**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Advance Directives reflect resident preference for one (R4) of one resident reviewed for Advance Directives in the sample of 30. Findings include: The facility's POLST (Practitioner Order for Life-Sustaining Treatment) policy and procedure, dated 3/20/23, documents the POLST is an important component of advance care planning that emphasizes eliciting, documenting, and honoring patients' preferences about treatments they want to choose or decline during a medical emergency or as their health status changes. The POLST is to be completed or reviewed with the resident and/or Healthcare Power of Attorney, and/or surrogate or guardian. A POLST is not a one-and-done document and is to be reviewed periodically. The POLST order set is intended to be dynamic, reflecting a resident's current condition and preferences about medical treatments. The POLST form for R4, dated 1/10/22, documents If patient has no pulse and is not breathing and Do Not Attempt Resuscitation/DNR The current Order Summary Report and current Care Plan document R4 as a DNR. The clinical medical record for R4 does not document any discussions were had with R4 regarding R4's wishes for Code Status. The admission MDS (Minimum Data Set) Assessments for R4, dated 1/16/22 (admission date) and Quarterly MDS assessment dated [DATE], document R4 as cognitively intact. On 5/21/25 at 2:40 PM, R4 stated no one has asked him what his wishes were if his heart stopped beating and he stopped breathing. R4 stated, without hesitation, I want them to do everything if I die. On 5/23/25 at 9:43 AM V11 SSD (Social Service Director) stated she talks with residents and family regarding Code status during the resident admission or readmission, quarterly, and if there is a significant change in condition. If the family or representative, or legal guardian are not here V11 SSD calls them on the telephone to discuss Code Status. If a resident is alert and oriented the patient makes the decision. We use the BIMS for cognition. V11 SSD stated she calls V17 (R4's) State Guardian, discusses R4's Code Status with her, V17 makes decisions for R4, and R4 is aware of the decisions made.

2. The facility's Fall log dated May 2025 documents R9 had a fall on 5/4/25 at 1:15 PM. The Fall Risk Assessment for R9, dated 3/5/25 documents R9 is at Moderate Risk for falls. The facility's Fall Investigation for R9, dated 5/4/25, documents R9 stated My foot wasn't in the right position, then I started just going down. V15's (Agency CNA/Certified Nursing Assistant) witness statement documents V15 was Transferring (R9) into wheelchair from toilet via (mechanical lift), footrest on wheelchair came down, footrest hit (R9's) foot causing (R9) to slip and be lowered to floor. The current Transfer Care Plan for R9 documents R9 requires extensive assistance for transfers. Interventions include to place R9's feet on foot plate of mechanical stand lift and fasten safety strap around R9's legs with knees against the pad. This same Care Plan was revised to include a new fall on 5/4/25. R9 was being transferred by V15 (Agency CNA) and R9's right leg wasn't positioned properly. R9 had to be lowered to the floor for R9's safety. On 5/21/25 at 2:30 PM, R9 stated V15 (Agency CNA) transferred her and didn't put her feet on the lift platform correctly, did not put the strap behind her legs, and did not listen to R9. R9 stated My right foot was curled and not flat. V15 (Agency CNA) said Let go, I got you. When V15 (Agency CNA) started raising the lift (R9's) foot slipped and I had a soft fall. On 5/22/25 at 11:53 AM, V2 (DON/Director of Nursing) stated she does all the fall investigations for the facility and determines the root cause analysis for each resident fall. V2 stated V15 transferred R9 without fastening the lift strap behind R9's legs and should have; and confirmed improper foot positioning prior to transfer. V2 stated the intervention would be for V15 (Agency CNA) to be re-educated on proper transfers. Based on interview and record review, the facility failed to ensure residents were safely transferred, monitored post fall and that the accident was appropriately investigated for two of eight residents (R9, R13) reviewed for accidents in a sample of 30 residents. Findings include: The Fall Prevention Policy dated 8/31/21 documents: All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. All falls are to be investigated and monitored. The Director of Nursing and/or designee is responsible for coordinating all investigations. An accident is an unexpected, unintended event that can cause a resident bodily injury. A 'fall' is the unintentional coming to rest on a lower surface, such as a chair, the bed or the floor or onto the next lower surface. Investigative guidelines documents to call a Post-Fall Huddle and complete a Fall Report, obtain detailed statement from any witnesses and document in the Nurses Notes. Document vital signs, neurological checks, medication taken, last time resident was seen and any other pertinent observations. Continue to observe resident throughout shift and provide documentation. Each nurse, each shift will observe resident and document for 72 hours in the resident's medical record. Monitor closely for any physical or neurological changes. Discuss the incident in morning meeting for review as Interdisciplinary team and update care plan. 1. R13's current Care Plan documents R13 was at risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, unsteady gait, hypocalcemia and weakness. On 3/21/25 R13 was noted to be on the floor by her wheelchair after she attempted to hang up her phone; did not have her wheelchair brakes locked when she was leaning forward to hang up her phone; was re-educated to lock her wheelchair brakes or use the call light to ask for help when needed; obtained a skin tear to her right elbow; monitor for signs and symptoms of infection; refer to therapy; and on 3/24/2025 to obtain an x-ray of right elbow; and to refer R13 to the wound doctor. R13's Physician's Order dated 3/21/25 documents to place and keep right elbow steri-strips in place, monitor for signs and symptoms of infection every shift for skin tear for two weeks. V5's (Advanced Registered Nurse Practitioner) Progress Note dated 3/24/25 documents R13 complained of right elbow pain and worsened with movement. The right elbow did have a deep laceration and complained of being sore from the fall, but the only specific area is the right elbow. There were no steri-strips on the elbow at the time of V5's assessment. V5 ordered an x-ray of the right elbow, prophylactically prescribed antibiotics for ten days and made a referral to the wound doctor. R13's Progress Note dated 3/24/25 documents a right elbow x-ray was conducted. On 3/25/25, the right elbow x-ray was reported as a fracture was not excluded but was inconclusive. On 3/27/25, the Progress Note documents R13's right elbow x-ray was negative. V6's (Wound Care Physician) Progress Note dated 3/26/25 documents Non-Pressure Wound of the right elbow full thickness caused by trauma/injury greater than four days ago and measured three cm (centimeters) by 1.6 cm by 0.8 cm; surface area 4.80 cm; undermining 1.2 cm, to apply collagen sheet to wound once daily and as needed for 30 days; apply gauze island with border once daily and as needed for 30 days.V6's treatments as listed on the Wound Log document on 4/2/25, 4/9/25 and 4/16/25, R13's right elbow wound had worsened and surgical debridement was conducted; 4/30/25 wound was debrided and unchanged; and on 5/7/25 wound was debrided and improved. V6 conducted weekly visits until 5/21/25 when wound was declared healed. The Fall Investigation dated 3/21/25 did not include an interview from V20 (Occupational Therapist) or V21 (Physical Therapy Assistant) who observed R13's fall, documented injuries as a bruise on the right forearm, redness to upper-mid back vertebrae and a skin tear to right elbow and no injuries observed post incident. R13's medical record did not include vital sign monitoring and/or an assessment of her right elbow wound for 72 hours each shift per policy (3/21/25, 3/22/25, 3/24/25) or for two weeks each shift per physician's order. The Interdisciplinary Note (IDT) dated 3/30/25 (nine days post fall incident) documents R13's fall details and post fall findings were discussed/reviewed, although does not include an interview from V20 (Occupational Therapist) or V21 (Physical Therapy Assistant) who observed and responded to R13's fall, why R13's deep laceration that required treatment by a wound doctor and complaints of pain of her right elbow was not accurately assessed until 3/24/25 when V5 (Advanced Registered Nurse Practitioner) conducted rounds. On 5/23/25 at 9:50 AM, V20 (Occupational Therapist) and V21 (Physical Therapy Assistant) stated they were in the room across from R13 and witnessed R13 reach forward to hang the phone up and slid off the front of the wheelchair onto her butt then rolled backward onto her back. V20 and V21 ran into R13's room and the nurse came in soon after. I didn't even know she cut her arm until the next day. On 5/23/25 at 11:00 AM, V2 (Director of Nursing) stated R13's right arm laceration was not appropriately assessed due to positioning of the arm during assessment; agreed post fall assessments were not appropriately conducted and/or documented per policy; and agreed the IDT met nine days after R13's fall.

Based on interview and record review, the facility failed to notify the Ombudsman of all hospital discharge/transfers for four of four (R30, R31, R44, and R48) residents reviewed for hospitalization in a sample of 30. Findings include: The facility's Hospital Tracking Portal, dated 2/1/25 to 5/23/25, documents R30, R31, R44, and R48 were transferred out to the hospital. The facility's Admit Discharge report, dated February 2025, does not include R30, R31, R44, or R48. On 5/22/25, at 3:35pm, V12 Business Office Manager/BOM stated that the Admit Discharge report that V12 sends to the Ombudsman does not include the Private Pay residents. V12 was unaware that it should include the Private Pay residents as well. The facility's Daily Census, dated 5/20/25, documents R30, R31, R44, and R48 have a Primary Payer source of Private Pay.

Based on observation, interview and record review, the facility failed to ensure the resident's environment was kept free from cross contamination during wound care for one of ten residents (R31) who receive wound care. These failures have the potential to affect all resident who reside in the facility with a current census of 46 residents. Findings include: The facility's undated Procedure for Clean Dressing Technique policy documents the following Take treatment cart to the resident's room, but not in contact with the resident belongings. Gather and set up supplies in the resident area. Establish clean field (can be unsterile plastic field, clean linen, etc.) not on the treatment cart. The facility's current Weekly Wound Tracking Forms identify ten residents (R1, R4, R5, R7, R8, R9, R13, R16, R31, R34) who currently are receiving wound care treatments in the facility. R31's Physicians Orders include the following pressure ulcer/wound care orders Cleanse Sacrum with NS (Normal Saline) apply Santyl (wound treatment ointment) to wound bed and cover with (dry dressing) and secure with tape daily and PRN (as needed) every day shift for wound care and as needed for wound care. On 5/22/25 at approximately 11:00 AM, V3 (Wound Nurse and Resident Care Coordinator) wheeled the facility's treatment cart into R31's room, removed R1's wound care supplies from a drawer in the cart and placed them on a clean under pad on the top of cart, including gauze pads, saline cleansing liquid, cloth tape, dry dressing and medicated ointment. V3 performed wound care for R31. After performing R31's wound care, V3 rolled the treatment cart out of R31's room and into the hallway. The wound care supplies for all residents receiving wound care are present in the facility's treatment cart. On 5/22/25 at 11:18 AM, V3 stated she does bring the treatment cart into residents' rooms for wound care treatments and stated, I usually put the treatment cart at the other end of (the resident's) room. On 5/23/25 at 10:30 AM, V4 (Infection Control Coordinator) stated the facility's treatment cart should remain outside the resident's room and should not be brought onto a resident's room. On 5/23/25 at approximately 11:30 AM, V4 provided the facility's Procedure for Clean Dressing Technique policy and verified the treatment cart may be taken to the resident's room door but not inside the resident's room.

Based on observation, interview and record review, the facility failed to ensure infection control practices were utilized while serving meals in the dining room. These failures have the potential to affect all resident who reside in the facility with a current census of 46 residents. Findings include: The Facility Resident Census Roster and Facility Matrix/802 dated 5/20/25 were reviewed. The Census Roster documented 46 Residents resided in the Facility. The Illinois Food Handler Training power point utilized for training facility dietary staff dated 6/3/16 documents food can become unsafe if staff practice poor personal hygiene. Personal hygiene consists of good hand washing practices, proper glove use, proper hand care and personal cleanliness. Wash hands between tasks. V18's (Dietary Aide) Certificate of Completion of the Illinois Food Handler Non-Restaurant Training was dated as completed on 12/1/23. On 5/20/25 at 11:14 AM, V18 was observed to be at the drink station in the dining room, put two meal tickets in her mouth, one meal ticket fell from her mouth onto the floor, she picked it up off the floor with her bare hand, poured apple juice into a glass and handed the glass off to another staff member, then made three cups of hot chocolate, picked up the three cups of hot chocolate and delivered them to R31. V18 then went to the serving window to deliver meal trays without conducting proper hand hygiene. On 5/23/25 at 11:55 AM, V22 (Dietary Supervisor) stated V18 should not have held the meal tickets in her mouth or picked up the meal ticket off the floor without conduction hand hygiene prior to making and serving R31 his drinks. V22 stated V18 had a current Certification of Completion of the State's Food Handler Training and knows better than to cross contaminate residents' food and/or drinks.

Based on observation, interview and record review, the facility's Governing Body failed to employ a licensed Administrator to oversee and manage the everyday operations of the facility. This failure has the potential to affect all 46 residents residing within the facility. Findings include: The Facility Resident Census Roster and Facility Matrix/802 dated 5/20/25 were reviewed. The Census Roster documented 46 Residents resided in the Facility. The Administrator's Job Description (not dated) documents the Administrator supervises all departments and employees and is responsible for planning, organizing, staffing, directing and coordinating the facility to ensure quality of care for residents, be knowledgeable of and implement federal, state, local laws and regulations applicable to the facility, residents, personnel and physical plant. The Administrator must hold a current, unencumbered nursing facility Administrator's license. On 5/20/25 from 9:15 AM through 3:30 PM, on 5/21/25 from 9:00 AM through 3:30 PM, on 5/22/25 from 9:00 AM through 3:30 PM and on 5/23/25 from 9:00 AM through 3:30 PM there was no licensed administrator within the building and no posted Administrator's license. On 05/20/25 at 9:30 AM, V2 (Director of Nursing) stated the facility has not had an Administrator since 4/9/25 and she was the acting Administrator.V2 stated V1 (County Administrator) was the facility's resource. V2 agreed the Facility did not have an Administrator license posted within the facility.

Based on interview, observation and record review, the facility failed to ensure fall interventions were implemented to prevent further falls for one of four residents (R38) reviewed for falls in the sample of 29. Findings include: The facility's Fall Reduction Program policy (revised 09/01/21) documents the following: All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care Plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. On 05/28/24 at 10:10 AM, R38 was lying in a low bed with a fall mat in place next to her bed. R38 was nonverbal and did not respond to verbal stimuli when approached due to her impaired cognition. R38's Fall Investigation (dated 01/08/24) documents the following: Nurse notified at this time of resident (R38) sliding out of chair in dining room. CNA (Certified Nursing Assistant) stated resident slid out of chair and did not hit head. R38's current care plan documents the following focus: Risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, poor coordination, poor safety awareness. This same care plan documents the following fall prevention intervention: 01/08/24: Re-educated staff to ensure (R38) has (non-slip mat) placed under her. On 05/30/24 at 02:00 PM, V17 (Licensed Practical Nurse/Care Plan Coordinator) stated that after investigation of R38's 01/08/24 fall, R38 did not have (non-slip mat) in place in her wheelchair and should have had it in place since it had been a previously implemented fall prevention intervention. V17 stated that staff was re-educated to check above and underneath R38's wheelchair cushion to ensure (non-slip mat) is in place.

Based on observation, record review and interview the facility failed to ensure psychotropic medications given on an as needed basis were not prescribed more than 14 days for 1 resident (R27) of 5 residents reviewed for unnecessary medications in a total sample of 29. Findings include: The facility's Policy / Procedure regarding Treatment/Services for Mental/Psychosocial Concerns dated 11/18/21 documents, A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R27's Physician Order Sheet (POS) dated May 30, 2024 documents R27 is prescribed Lorazepam 0.5 milligrams by mouth every eight hours for anxiety. On 05/28/24 at 9:38 AM R27 was observed laying quietly in her bed on her left side. R27 was asleep and having no behaviors. On 05/28/24 at 12:23 PM, R27 was noted laying in her bed quietly, having no behaviors. On 05/30/24 at 11:09 AM, R27 was sitting in a wheelchair in the dining room at a table with two other residents and a staff while eating her lunch independently. R27 was not noted to have behaviors. On 05/30/24 at 11:07 AM V18, Certified Nursing Assistant, stated R27 sometimes hallucinates but is not aggressive nor displays self-injurious behavior. On 05/30/24 at 1:00 PM, V8, Licensed Practical Nurse/LPN, stated R27 had behaviors when she was new to the facility and the environment was different to her, however, typically her behaviors are an indicator of the beginning of a urinary tract infection or sometime similar. R27's Medication Administration Records document the last time she was administered Ativan on an as needed basis was February 15, 2024. A Note to Attending Physician/Provider documents R27 has an as needed (PRN) psychotropic order for Ativan 0.25 mg (milligrams) q8h prn (every eight hours as needed). Previously documented stop date of 04/23/24 will expire soon. 6 months is handwritten into the area for duration and dated 04/18/24. On 05/30/24 at 2:07 PM, V17, LPN, stated, It is not in our policy for a PRN psychotropic to not be ordered for more than 14 days, but it is our practice.

Based on interview and record review, the facility failed to ensure their Antibiotic Stewardship program was implemented. this failure has the potential to affect all 62 residents residing at the facility. Findings include: The facility's Antibiotic Stewardship Program policy (undated) documents the following: Infection Preventionist will encourage and educate staff to use McGeer's definitions of infections. Standards of infection observation are checking for signs observed and/or resident has a change of condition. The following steps will be implemented: monitor vital signs, monitor intake and output for 48 hours, assessment of lung sounds, and assessment of other signs of infection and update the physician and family. If UTI (urinary tract infection) is suspected, then 48 hour watch will be implemented by monitoring temperature, intake and output, urine color and character, pain assessment and changes in mental status using McGeer's definition as a guide. On 05/29/24 at 09:20 AM, V3 (Registered Nurse/Infection Preventionist) stated the facility does not implement any protocols to review clinical signs and symptoms and/or laboratory reports prior to implementation of an antibiotic for a resident. V3 stated the facility does not utilize any assessment tools or management algorithms to determine if an antibiotic is warranted, We just call the doctor and get an order for an antibiotic if we believe one is needed. The facility's Long Term Care Facility Application for Medicare and Medicaid, Form 671, dated 05/28/24 and signed by V1 (Administrator), documents 62 residents currently reside in the facility.

Based on document review, observation and interview, the facility failed to ensure call lights were equipped to communicate directly to staff. This failure has the potential to affect all 62 residents residing in the facility. Findings include: The Software User Guide dated 2020 documents the web-based application is designed for nurse call and wander management use for Independent and Assisted Living facilities. The Guide documents to log-into the application with username and password. When the Alarms (nurse call or wander alarms) are activated, the computer will make a sound and display the location of the alarms. On 5/28/24 at 10:58 AM, R25 stated, I have to help when I go number two. I have waited up to 70 minutes for them (staff) to respond to my light. I would say the average wait time is between 30 minutes to 70 minutes. On 05/28/24 11:10 AM, R17 stated, The call light response time could be better. Especially in the morning when they are so busy. Sometimes you have to wait a really long time for help. On 5/29/24 at 11:45 AM, V10 Registered Nurse) demonstrated at the nurse's station a device called Code Alert which the screen will light up a resident's room number when the nurse call is activated or identify a resident's location if the wander guard alarm is activated. V10 stated, the computers will also notify the Nurses and/or Certified Nurse Aides (CNA) in the same manner. V10 stated, You (Nurses and CNA's) have to be at the desk (nurse's station) or at their computer to know if a resident needs assistance. On 5/29/24 at 12:00 PM, V12 (Physical Therapist) and V13 (Occupational Therapist) stated call light response time could be a lot better especially when a resident is toileting. V13 stated, We (Therapy) used to be able to help with call lights and toileting but ever since they switched to this new system, we are not alerted to when they (nurse calls) are on. On 5/29/24 at 1:34 PM, R25's nurse call was activated. At 1:37 PM, V17 (Licensed Practical Nurse) was observed to enter R25's room and state Music is in the Activity Room at 2:00 PM. V17 did not address and/or was not aware the nurse call was activated. On 5/29/24 at 1:45 PM, V14 (CNA), V15 (CNA), and V16 (CNA) were observed in the [NAME] Hall with a computer and demonstrated the use of the nurse call system. A call light was activated; an alert was displayed with the room number and location and a sound was heard. V16 stated, If we are not at the computer, we turn the sound on the computer up, but we still have to come out and look to see where the alarm is. On 5/29/24 at 1:55 PM, V8 (Licensed Practical Nurse/LPN) stated the computers time out (of the nurse call/wander guard software application) in one or two hours. On 5/29/24 at 1:55 PM, V5 (LPN) stated, If a call light (nurse call) is shut off in the room, it's still on in the system and we have to restart the system. Sometimes the call light gets stuck on, and we have to restart the system. It's (software application) kinda squirrely sometimes. It worked a lot better when we could just see the lights. On 5/30/24 at 9:45 AM, V1 (Administrator) stated if the wi-fi or power is lost, the facility has bells to give the residents and 15-minute checks are conducted. On 5/30/24 between 10:29 AM and 10:40 AM, two computers in the South Hall, one computer in the [NAME] hall and one computer in the East hall displayed two alarm notifications (1 notification on for 18 minutes in 3 North bathroom, 1 notification on for 9 minutes in 7 [NAME] bathroom) although no sound was heard. On 5/30/24 at 10:40 PM, V18 (CNA) stated, The volume was turned down because it's annoying. The following observations lacked nurse call monitoring by a nurse or CNA: The North Hall- on 5/28/24 between 10:20 AM and 11:00 AM, 12:00 PM and 12:30 PM; On 5/29/24 between 11:45 AM and 11:59 AM, 12:10 PM and 1:30 PM - 1:39 PM; 5/30/24 between 9:29 AM and 9:35 AM and 10:34 AM. The East Hall- on 5/29/24 at 1:40 PM and 5/30/24 at 9:29 AM. The South Hall- 5/29/24 at 1:29 PM and 5/30/24 at 9:28 AM. The Resident Census dated 5/28/24 documents that 62 residents currently reside in the facility.

Based on observation, interview, and record review the facility failed to perform wound care in a way that prevents cross contamination of wounds for 2 residents (R56 and R68) of 4 residents reviewed for wound care in a total sample of 36. Findings Include: The Facility's Aseptic Wound and Skin Treatment Procedure, dated 08/21, documents the purpose of the procedure is to prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structure and to promote resident comfort. The Aseptic Wound and Skin Treatment Procedure documents, Establish your clean and dirty fields. Remember the dirty field should be the farthest away from your clean field. (Place the plastic bag at the end or foot of the bed to receive soiled dressings). Clean the wound as ordered. Clean from center outward, never going back over area which has been cleaned. (If two (2) wounds, treat each wound as separate wounds.) On 4/5/23 at 8:05 AM V4 (RN) donned gloves, opened a single protective barrier wipe package, lifted R58's right arm sleeve and wiped up and down on a small skin tear, then lifted R58's left pant leg and with the same gloves and the same wipe wiped up and down and back and forth on a small skin tear. On 4/5/23 at 8:15 AM V4 used spray Normal Saline to wash R68's two sacral wounds. V4 sprayed both areas and used the same gauze 4x4 to wipe back and forth and up and down on both wounds. V4 dropped the gauze on the bed linen and picked it up and wiped the areas again. After cleansing the area V4 washed her hands, changed gloves, and then put both of her hands inside both of her scrub top pockets to get her scissors and then touched both wounds again. On 4/5/23 at 11:00 AM V4 (RN) stated, I should have treated both wounds separately for both (R58) and (R68). I also should not have put my hands with clean gloves in my pockets.