Based on observation, interview and record review the facility failed to administer medications per physician's orders for 2 of 3 (R195 and R37) reviewed for medications given on time in a sample of 38. Findings include: 1. R195's Physician's Order Sheet (POS), dated 11/2024 documents diagnosis included diabetes with no diagnosis of rash. 11/21/2024 Tacrolimus topical 0.1% ointment BID (twice a day) for rash on legs. 11/21/2024 Clobetasol topical 0.05% cream BID for rash. 11/21/2024 Metformin 850 milligrams (mg) BID for diabetes. R195's Medication Administration Record (MAR), dated 11/2024 documents Tacrolimus 0.1% topical ointment BID (twice a day) for rash on legs 0 documented as not given on 11/22/2024 through 11/24/2024 8:00 AM dose and 11/22/2024 through 11/26/2024 at 8:00 PM. Clobetasol 0.05% topical cream apply BID to rash 0 documented as not given at 8:00 PM on 11/22/2024, 11/26/2024 and 11/27/2024. Metformin 850 mg BID 8:00 PM dose 0 documented as not given. On 12/5/2024 at 10:30 PM V12, R195's wife stated she did not bring any medications including creams or ointments to the facility and no staff asked her to do that. 2. R37's POS, dated 11/2024 documents no diagnosis listed for anxiety. A physician's order dated, 11/9/2024 Alprazolam 0.25 mg TID (three times a day) for anxiety. R37's MAR, dated 11/2024 documents an order dated 11/5/2024 Alprazolam 0.25 mg tablet TID for anxiety 8:00 AM, 2:00 PM and 8:00 PM 0 was documented as not given on 11/11/2024 at 8:00 PM dose. On 12/5/2024 at 10:00 AM V2, DON (Director of Nurses) stated when a resident is admitted to the facility from the hospital the hospital submits prescriptions for a few days then the facility physician has to send prescriptions to the facility and if the prescription is sent STAT it usually takes the pharmacy to deliver the medication within 4-6 hours and when the medication is not send STAT if the medication is ordered before 5:00 PM the medication is usually here by 10:00 PM and when the medication is ordered after 5:00 PM the medication will be delivered to the facility at 2:00 AM. V2 stated the facility has an emergency backup medication system but it does not hold controlled medications or creams/lotions and only holds certain medications which doesn't include Metformin 850 mg. The wound nurse has prescription creams/ointments on her wound cart but staff wouldn't be able to get a hold of the wound nurse and do not have access to her wound cart at 8:00 PM. When a medication is not available at the facility staff document a 0 on the resident's MAR and then write a note as to why the medication was not given and these missed medications were documented not available from pharmacy. On 12/5/2024 at 10:50 AM V2 stated she expects staff to follow the facility's medication administration policy and to notify nurse supervisor and the resident's provider when a physician prescribed medication is not available to see if there is an alternate medication to be administered. On 12/5/2024 at 11:19 AM V1, Administrator showed documentation V14, LPN/RN notified the afterhours telehealth provider that only prescribed patient 5 Alprazolam which he takes TID. Are you able to call in more. If not, I can try the afterhours telehealth provider again. Response was RX (physician prescribed medication) sent. There was no documentation of resident name or any other identifying information on the paper. V1 stated this was the only documentation of medications that were documented as not available from pharmacy/documented as not given for the residents and she expected staff to follow the facility's medication administration policy and to notify the nursing supervisor and the resident's provider when a medication is not available. The Facility's Administration of Medication Policy, revised 6/2023 documents purpose: to provide general guidelines for staff to follow in the administration of medications. Responsibility: it is the responsibility of all RNs, LPNs, and CMTs to understand and comply with this policy. It is the Nurse Manager's responsibility to maintain and enforce this policy. Policy: if the medication is unavailable any time, the Nursing Supervisor should be contacted and may obtain medication from the emergency drug supply or contact the physician to try to obtain an alternate order.

Deficiency Text Not Available

Deficiency Text Not Available

Based on interview and record review the facility failed perform antibiotic stewardship for 2 of 3 residents (R27, R39) reviewed for antibiotic stewardship in the sample of 29. Findings include: 1. R27 was documented on the Infection Control log, dated 1/3/2024, for a urine infection. The organism documented was Enterococcus aerogenes. R27's Progress Notes, dated 1/3/2024, documented, Patient with urinary retention, suprapubic discomfort at times, leukocytosis. UA (urinary analysis) positive. Awaiting final urine culture. Patient has a history of pyelonephritis with pansensitive E. coli. We will start cefdinir 300 mg (milligrams) for 7 days. Adjust if needed once culture available. R27's Culture and Sensitivity Report, dated of 1/2/2024 at 3:14 PM, documented, Organism 1L Enterobacter aerogenes, and documents the organism was resistant to cefdinir. R27's Medication Administration Record (MAR) for January 2024 documented, Cefdinir (Cefzon, Omnicef) 300 milligrams (mg) oral capsule, start date 1/3/2024. R27's MAR also documents R27 received a total of four doses, January 3-January 4,2024 for a urinary tract infection. 2. R39 was documented on the infection control log,dated 1/7/2024, for urine infection. R39's Progress Notes, dated 1/8/2024 at 1:08 PM, Urinary tract infection associated with indwelling urethral catheter, initial encounter (HCC). Assessment Plan: Urine cloudy, continues to have good output from catheter. Culture positive for probable pseudomonas growth, awaiting sensitivities. Continues cefdinir for now, will adjust medication if needed once sensitivities available. R39's Urine Culture report, dated 1/7/2024 at 11:35 AM, documented, Final report organism 1: Pseudomonas aeruginosa. Cefdinir (Cefzon, Omnicef). The organism was not documented as being sensitive or resistant to cefdinir. R39's MAR, dated January 2024, documented, Cefdinir 300 mg, 1 capsule two times a day for seven days. Start date 1/7/2024. it continued to document that R30 received four doses from 1/7/2024 to 1/10/2024. The facility's Antibiotic Report, dated January 2024, documented that Cefdinir as being resistant to pseudomonas aeruginosa. R39's MAR, dated January 2024, documented, a 1/9/2024 start date for Ciprofloxacin (Cipro 500 mg) oral tablet every 12 hours for urinary tract infection for 7 days. R39's MAR document R39 received 7 days of the medication. The facility's Antibiotic Report, dated January 2024, documented for R39 that Cipro as being Sensitive for pseudomonas. On 1/17/2024 at 4:46 PM, V3, Infection Control Specialist, stated, Sometimes the PA (Physician Assistant) will start the antibiotics before the Culture and Sensitivity comes back but they do a good job of following up with them and making sure they are the correct antibiotics once the culture has been returned. When the physician sees the C & S it shows up on their screen the exact name of the medications and if they are resistant or have sensitivity. I myself, when I get the report there is only one or two letters for the drugs. I have a sheet from the pharmacy documenting what drug is what. R27's MAR, dated January 2024, also documented an order, Sulfamethoxazole-trimethoprim, (Bactrim DS (double strength), 800 mg to 160 mg, oral tablet. Start date 1/5/2024. The Antibiotic Stewardship Program Policy, dated of 9/22, documented, To provide guidelines to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. It is the policy of this community to implement an Antibiotic Stewardship Program as part of the community's overall infection prevention and control program. It promotes the appropriate use of antibiotics and is a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-residents organisms or other adverse consequences or outcomes. This program will be reviewed on an annual basis and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R59's MDS, dated [DATE], documents she is cognitively intact. R59's Final Illinois Department of Public Health (IDPH) report, dated 01/17/23, documents On 01/12/23 at 10:30 AM, V13, Respiratory Therapist notified V1, Administrator that R59 alleged that she was punched in the stomach, foot stomped on and thrown onto the bed. The initial Illinois Department of Public Health Facility Reported Incidents dated 01/12/23 at 11:13 AM, documents A reportable Event occurred, a final report will be sent to the department within 5 business days. The report did not document this was an allegation of abuse or a description of the alleged occurrence. 4. R220's MDS, dated [DATE], documents she is cognitively intact. R220's Final IDPH Report, dated 01/31/23, documents On 01/24/23 x-ray was obtained of the right knee, upon review, x-ray resulted a mildly displaced peri-hardware fracture involving the right distal femur. Upon speaking with V14, Nurse Practitioner, she obtained the x-ray because patient states that on Sunday 1/23/23 when in the Hoyer lift, her leg slipped. The initial Department of Public Health Facility Reported Incidents dated 01/25/23 at 9:51 AM, documents A reportable Event occurred, a final report will be sent to the department within 7 business days. The report did not document that this was an injury of unknown origin. On February 2, 2023, at 1:55 PM V1, stated that she is the person that reports the abuse to IDPH. V1 stated that she has an open-door policy. V1 stated that residents, families, and staff report abuse. V1 stated that when she is made aware of the allegation of abuse, she makes sure that she gets the details of the allegation. V1 stated that she then sends an initial report to IDPH. V1 stated that she does not document the actual allegation in the initial report. V1 stated that she documents that there has been an incident. V1 stated that when sending the report, you must indicate if this the initial or the final. V1 stated that she just reports there's been an event, check what is abuse or accident. V1 stated that then she hits send me confirmation and that's that. V1 stated that she just sends over there is a reportable event. V1 stated that she doesn't send any more information. V1 stated this is what her corporate told her to do. The Facility's Policy and Procedure, Resident Abuse/Neglect/Exploitation, with a revised date of 09/22, documents PURPOSE: To provide guidelines for identifying, investigating and reporting resident abuse/neglect and exploitation, including any reasonable suspicion of a crime directed towards the resident. The Policy and Procedures documents 3. An investigation shall be initiated immediately. Any allegation of abuse must be fully investigated and self-reported to appropriate State Agency. The Policy documents Any incident of unknown origin needs to be immediately investigated. If cause cannot be determined within 24 hours, it must be self-reported to DHSS or IDPH. Based on interview and record review, the facility failed to provide identifying information regarding abuse allegations in the initial report to Illinois Department of Public Health (IDPH) for 4 of 4 (R59, R170, R171, R220) reviewed for abuse reporting in the sample of 52. Findings include: 1. R170's Minimum Data Set (MDS), dated [DATE], documents that R170 is cognitively intact. An undated and untitled document provided by the facility documented on January 20, 2023, at 10:00 AM R170 notified V1, Administrator, that a staff member came in to take vital signs and slapped him across the face. On January 20, 2023, at 10:19 AM V1 reported the incident to IDPH. The initial report documented A reportable event occurred. A final report will be sent to the department within 5 business days. The Report documented the date of the incident as 1/20/23 and R170. The report did not document that this was allegation of abuse and a description of the occurrence. 2. An undated and untitled document provided by the facility documented on November 23, 2022, at 10:30 AM R171 reported that V15, Registered Nurse, grabbed her gown by the front and pulled her over to the bed in a rough manor on November 22, 2022. On November 23, 2022, at 11:00 AM V1 reported the incident to IDPH. The initial report documents A reportable event occurred. A final report will be sent to the department within 5 days. The Report documented the name of the resident as R171, date of birth of R171 and the incident date as 11/23/22. The report did not document that this was an allegation of abuse and a description of the occurrence, and the alleged perpetrator.

Based on interview and record review, the Facility failed to ensure the admission Comprehensive Minimum Data Sets (MDS) were completed by the Assessment Reference Date (ARD) for 4 of 12 (R119, R120, R168, R170) reviewed for comprehensive assessments in the sample of 52. Findings include: On 2/6/2023 at 11:41 AM, V12, MDS Nurse was questioned regarding the MDS assessment timeliness. V12 stated I just did the last of them today (MDS that were due). I was waiting on Social Services to do their parts. All of my sections were done last week but I can't submit them until all the sections are complete. I have several that are past due. I've been keeping track of it. The ARD (No later than the 14th calendar day of the residents' admission which is the admission date plus 13 calendar days) at the top is the due date. On 2/6/2023 at 12:15 PM, V12 provided a document dated 2/6/2023 and signed by V12. It documents, These are the last assessments for January 2023. This list included R119, R120, R168 and R170. R119's MDS ARD was 1/28/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. R170's MDS ARD was 1/21/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 1/27/2023. R120's MDS ARD was 1/29/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. R168's MDS ARD was 1/28/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. On 2/6/2023 at 12:25 PM, V1, Administrator, stated, I am aware of some late MDS. We have talked about it during QAPI (Quality Assurance Performance Improvement). On 2/6/2023 at 1:40 PM, V12 stated, Everyone who is admitted and entered into our system has to at least have a 5-day assessment, even if they don't stay for 5 days. On 2/6/2023 at 1:53 PM, V1 stated, I would expect the staff to follow our policy regarding timeliness of MDS Assessments. The Facility's Resident Assessment Instrument/Minimum Data Set Protocol dated 10/2019 documents, All team members should complete their respective section of the MDS by the specified time frame so that the MDS coordinator/designee can coordinate and transmit within the appropriate time allowances.