protect residents, visitors, students, and staff from communicable diseases and healthcare-associated infections .5. The nurse or physician shall institute and maintain isolation techniques as required by .suspicion of disease or as recommended by infection control officer.
The Immediate Jeopardy that began on 12/26/22 was removed on 1/6/2023 when the facility took the following actions to remove the Immediacy.
Administrative staff consisting of DON, and Administrator, completed a review of the current resident roster of 45 residents to determine any unidentified cases of illness presented on 1/5/23. No new residents were identified with GI or respiratory symptoms as of this date.
The 19 residents identified who presented with GI/respiratory symptoms beginning 12/26/22 thru 1/5/23 were assessed for ongoing symptoms effective 1/5/23.
Of those 19 residents, 1 resident identified will have a stool specimen collected as soon as possible. Primary care provider was notified and order obtained for GI panel.
8 of the 19 residents identified currently are exhibiting respiratory symptoms.
Of these 8 residents, 1 resident was hospitalized [DATE] and tested for influenza and COVID, results were negative for both influenza and COVID.
1 resident is currently being treated for aspiration pneumonia and PCP declines need for respiratory panel.
The remaining 6 residents have had nasal swabs obtained for an expanded respiratory panel on 1/5/23 as orders were obtained from primary care providers.
R25 was moved to a private room for isolation effective 1/5/23.
R29 was moved to a private room for isolation effective 1/5/23.
R11 was isolated in his room as his roommate was moved to another room. He will remain in another room for the duration of the isolation effective 1/5/23.
The Medical Director, was notified of GI/respiratory symptoms outbreak on 1/5/23.
The Local Health Department Communicable Disease Nurse was notified by of the GI/respiratory symptom outbreak in the residents. Discussion took place regarding resident surveillance of symptoms, isolation, testing of residents, and appropriate cleaning measures.
The DON has identified a surveillance tracking tool within the Point Click Care documentation system. The DON is completing the surveilling tracking within Point Click Care. This tool has been completed effective 1/5/23 for the current 8 residents that are exhibiting GI/respiratory symptoms. The surveillance tracking tool will be utilized when any resident develops symptoms which could be considered to be communicable or transmissible to others. The nursing staff will be educated by the DON RN, by 1/10/23. The Infection Control Coordinator will audit to ensure nursing staff is using the surveillance tracking log as part of her daily assignment. This data will be utilized to help identify when 2 or more residents have similar symptoms within 72 hours and the Local Health Department needs to be notified.
Maintenance staff completed a deep clean of the facility to include high touch surfaces with use of an EPA registered appropriate cleaning product. High touch areas within the facility will be cleaned three times a day beginning 1/6/23 until symptoms resolve.
Quality Assurance will be completed by the administrator with staff completing a daily log to ensure this is done three times per day when two or more residents have similar symptoms within 72 hours. This log will be reviewed daily.
Administrative staff and the Infection Control Coordinator were trained on facility response to illness outbreak by the Local Hospital Infection Control Nurse and the Local Health Department Public Health Communicable Disease Nurse. This training included a review of Appendix A Type and Duration of Precautions found on the CDC website and the need to contact the local county health department at any time when there are 2 or more residents identified with similar symptoms within 72 hours of onset.
Staff training took place on 1/5/23 at 4:30PM with all staff currently on shift. Training was completed by the local hospital Assistant DON. This training included the importance of hand hygiene, increased frequency of cleaning/disinfecting including high touch areas, reporting of resident symptoms to the shift nurse, and isolation protocols. The Administrator, returned to educate 3rd shift and arrived at 7AM to educate first shift. Please see sign-in sheet. As of 1/6/23 at 7:00AM, 26 employees received this education and the remainder of staff will be educated at their next scheduled shift up and until mandatory meetings that are scheduled for 1/10/23 for all staff. 3 different meeting times are scheduled for 1/10/23 which will include this education and it will be an opportunity for some staff to hear it twice.
The Hospital CEO, will touch base with the administrator five days per week for the next three months to ensure that these plan of correction measures are being carried out.
The Infection Preventionist, will be responsible for the new infection control program. An infection control program/committee will consist of the administrator, DON, a designated floor nurse, a designated CNA and a designated housekeeper and/or designated maintenance member. This committee will meet on a monthly basis. The Infection Preventionist will provide an infection control report at the quarterly quality assurance meetings. The Hospital CEO will attend the quarterly quality assurance meetings.
On 1/6/23 at 12:00PM, a review of the facility's in-service record showed all staff working the remainder of the day on 1/5/23 and staff working on 1/6/23 were in-serviced on infection control procedures consisting of identifying and monitoring residents for symptoms, notification to nurse for residents identified as having new symptoms, isolation of potentially contagious residents, hand hygiene, and disinfection of high touch surfaces. As of this time, 44% of the entire staff had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift and/or on scheduled in-services on 1/10/23.

Based on observation, interview, and record review the facility failed to prepare pureed foods according to the recipe to preserve nutritive value and flavor. This applies to 1 of 1 residents (R15) reviewed for nutrition in the sample of 13 and one resident (R26) outside of the sample.
The findings include:
The facility provided list on 1/4/22 showed R15 and R26 were on pureed diets.
On 1/3/22 at 5:35 AM, V9 [NAME] said there was no dietary manager and she does it all.
On 1/03/23 at 9:34 AM, V9 began the puree process for the noon meal. V9 added approximately a cup of water to the pork cutlets and approximately a cup of water to the already wet stewed tomatoes. After blending, the tomatoes were as thin as a tomato juice.
On 1/04/23 at 9:08 AM, V9 stated We do follow the recipe except for the shape and served (thickener and molds used for purees.) V9 said, We can use water or broth, juice, or tomato juice. It would be for more flavoring to use broth instead of water. It makes it more appetizing and they might eat a little bit more (if broth or juice is used instead of water.)
R15's Weights and Vitals showed she lost 8.5 pounds from 12/1/22 to 1/3/23 (4.4 percent weight loss.)
R26's Weights and Vitals showed she lost 5.5 pounds from 12/1/22 to 1/2/23 (4.9 percent weight loss.)
The facility's recipe for Pureed Apple Glazed Pork Loin showed, Combine chicken base and water to make chicken broth. May use pork base if available .If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency .
The facility's recipe for Pureed Stewed tomatoes showed, Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed.) Some recipes items will require no liquid added to achieve the desired consistency. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to supervise a resident who smokes for 1 of 4 residents (R9) reviewed for safety and supervision in the sample of 13.
The findings include:
R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include cirrhosis of liver, Type 2 Diabetes, hypertension, osteoarthritis, and hyperlipidemia. R1's facility assessment dated [DATE] showed he has no cognitive impairment and is independent for ambulation and mobility.
On 1/3/22 at 9:15 AM, V1 (Administrator) identified one resident (R9) as a smoker within the facility.
On 1/04/23 at 10:46 AM, V4 CNA (Certified Nursing Assistant) said, I'm not sure how smoking works here exactly but R9 is a smoker. He does it mostly at night, not during the day. I heard he goes out on the deck.
On 1/04/23 at 12:36 PM, V6 RN (Registered Nurse) said R9 is a smoker but does not know where he keeps his smoking supplies. V6 said R9's smoking supplies are not kept in the medication cart or room. V6 said nursing has reported R9's smoking to the Director of Nursing in the past. At 12:50 PM, V6 said, she thinks R9 keeps his smoking supplies in his room. V9 said she knows R9 goes out and smokes at night on the deck. V6 said, This past week we (the staff) could smell smoke in the bathroom and we think that he flushed his cigarette down the toilet. I worry about my license because what am I supposed to do if he does something that causes a problem for someone else?
On 1/04/23 at 1:40 PM, V3 (Social Services Assistant) said, I heard he was smoking in the bathroom. I don't know exactly what happened. I'm part time so I don't know what they would have documented or what they would have done in response to that. They can't smoke on campus.
On 1/4/23 at 1:45 PM, V5 (Social Services) said, I heard he was caught smoking in the bathroom, I believe it happened over the weekend. I did not have anything to do with the incident, [V2 (Director of Nursing)] did follow up with him about it.
On 1/6/23 at 11:02 AM, V18 (Activity Director) said R9 is the only smoker she knows at the facility. V18 said she heard R9 was caught smoking but does not know exactly when it happened.
On 1/06/23 at 11:33 AM, V2 DON (Director of Nursing) said it was reported to her that R9 was smoking in the bathroom. V2 said, [R9] usually leaves the facility to smoke. I asked him if he was smoking in the building and he said no. I didn't see any evidence of it and he denies everything. I told him this is a smoke free campus. I went around and looked to see if he had anything and I didn't see anything. I didn't document any of that. I have not seen him out smoking on the deck. [R9] is naughty.
The facility's undated policy and procedure titled, Tobacco Free Campus showed . Tobacco use is prohibited in facilities managed by the healthcare center . This policy applies to colleagues, patients, medical staff, students, contracted personnel, auxiliary, volunteers, visitors, vendors Staff shall be responsible for the enforcement of this policy . Supervisors and managers are responsible for managing this policy within their respective work areas .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to either offer, provide, or educate residents regarding flu and pneumonia vaccines. This applies to 6 of 6 residents (R39, R42, R12, R97, R2, and R6) reviewed for immunizations in the sample of 9 and 17 residents (R38, R40, R37, R30, R31, R13, R32, R25, R96, R36, R41, R35, R17, R34, R21, R95, and R16) outside of the sample.
The findings include:
1. The CMS 672 dated 1/4/22 showed 44 residents reside in the facility.
R40, R21, R97, R41, R31, R6, R17, R12, R39, R38, R36, R42, R96, R95, R30, R25, R34, R13, R37 and R35's Immunization Reports and Immunization Records showed the Pneumococcal vaccine was not documented in any capacity, either offered, refused, historical (given prior to admission) and/or education was provided for the vaccine.
R2's Immunization Record showed, as of 1/3/23, she was [AGE] years old, and the pneumococcal vaccine variant, PCV13 was given on 9/26/2017. (Over 5 years ago.)
R16's Immunization Record showed, as of 1/3/23, she was [AGE] years old, and the pneumococcal vaccine variant, PCV13 was given on 1/4/18. (5 years ago.)
R32's Immunization Record showed, as of 1/3/23, she was [AGE] years old and the pneumococcal vaccine variant, PCV13 was given on 10/8/15. (Over 7 years ago.)
R6's immunization record from a local area hospital showed she received the PCV13 vaccine on 10/3/19. (Over 3 years prior.)
The Centers for Disease Control and Prevention (CDC) guidance titled Pneumococcal Vaccine Timing for Adults (dated 4/1/22) showed, For those who have never received a pneumococcal vaccine or those with unknown vaccination history administer one dose of PCV15 or PCV20 . The CDC guidance also showed; for adults 65 and older, without an immunocompromising condition, and who received the PCV13 vaccine; they should be given the PPSV23 at least 1 year after the PCV13 vaccine was given. This is regardless of the age at which the PCV13 vaccine was given.
On 1/4/23 at 11:14 AM, Immunization Records, to include flu and pneumonia, were requested for all residents in the facility.
On 1/5/23 at 10:21 AM, V2 Director of Nursing/Infection Preventionist stated the resident vaccine records and reports, if completed and documented, would include administration, refusal, and education for the flu and pneumococcal vaccines. V2 stated she would use the CDC website for determine proper guidance for the scheduling of pneumococcal vaccines. V2 stated, if the PCV13 vaccine was given then the PPSV23 should have been offered per CDC guidance. V2 stated the purpose of the pneumococcal vaccine is to prevent or lessen the effects of bacterial illness.
The CDC Vaccine Information Statement Pneumococcal Conjugate Vaccine (PCV13): What You Need to Know (dated 8/6/21) and the CDC Vaccine Information Statement Pneumococcal Polysaccharide Vaccine (PPSV23): What You Need to Know (dated 10/30/19) both showed the vaccines are important to prevent pneumococcal disease which can include pneumonia, which is an infection of the lungs .pneumococcal bacteria can also cause ear infections, sinus infections, Meningitis (infection of the tissue covering the brain and spinal cord), bacteremia (bloodstream infection.) The education pamphlets showed adults over [AGE] years of age are at the highest risk for pneumococcal infections. The education showed PCV13 an PPSV23 protect against 13 and 23 types of bacteria respectively.
The facility's undated Influenza and Pneumococcal Vaccination policy (undated) showed the objective of the policy is to decrease the morbidity and mortality rate from influenza and pneumonia. The policy showed Upon admission, assess and document the resident's influenza and pneumococcal vaccination history on the resident's face sheet .influenza vaccination is provided annually from September thru March .Pneumococcal vaccination is provided at time of admission if the resident has not had a documented vaccine in the past 5 years .
2. On 1/4/23 at 11:14 AM, Immunization Records, to include flu and pneumonia, were requested for all residents in the facility.
R35, R30, R40, R41, and R6 showed the Influenza (Flu) vaccine was not documented in any capacity (for the 2022/2023 flu season), either offered, refused, historical (given prior to admission) and/or education was provided for the vaccine.
On 1/5/23 at 10:21 AM, V2 Director of Nursing/Infection Preventionist stated she does resident admissions. V2 stated if vaccine history cannot be determined then she would contact the physician to see if the vaccine can be given.
The CDC Recommended Adult Immunization Schedule for 2022 showed the influenza vaccine, is recommended for adults who meet age requirements, lack documentation of vaccination, or lack evidence of past infection. The schedule shows the age group is 19 and older.