**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to keep the medication preparation room free of ants where intramuscular medications are drawn up for 2 of 2 residents (R27 and R5) reviewed for pest control in the sample of 20. Findings include: R27 was admitted to the facility on [DATE], with diagnoses of antiphospholipid syndrome and hypogonadism. R27's orders, dated 11/13/24, documented a current order for Testosterone Cypionate Intramuscular Solution 100 MG/ML (Testosterone Cypionate) for hypogonadism. R5 was admitted to the facility on [DATE], with diagnosis of chronic fatigue. R5's orders, dated 6/25/24, documented a current order for Testosterone Cypionate Intramuscular Solution 200 MG/ML (Testosterone Cypionate) for Replacement therapy. On 11/12/24, at 10:55 AM, the facility's Medication Room was checked with V7, Licensed Practical Nurse (LPN). There were ants seen on the counter, in medication cabinets, and in the refrigerator. V7 stated there is an ant problem, but only in this room to her knowledge; unsure what from. On 11/13/24, at 2:45 PM, in a joint interview with V3, Minimum Data Set (MDS) nurse, and V10 (Licensed Practical Nurse/LPN) both stated the medication room is used to pull up vials of medications such as intramuscular injections. V3 stated the facility has two residents currently on Testosterone, which is be pulled up in the medication room. On 11/14/24 at 9:15 AM, V1, Administrator, stated she expects the facility to be free of insects and pests, and for the staff to be reporting any infestation of ants. The facility's Insect and Pest Control Policy undated, documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Any employee observing insects or rodents shall inform their supervisor giving the exact location and type of infestation.

Based on interview and record review, the facility failed to obtain conduct pre-employment screening, including the Illinois and National Sex Offender Registry, the Illinois Department of Corrections Inmate search, and obtain results of fingerprint checks, to determine if employees had a prior criminal history which would disqualify them for employment. This had the potential to affect all the 36 residents living in the facility. Findings include: The facility's Abuse Prevention Program Policy, dated 11/28/16, documents, This facility affirms the right out of our residents to be free from abuse, neglect, misappropriate of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of our residents. This will be done by conducting required pre-employment screening of employees. The facility's Health Care Worker Background Check Policy and Procedure, dated 2/28/12, documented it is the policy of the facility that all persons employed in the care facility are required to be free of conviction of committing, or attempting to commit any crime listed in the Health Care Worker Background Check Act. The facility will request a background check on all employees. Employees will be terminated if the background check or the results of the Health Care Worker Registry reveal a finding of ineligibility. Persons applying for employment will be hired conditioned upon results of the appropriate background check as follows: A fingerprint based criminal history records check will be required of all individuals applying for a direct care position or having access to long-term care residents or the living quarters or financial, medical or personal records of long-term care residents, hereinafter referred to as Direct Care Applicant. A UCIA non-fingerprint conviction background check will be required of all individuals licensed by the Department of Financial and Professional Regulation or the Department of Public Health under another law of this state, hereafter referred to as Licensed Applicant. It continues, 2. The Administrator/designee confirms the certification of an employee by checking the Health Care Worker Registry. Whether a fingerprint-based criminal history records check has previously been conducted is indicated by the identifier of Fee App or CAAPP. It continues, 5. In all cases, the facility shall conduct internet searches on certain web sites, including without limitation: the Illinois Sex Offender Registry; the Department of Corrections' Sex Offender Search Engine; the Department of Corrections Inmate Search Engine; The Department of Correction Wanted Fugitives Search Engine; the National Sex Offender Registry and the website of the Health and Human Services Office of Inspector General to determine if the applicated has been adjudicated a sex offender, has been a prison inmate, or has committed Medicare of Medicaid fraud. On 11/12/24, ten employee files were reviewed for pre-employment screening. The following was documented: V13, Certified Nurse's Aide (CNA), was hired on 7/29/24. The facility initiated a Health Care Registry check, an Illinois Sex Offender search, an Illinois Department of Corrections (DOC), and an inmate/wanted fugitive search on 7/29/24. The facility did not have an Office of Inspector General (OIG) search to determine if V13 has a disqualifying conviction. V5, Activity Director, was hired on 9/27/24. The facility did not initiate a Health Care Registry check, an Office of Inspector General (OIG) search, a fingerprint based criminal background check, an Illinois Sex Offender registry, the National Sex Offender registry, or the Illinois Department of Corrections (DOC) inmate/wanted fugitive search to determine if V11 had a disqualifying conviction. On 11/13/24 at 11:25 AM, V1, Administrator, stated the facility failed to complete the required background checks for V5, Activity Director, upon hire. V1 stated she thought her BOM (Business Office Manager) V12 completed the required background checks and V12 thought V1 had completed the background checks, so they were missed. V1 stated she terminated V5 this am because she discovered V5 has disqualifying convictions after the surveyor requested V5's healthcare worker background checks. V8, Dietary Aide, was hired on 8/8/24. The facility did not initiate a Health Care Registry check, an OIG search, a fingerprint based criminal background check, an Illinois Sex Offender registry search, nor an Illinois DOC inmate/wanted fugitive search to determine if V8 had any disqualifying convictions. On 11/13/24 at 2:05 PM, V1 stated V8 was supposed to go and get a fingerprint background check but she did not. V1 stated she will inform V8 she must get the fingerprint background check completed, and she will not be able to work anymore until it is done. V14, CNA, was hired on 11/11/24. The facility initiated a Health Care Registry check, an Illinois Sex Offender search, an Illinois Department of Corrections (DOC), and an inmate/wanted fugitive search on 11/11/24. The facility did not have an Office of Inspector General (OIG) search to determine if V14 has a disqualifying conviction. V15, CNA, was hired on 10/21/24. The facility initiated a Health Care Registry check. The facility did not have an Illinois Sex Offender registry search, an Illinois DOC inmate/wanted fugitive search, nor an OIG search. V16, CNA, transferred to this facility from a sister facility on 6/25/24. The facility failed to complete a new Health Care Worker Registry check. The facility did not have an Illinois Sex Offender registry search, an Illinois DOC inmate/wanted fugitive search, nor an OIG search. On 11/13/24 at 2:08 PM, V1 stated the facility did not complete background checks on V16 because V16 transferred from a sister facility. V1 stated this facility and the sister facility are on separate payrolls. V18, CNA, was hired on 10/15/24. The facility initiated a Health Care Registry check, an Illinois Sex Offender search, an Illinois Department of Corrections (DOC), and an inmate/wanted fugitive search on 10/15/24. The facility did not have an Office of Inspector General (OIG) search to determine if V18 has a disqualifying conviction. V19, CNA, was hired on 6/24/24. The facility failed to check the Health Care Worker Registry, Illinois Sex Offender Registry, and Illinois DOC, and an inmate/wanted fugitive search until 9/24/24. The facility did not have any documentation showing that the facility completed an OIG search on V19. V23, CNA, was hired on 6/25/23. The facility failed to check the Health Care Worker Registry to ensure V23 was eligible to work until 12/29/23. The facility did not have an Illinois Sex Offender registry, the Illinois Department of Corrections (DOC) inmate/wanted fugitive search, nor an OIG search to determine if V23 had a disqualifying conviction. V12, Business Office Manger and CNA, transferred to the facility on 6/25/24 from a sister facility. The facility failed to complete a new Health Care Worker Registry check, Illinois Sex Offender registry search, an Illinois DOC inmate/wanted fugitive search, nor an OIG search. On 11/14/24 at 11:38 AM, V1 stated V12 transferred from a sister facility, and she did not complete any new background checks, including the Health Care Worker Registry. V1 stated she did not think it was required when an employee transfers to a sister facility. V1 stated these two sister facilities are not on the same payroll. V17, RN (Registered Nurse), was hired on 8/15/24. The facility failed to check the IDFPR (Illinois Department of Financial and Professional Registry) to ensure V17's RN license is active until 11/13/24, after the surveyor requested the information. V2, RN/DON (Director of Nursing), was hired on 6/14/24. The facility failed to check the IDFPR to ensure V2's RN license is active until 11/13/24, after the surveyor requested the information. On 11/13/24 at 1:50 PM, V1 stated only 1 nurse of the 3 requested had proof that the IDFPR was checked for active nursing licenses. V1 stated she did not have anything showing the facility checked the IDFPR website to ensure V17 and V2 had active RN licenses prior to hire. On 11/14/24 at 11:06 AM, V1 stated she expects the facility to complete employee background checks prior to an employee working the floor. On 11/14/24 at 11:07 AM, V11, Regional Nurse, stated she expects the facility to complete employee background checks per the regulations and policy.

Based on interview, observation, and record review, the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 36 residents in the facility. Findings include: On 11/13/24 at 1:11 PM, V2, Director of Nursing (DON) stated, When I'm here we have RN coverage. We also have two prn (as needed) RNs. There was a week I wasn't here. I left the 30th (October) and came back this Monday (November 11th). On 11/14/2024 at approximately 10 AM, V2 provided a document titled, (Facility) RN Hours, documents there was no RN coverage on October 4th, 5th, 6th, or 13th, as well as November 1st, 2nd, 3rd, 4th or 5th, 8th, 9th, or 10th all 2024. The Facility's Nurse Staffing Policy, undated, documents, It is the policy of (Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specificized by the Illinois Department of Public Health. Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The Facility's CMS-671, dated 11/12/2024, documents there are 36 residents residing at the Facility.

Based on interview, observation, and record review, the facility failed keep their emergency medication kit sealed after use. This has the potential to affect all 36 residents living in the facility in the sample of 20. Findings include: On 11/12/24 at 10:55 AM, upon inspection of the facility's medication preparation room, an Emergency Medication Kit labeled DJ did not have a green lock tag securing it. The Emergency Medication Kit labeled DJ contained the following list of medications: Albuterol HFA Inhaler, Albuterol Sul Neb, Atropine 1% eye drops, Bacteriostatic saline, BD 3 mL syringe, BD Insulin Syringe, BD Luer-lok syringe, BD needles, Cefazolin, Ceftriaxone, Dexamethasone, Diphenhydramine, Enoxaparin, Epinephrine, Filter needle, Furosemide, Gentamicin, Glutose, Gvoke Hypopen, Haloperidol, Heparin, Ipratripium, Lidocaine, Naloxone, Ondansetron, Phytonadione, Promethazine, Scopolamine patch, Sodium Polystyrene powder, Solu-Medrol, Tobramycin, and water for injection. On 11/12/24, at 11:00 AM, V7, Licensed Practical Nurse (LPN), stated there would be no way of knowing what was still in the kit, or what was used, if anything. V7 stated those kits are supposed to be resealed with a new lock tag after each use and pharmacy is supposed to be notified. On 11/13/24 at 2:40 PM, V2, Director of Nursing, stated the Emergency kit labeled DJ includes medications that could be used on all the residents in the facility. On 11/14/24 at 9:30 AM, V1, Administrator, stated she expects that the Emergency Kits are kept locked, and that pharmacy is immediately notified after each time it is used. The facility's Pharmacy Emergency Box Policy, last review on 3/16/23, documented the box is to be properly sealed, and completely replaced each time the seal is broken. When the Emergency Box is opened, the pharmacy should be notified.

Based on observation, interview, and record review, the Facility failed to ensure repairs were made to the environment to provide peace of mind to residents. This failure has to potential to affect all 36 residents residing in the Facility. Findings include: On 11/12/2023 at 1:54 PM, R1 stated, The outside smoking area concrete needs fixed or someone is going to fall. On 11/13/2024 the patio area on the East side of the building was observed to have a 4-5-foot-long patch of cracked concrete. The Facility's Resident Council Minutes, dated 4/2024, documents, Maintenance: concrete by patio door. The Facility's Resident Council Minutes, dated 5/2024, documents, Old Business: Maintenance has ordered concrete supplies. The Facility's Council Memorandum, dated 5/23/2024, documents, Issue: Concrete by patio door needs replaced. It continues to document concrete patch material has been ordered. The Facility's Council Memorandum, dated 6/12/2024, documents, Patio concrete is getting worse. Residents are getting stuck. The Facility's Resident Council Minutes, dated July 2024, documents, Old business: Patio concrete. The Facility's Resident Council Minutes, dated 9/15/2024, documents, Concrete needs fixed by patio door. The Facility's Resident Council Minutes dated 10/7/2024, documents, Reports from the officers: Concrete on back patio needs fixed where table is. The Facility's Council Memorandum, dated 10/7/2024, documents, Nature of concern: Concrete on back patio needs fixed-as a dip in it. Resolution: I (V25, Maintenance) don't think a patch will work. It has been patched before. New owners noted a few areas on portion that need repaired. Hopefully they will address this when they take over. The Facility's Resident Council Minutes, dated 11/4/2024, documents, Maintenance-back patio. On 11/13/24 at 12:34 PM, V25 stated, It's been patched before. It just didn't stay. It has to get worked out with the new company. They are aware of it and it was pointed out to them in their tours both times. They (the residents) have asked several times in resident council about it. The patch just doesn't stay. I don't think it's that bad. There hasn't been any work orders put in for it. On 11/14/2024 at 11:57 AM, V24, Illinois Department of Public Health Life Safety Surveyor, stated the area of concrete on the East patio could be a tripping hazard and in need of repair. The Facility's Physical Plant & Environment Policy & Guidelines documents, Policy Statement: It is the utmost importance to provide a safe, hospitable, clean, and organized facility and grounds to ensure an environment that is conductive to providing the best care, comfort, and home-like surrounds for residents. A well-maintained building and environment is also important for creating safe work surrounds across all departmental staffing and their ability to effectively and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping and ensuring compliance with current federal, state, local and NFPA codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. It continues to document, Policy Implementation: The Facility administrator must ensure that the overall scope and effective procedures are followed by each department supervisor and staff or request of approved contractors for creating and maintaining work orders are completed in a timely manner and ensure items necessary for repairs are ordered to complete repairs. It further documents maintenance/approved contractors are responsible for a safe and clean designated outdoor resident and staff smoking areas. The Facility's CMS-671 dated 11/12/2024 documents there are 36 residents residing at the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision and assistance required to prevent accidents for one (R3) of three residents reviewed for accidents and supervision. Findings Include: R3's face sheet, dated 9/5/24, documented R3 has diagnoses of sepsis, urinary tract infection, bipolar disorder, acquired absence of right leg below knee, acquired absence of left leg below knee, chronic pain, atherosclerotic heart disease, heart failure, hypertension, obstructive and reflux uropathy, hyperlipidemia, fibromyalgia, type 2 diabetes mellitus, COPD (chronic obstructive pulmonary disease, and aphasia following cerebral infarction. R3's MDS (Minimum Data Set), dated 7/19/24, documented R3 has severe cognitive impairment. R3's MDS, dated [DATE], documented R3 has impairment on one side of upper extremities secondary to cerebral infarction and impairment of both lower extremities secondary do bilateral lower leg amputations. This MDS documented R3 is dependent on staff for all ADLS (Activities of Daily Living). R3's care plan, undated, documented R3 has a communication deficit related to an old stroke and cannot speak. Makes preferences known by yelling sounds and making hand gestures. This care plan also documented R3 requires a mechanical lift with two assists for all transfers. R3's care plan does not address falls nor fall risk. R3's Quality Care Reporting Form, dated 8/23/24 at 2:00 pm, documented resident had an unwitnessed fall in the courtyard. Intervention is resident isn't to be alone outdoors. R3's paper nurse's notes, dated 8/23/24 at 2:00 pm, documented notified resident was on ground. ROM (range of motion) WNL (within normal limits). Noted an abrasion to above her right knee. Area cleansed and left OTA (open to air). DON (Director of Nursing), MD (Medical Doctor) and Administrator made aware. R4's face sheet, dated 9/5/24, documented R4 has diagnoses of osteoarthritis, depression, hypertension, unspecified dementia, neuropathy, type 2 diabetes mellitus, and chronic pain. R4's MDS, dated [DATE], documented R4 is cognitively intact. R4's care plan, undated, documented R4 requires a sit to stand lift and assistance of 2 for all transfers and requires a wheelchair for mobility. R4's care plan also documented R4 is a fall risk and that R4 has risk factors that require monitoring and intervention to reduce R4's potential for self injury. Risks include incontinent of bowel at times, use of psychotropic medication, and diabetes. On 9/5/24 at 10:00 AM, R4 stated she was outside on the patio with her friend/fellow resident (R3) about a week or two ago. R4 stated she attempted to push (R3's) wheelchair up to the table and (R3's) wheelchair hit a dip in the concrete by a drain causing (R3) to fall out of the wheelchair. R4 stated no staff were around and she had to use her cell phone to call the facility to get staff out on the patio to assist (R3). R4 stated staff had pushed (R3) out on the patio, but they did not stay out there. R4 stated she was very upset by this and was crying because she felt so bad about (R3) falling out of her wheelchair. On 9/5/24 at 9:10 AM, V5, Activity Director, stated she was out of the building on a van transport the day (R3) fell out on the patio. V5 stated (R3) should not have been outside unless an employee was present. On 9/5/24 at 9:42 AM, V3, CNA (Certified Nurse Assistant), stated she was not working on the day (R3) fell out on the patio. V3 stated (R3) was not supposed to be outside without an employee being out there with her. On 9/5/24 at 12:25 PM, V1, Administrator, stated R3 should have never been outside without staff present. V1 stated an employee had been outside supervising the residents who smoke and when the residents were done smoking, the employee left R3 outside with R4. V1 stated =she cannot recall who the employee was that left R3 unattended. On 9/5/24 at 2:20 PM, V9, LPN (Licensed Practical Nurse), stated she was R3's nurse the day she fell out on the patio. V9 stated R4 called the facility from her cell phone to alert staff R3 was on the ground. V9 stated she and the CNAs had to use a mechanical lift to get R3 up off the concrete patio. V9 stated R3 should not have been outside without staff present. The facility's Fall Prevention Policy, dated 11/10/18, documented the policy is to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: all staff. Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. It continues, all staff must observe residents for safety.

Based on interview and record review, the facility failed to provide transportation from the emergency room where R2 received laboratory services for one of three (R2) residents reviewed for transportation to and from the source of service. Findings include: R2's face sheet, dated 3/21/2024, documents an admission date of 2/16/2024, and diagnoses that include hemiplegia, dysarthria and cerebral infarction. R2's progress note, dated 3/8/2024 at 11:55pm, documents, Local hospital emergency nurse called facility at 8:44pm and said (R2) would be returning. Local hospital nurse called facility back at 2056 and stated facility would have to set up transfer and gave local ambulance number. Notified (V3) at 9:00pm due to unknown to who can drive the van and knowing (R2's) transfer status and not being eligible for ambulance transfer through insurance. At 9:28pm ambulance service worker called facility asking for approved payment for (R2). The hospital had called and set it up and ambulance had a crew at the hospital waiting. Notifed (V3) who stated facility was not able to approve payment and said everyone who is approved to drive the van either said no or had not answered (V3) yet. (V3) asked if family maybe available to transport. called emergency contact #1 and it went straight to VM (voice mail). then called emergency contact #2 and emergency contact #1 answered on that number and said he was in Decatur and couldn't give (R2) a ride but if (R2) still needed a ride in the AM he would. at 10:48pm (V3) informed that maintenance man to pick (R2) up in AM and hospital aware. Hospital then called back at 11:20pm and inform that the physician on shift is going to report facility to state for abandonment if (R2) is not picked up now. R2's progress note, dated 3/9/2024 at 09:12am, documents, (R2's) family called inquiring about why Hospital called them stating that facility had abandoned the (R2) there. The hospital had called family multiple times as well as the facility and had explained that facility did not have transport at the time. Family requested that facility call them once (R2) is back in the facility. R2's progress noted, dated 3/9/2024 at 9:53am, documents, (R2) returned from local Hospital at approx 9:45am. (R2) stated hospital did not feed him breakfast, ,dietary brought (R2) something to eat. updated family on (R2') return and condition. R2's hospital records dated 3/8/2024 document laboratory services and radiology services were provided during emergency room visit. On 3/21/2024 at 12:20 PM, V1 (Administrator) stated R2 went to the hospital on the evening of 3/8/2024 and the hospital called wanting to send (R2) back later that evening. V1 stated the facility did not have anyone to drive the transport van that evening, but the following morning, R2 was picked up from the hospital by the facility transport van and returned to the facility. On 3/21/2024 at 12:40 PM, V3 (Licensed Practical Nurse)stated, (R2) went to the hospital on the evening on 3/8/2024 and the hospital called wanting to send (R2) back to the facility, and wanted to know if the facility would pay for ambulance transfer. V3 stated she could not make that authorization to pay for transport. V3 stated she made multiple calls to several staff to find a driver for the van to pick up R2 from the hospital, but wasn't able to find someone to pick R2 up until the morning of 3/9/2024 from the hospital. V3 stated R2 returned to the facility on the morning or 3/9/2024. V3 stated the family was not able to transport R2 to the facility either. Facility provided medical transportation cost policy, dated 7/2018, documents, facility will provide medical transportation when the facility's vehicle is able to accommodate the trip. Medical transportation will be a private expense billed to the resident.

Based on observation, record review, and interview, the facility failed to provide therapy services for 6 of 6 residents (R1, R3, R4, R5, R8, R9) reviewed for therapy services. Findings include: On 3/21/2024 at 11:00 AM, V1 (Administrator) stated, Therapy services ended on 2/17/2024, and a new company starts soon. The new therapy company was in this week. V1 stated she is not sure if she has anyone with therapy orders right now. On 3/21/2024 at 11:10 AM, V2 (Business office Manager) stated they do not have therapy services, and it has been about a month since therapy was here. V2 stated they have a new therapy company that is starting soon. On 3/21/2024 at 12:20 PM, V1 stated there are 6 residents with orders for therapy that are not receiving therapy services. On 3/21/2024 at 12:40 PM, V3 (Licensed Practical Nurse) stated the facility has not had therapy services for about a month now. V3 stated, (R1), (R3), (R4), (R5), (R8), and (R9) had an order to hold therapy services dated 2/18/2024 for one week. Since those residents still have not received therapy even though there are doctor's orders for therapy. Corporate has not let us know the status of therapy servicing starting up again. We have no idea when those residents will begin receiving therapy services again. On 3/21/2024 at 2:30 PM, V6 (Licensed Practical Nurse) stated there have been no therapy services since the middle of February. Observations of no therapy staff in building on the date of 3/21/2024 11:00 AM-3:30 PM. R1's physicians orders contain order, dated 2/9/2024, for PT (Physical Therapy) to eval and treat. R3's physicians orders contain order, dated 2/12/2024, for physical therapy clarification order skilled physical therapy 4 times a week for 4 weeks to include therapeutic exercise therapeutic activities neuromuscular re-education gait training electrical stimulation ultrasound short wave diathermy per plan of care. R4's physicians orders contain order, dated 2/22/2024, for may have physical therapy/occupational therapy/speech therapy as determined by intradisciplinary team recommendation. R5's physicians orders contain order, dated 2/1/2024, for physical therapy recertification orders skilled physical therapy I time a week for 4 weeks to include therapeutic exercises therapeutic activities neuromuscular reeducation gait training electrical stimulation ultrasound short wave diathermy per plan of care. R8's physicians orders contain order, dated 2/9/2024, for physical therapy and occupational therapy clarification order skilled physical therapy 5 times a week for 4 weeks to include therapeutic exercise, therapeutic activities neuromuscular reeducation, gait training, electrical stimulation ultrasound short wave diathermy for diagnosis of weakness. R9's physicians orders contain order, dated 2/19/2024, for physical therapy 3 times a week for 4 weeks, therapeutic exercise therapeutic activities neuro re-ed manual techniques gait training and estim. Facility provided contract from new therapy company, dated 3/13/2024.

Based on interview and record review, the facility failed to provide the services of a Director of Nursing on a full-time basis, and a Registered Nurse for 8 consecutive hours a day. This failure has the potential to affect all 31 residents in the facility. Findings include: On 3/21/2024 at 11:00 AM, V1 (Administrator) stated they do not have a Full time Registered Nurse on duty. V1 stated V5 (Director of Nursing) is not here today either. On 3/21/2024 at 12:20 PM, V1 stated V5 is not in the facility 40 hours a week, and does not remember the last time V5 was in the facility. On 3/21/2024 at 12:40 PM, V3(Licensed Practical Nurse) stated V5 is the DON of record for the facility, but she has not been in the facility for 40 hours a week. On 3/21/2024 at 2:00 PM, V2 (Business Office Manager) stated V5 hasn't been in the facility for weeks now, and V5 is the only RN here. On 3/21/2024 at 2:30 PM, V6 stated the facility rarely has a Registered Nurse working. The facility's Nursing staffing scheduled reviewed with no full time Director of Nursing and no Registered Nurse for the month of February and March 2024. On 3/21/2024 at 11:00 AM, V1 stated the current census of facility is 31.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to prevent the development and worsening of pressure ulcers as well as implement Physicians Orders and Care Plan interventions for 1 of 2 residents (R16) reviewed for pressure ulcers in the sample of 30. Findings include: R16's Face Sheet, dated 10/24/2023, documents R16 has a open wound to R16's left foot. R16's Minimum Data Set (MDS), dated [DATE], documents R16 is totally dependent on staff for bed mobility. The Facility's Weekly Wound Tracking documents R16's left heel pressure ulcer was acquired on 8/11/2023 and was 1.5 centimeters (cm) by 2 cm. R16's Skin Evaluation, dated 10/17/2023, documents R16's left heel pressure ulcer measured 2.5 cm by 3.1 cm, indicating R16's wound has grown in size. R16's Care Plan, dated 2/24/2023, documents R16 is at risk for pressure ulcers. R16's Care Plan was updated on 8/11/2023, and an intervention to always wear heel protectors when in bed due to a stage 2 pressure ulcer to R16's left heel. R16's Order Summary Report, dated 10/24/2023, documents, Heel protectors on at all times while in bed. On 10/23/23 at 10:25 AM, R16 was sitting in her recliner with the footrest elevated. Both of R16's heels were resting on the foot of the recliner. On 10/23/2023 at 1:44 PM, R16 was lying in bed. Neither of R16's feet had heel protectors on. On 10/24/2023 at 9:30 AM, R16 was lying in bed without heel protectors on either foot. One of the heel protectors was located on top of the light fixture above R16's bed, and the other one was located in the empty bed across the room. On 10/24/2023 at 10:10 AM, V9, Certified Nursing Assistant (CNA) removed R16's sock to show the surveyor R16's bandage to her left heel. V9 then reapplied the sock, covered R16 up with a blanket, and left the room without applying R16's heel protectors. On 10/24/2023 at 11:19 AM, R16 remained in bed without either heel protectors on. On 10/25/2023 at 3:29 PM, V2, Regional Director of Nursing, stated R16 acquired the pressure ulcer to her left heel 8/11/23 while at the Facility. V2 stated R16 is supposed to wear both booties and (R16) should definitely have one on her left heel. On 10/26/2023 at 10:30 AM, R16 was lying in her bed, without either heel protectors on. On 10/26/2023 at 1:50 PM, R16 was lying in her bed, without either heel protector on. One heel protector remained on top of the light fixure and the other one was located under a blanket in R16's recliner. The Facility's Decubitis Care/Pressure Areas Policy, dated 1/2018, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. It continues to document, When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers.

Based on interview and record review, the facility failed to provide 4 out 4 (R25, R179, R180, R181) residents, Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage and/or the Notice of Medicare Non-Coverage, (NOMNC), forms during discharge from Medicare A services. findings include: 1.) R25's face sheet documents admission date 0f 12/29/2022. R25's Skilled Nursing Facility Beneficiary Protection Review document states R25 began skilled Medicare A services on 2/14/2023 and facility provider initiated the discharge for Medicare part A services when benefit days were not exhausted with last covered day of Medicare A services to end on 4/28/2023. Facility provided document, titled Notice of Medicare Non-Coverage, (NOMNC), form for R25 that is not dated, nor is it signed by R25 or her representative. On 10/25/2023 at 1:11 PM, V1 (Administrator) stated the facility filled out the forms, but has no proof R25 received the ABN/NONMC forms. 2.) R179's face sheet documents admission date of 4/14/20223. R179 's Skilled Nursing Facility Beneficiary Protection Review document states R179 began skilled Medicare A services on 4/14/2023 with voluntary discharge of last covered day of Medicare A services to end on 7/20/2023. This document states that facility provided R179 with Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form. Facility provided Notice of Medicare Non-Coverage, (NOMNC), form. On 10/25/2023 at 1:11 PM, V1 stated, We should have given (R179) the SNF/ABN form, but didn't. 3.) R181's face sheet documents admission date of 4/26/2023 with Medicare A as payor. R181's Skilled Nursing Facility Beneficiary Protection Review document states R181 began skilled Medicare A services on 4/26/2023 with voluntary discharge of last covered day of Medicare A services to end on 5/12/2023. On 10/25/2023 at 1:11 PM, V1 stated they have no SNF/ABN/NONMC documents for R181's discharge. 4.) R180's face sheet documents admission date of 5/12/2023 with Medicare A as payor with discharge date of 6/2/2023. On 10/25/2023 at 1:11 PM, V1 stated the facility has no documents for discharge of R180, including no SNF/AB/NONMC forms. On 10/25/2023 at 1:11 PM, V1 stated the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage and or the Notice of Medicare Non-Coverage, (NOMNC) forms were not done correctly for R2r, R179, R180, and R181. On 10/26/2023 at 10:00 AM, V1 stated the facility does not have a policy on SNF/ABN/NONMC.

Based on interview and record review, the facility failed to transmit MDS, (Minimum Data Set), within 28 days of Assessment Reference Date (ARD) for 4 of 4 (R18, R21, R24, R27) in a sample of 30 residents reviewed for timely submission of quarterly review assessments. findings include: 1.) R18's MDS documents Quarterly Review Assessment, dated 9/13/2023, was signed as complete on 10/22/2023, with a submission date of 10/26/2023. 2.) R21's MDS documents Quarterly Review Assessment, dated 9/8/2023, was signed as complete on 10/3/2023, with a transmission date of 10/26/2023. 3.) R24's MDS documents Quarterly Review Assessment, dated 9/6/2023, was signed as complete on 10/3/2023, with a transmission date of 10/26/2023. 4.) R27's MDS documents Quarterly Review Assessment, dated 9/6/2023, was signed as complete on 10/3/2023, with a transmission date of 10/26/2023. On 10/25/2023 at 3:00 PM,V13 (MDS coordinator) stated she probably made a mistake and didn't transmit the MDS timely because she got confused, because there were computer issues. On 10/26/2023, V1 (Administrator) stated she expects the MDS coordinator to transmit the MDS timely.

Based on observation, interview, and record review, the Facility failed to ensure medications requiring refrigeration were kept at an acceptable temperature for 9 of 9 residents (R1, R7, R8, R9, R10, R12, R18, R19, R26), reviewed for medication storage in the sample of 30. Findings include: On 10/24/23 at 10:25 AM upon entering the medication room, the door to the refrigerator, which stores medication, was open. V5, Licensed Practical Nurse (LPN), closed the door at this time. There was a paper hung up on the door titled Refrigerator Temperature Log: October 2023. This documents no temperature was taken on 10/4/2023, 10/5/2023, 10/9/2023, and 10/15/2023. It further documents the temperature on 10/13/2023 was 60 degrees (Fahrenheit). The thermometer inside the refrigerator was 62 degrees. V5 stated the night shift is responsible for taking and documenting the temperatures. V5 also stated the refrigerator door had probably been open since she got supplies out of it sometime earlier in the morning. On 10/25/2023 at 3:28 PM, V2, Regional Director of Nursing, stated the temperature of the refrigerator should not be above 40 degrees. When V2 was informed of the temperature she stated, We will have to call pharmacy to see what we need to get rid of. On 10/24/2023 at 9:13 AM, V2 stated all unopened insulin should be refrigerated and all the insulin dependent residents could have been affected. The Facility provided a document titled, Insulin Dependent Residents. The document listed 9 residents (R1, R7, R8, R9, R10, R12, R18, R19, R26). The Facility's Procurement and Storage of Medications, dated 11/6/2018, documents, 11. Medications requiring refrigeration are to be kept in the locked refrigerator, or in a refrigerator in the locked area. The Policy does not address the temperature requirements.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse, for 8 consecutive hours, 7 days a week. this deficient practice has the potential to affect all 27 residents residing in the facility. findings include: On 10/24/23 at 2:32 PM, Nursing Schedules reviewed with noted dates of 9/2/2023, 9/3/2023, 9/9/2023, 9/10/2023, 9/16/2023, 9/17/2023, 9/24/2023, 9/30/2023, 10/15/2023, 10/21/2023 and 10/22/2023, with no RN scheduled. On 10/24/2023 at 9:43 AM, V2 (Director of Nursing) stated the facility is having a hard time staffing RNs on the weekend. On 10/24/2023 at 9:43 AM, V1 (Administrator) stated they have a DON, but have a hard time getting RNs to work the weekends, and currently resident census is 27.

Based on interview and record review, the facility failed to complete a performance review of Certified Nursing Assistant at least once every 12 months. This deficient practice has the potential to affect all 27 residents residing in the facility. findings include: On 10/25/2023 at 2:00 PM, employee file for V8 reviewed, with no documentation of annual performance evaluations completed. On 10/25/2023 at 2:00 PM, employee file for V10 reviewed, with no documentation of annual performance evaluations completed. On 10/25/2023 at 2:00 PM, employee file for V14 reviewed, with no documentation of annual performance evaluations completed. On 10/24/2023 at 9:43 AM, V2 (Director of Nursing) stated if needed, the facility will do competency training for CNAs, but they do not do annual performance reviews. V2 stated she does not have any employee records of performance or competency reviews. On 10/23/2023 at 9:00 AM, V1 (Administrator) stated census is 27.

Based on record review and interviews, the facility failed to report allegation of abuse delaying the investigation for two of three residents (R1 and R2) reviewed for reporting of abuse allegations in the sample of 8. Findings include: The Illinois Department Notification from, dated 9/21/23, documented, Resident (R1) was found touching Resident (R2) inappropriately. There were immediately separated. Both residents have DX (diagnosis) of dementia. Addendum to Incident, written by V1, Administrator, regarding her phone interview with V12, Licensed Practical Nurse, documented, Passing meds went to nurse's desk. (R1) was groping her (R2) breast. He was squeezing and massaging her. When asked, he said he was teasing her. I told him he couldn't do that. Immediately separated them. She looked very uncomfortable. Knees to her chest and looked upset. I kept her with me until CNA (Certified Nursing Assistant) could lay her back down. Addendum to Incident, dated 9/26/23, written by V1 while she conducted a telephone interview with V11, Certified Nursing Assistant (CNA), documented, I caught (R2) and (R1) in the dining room in the dark. (R2) was starting to undo (R1's) pants. I gave report to the nurse. This document did not include a date when this incident occurred. Statement written by V10, CNA, dated 9/20/23, documented, Last time this happened, (R1) inappropriately touching (R2), (V8, LPN/Licensed Practical Nurse) told me he's not alert x 3 and because (R2) is known to also touch res (residents), she's just as much at fault, and that (R1) doesn't know it's wrong, but he VERY MUCH does. Last time he asked me if I was gonna get him in trouble for putting 'his hands in the cookie jar'. He said he knows he shouldn't. Tonight, we caught him again and he stated, he knows she wants it. She didn't look happy and wasn't touching or looking @ (at) him. Addendum to Incident, dated 9/26/23, written by V1 during phone interview with V10, CNA, documented, I've caught (R1) three times touching (R2). I was told nothing can be done about it because he is not alert and oriented times three by (V8). On 10/10/2023 at 11:45 AM, V10 states she didn't report the previous incidents regarding R1 and R2 to administration. On 10/10/2023 at 11:45 AM, V11 states she didn't report the previous incidents to administration. On 10/5/2023 at 3:00 PM, V1 (Administrator) stated V12 witnessed R1 touching R2's breast at the nurse's station on 9/21/2023. V1 stated she investigated this and found it had occurred. V1 stated V9, LPN, called her and reported the inappropriate touching as V12 informed V9 during report on 9/21/23. V1 stated V12 did not report the occurrence between R1 and R2 at the time it occurred. V1 stated she did report it, notify the police, and start her investigation when she was notified. V1 stated during the investigation of the 9/21/2023 incident between R1 and R2, V10 made a written statement of R1 touching R2 three times, and that R1 made comments after the last episode of inappropriate touching that he knew he shouldn't do it. V1 stated she was not notified of these previous occurrences, did not report these, and did not investigate these statements. V1 also stated V11's written statements stated R2 was caught undoing R1's pants on a previous occasion. V1 stated that she did not report this, nor did she investigate this. The Facility's Abuse Prevention Program, dated 11/28/2016, documents employees are required to immediately report any alleged abuse to administrator. The Program documents Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports or potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property.

Based on record review and interviews, the facility failed to investigate allegations of abuse to protect residents from potential future abuse for two of three residents (R1 and R2) reviewed for investigation of abuse allegations in the sample of 8. Findings include: Addendum to Incident, written by V1, Administrator regarding her phone interview with V12, Licensed Practical Nurse/LPN, documented, Passing meds went to nurse's desk. (R1) was groping her (R2's) breast. He was squeezing and massaging her. When asked he said he was teasing her. I told him he couldn't do that. Immediately separated them. She looked very uncomfortable. Knees to her chest and looked upset. I kept her with me until CNA (Certified Nurse's Aide) could lay her back down. Addendum to Incident, dated 9/26/23, written by V1 while she conducted a telephone interview with V11, Certified Nursing Assistant (CNA), documented, I caught (R2) and (R1) in the dining room in the dark. (R2) was starting to undo (R1's) pants. I gave report to the nurse. This document did not include a date when this incident occurred. The facility had no documentation that this incident was investigated. Statement written by V10, CNA, dated 9/20/23, documented, Last time this happened, (R1) inappropriately touching (R2), (V8, LPN) told me he's not alert x 3, and because (R2) is known to also touch res (residents), she's just as much at fault, and that (R1) doesn't know it's wrong, but he VERY MUCH does. Last time he asked me if I was gonna get him in trouble for putting 'his hands in the cookie jar'. He said he knows he shouldn't. Tonight, we caught him again and he stated, he knows she wants it. She didn't look happy and wasn't touching or looking @ (at) him. Addendum to Incident, dated 9/26/23, written by V1 during phone interview with V10, CNA, documented, I've caught (R1) three times touching (R2). I was told nothing can be done about it because he is not alert and oriented times three by (V8). The facility had no documentation regarding V10's allegation of R1 touching R2 inappropriately three times. On 10/10/2023 at 11:45 AM, V10 stated she didn't report the previous incidents regarding R1 and R2 to administration. On 10/5/2023 at 3:00 PM, V1 (Administrator) stated V12, LPN, witnessed R1 touching R2's breast at the nurse's station on 9/21/2023. V1 stated she investigated this, and found it had occurred. V1 stated V9, LPN, called her and reported the inappropriate touching, as V12 informed V9 during report on 9/21/23. V1 stated V12 did not report the occurrence between R1 and R2 at the time it occurred. V1 stated she did report it, notify the police, and start her investigation when she was notified. V1 stated during the investigation of the 9/21/2023 incident between R1 and R2, V10 made a written statement of R1 touching R2 three times, and R1 made comments after the last episode of inappropriate touching that he knew he shouldn't do it. V1 stated she was not notified of these previous occurrences, did not report these, and did not investigate these statements. V1 also stated V11's written statements stated R2 was caught undoing R1's pants on a previous occasion. V1 stated she did not report this, nor did she investigate this. The Facility's Abuse Prevention Program, dated 11/28/2016, documents employees are required to immediately report any alleged abuse to administrator. The Policy documented Upon learning of the report, the administrator or designed shall initiate an investigation. The Program documents Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on interview and record review, the facility failed to provide the services of a Director of Nursing on a full time basis. This failure has the potential to affect all 26 residents in the facility. Findings include: On 10/3/2023 at 3:00 PM, V1, Administrator, stated V2, Director of Nursing (DON), is the fulltime DON and works full time hours as of 10/1/202,3 but prior to 10/1/2023, there was no fulltime DON. On 10/3/2023 at 9:45AM, V8, Licensed Practical Nurse, LPN, stated V2 is not in building every day, but they can get a hold of her. 10/3/2023 at 11:00 AM, V6, Certified Nursing Assistant, CNA, stated V2 is reachable by phone, but not sure what hours she works at the facility. The facility's Nursing staffing was reviewed, with no noted DON for the month of September until 10/1/2023. On 10/2/2023 at 3:00 PM, V1 stated the current census of facility was 26.

Based on interview, observation, and record review, the facility failed to employee a full time Director of Nurses and provide 8 hours of continous Registered Nurse coverage. This failutre has the potential to affect all 28 residents residing in the facility. Findings include: On 8/31/23 at12:56 PM, V2, Regional Clinical Nurse, stated, We have no sitting DON (Director of Nurses); I am here 3 to 4 times a week and I work the floor here also. We have not had a DON since July. We are advertising and offering sign on bonuses to try and hire. We advertised through Talent Care which posts to Monster and Indeed. Also we have a Facebook page ad. We have a few prn (as needed) RN's (Registered Nurses) but not everyday. We are hiring for RN's also. The last day we had a sitting DON was July 13, 2023. V2 further stated the facilities policy is to follow the State and Federal guidelines for Director of Nurse and Registered Nurse coverage. During this investigation, no RN's were observed in the building outside of V2. The schedules for July and August were reviewed the facility only had RN coverage on 7/15/23 and 8/14/23. The Resident Census and Conditions of Residents, CMS 672, dated 8/31/23, documents the facility has 28 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide pressure relief and follow physician's orders to treat pressure ulcers for 1 of 1 resident (R14) reviewed for pressure ulcers in the sample of 21. Findings include: The Facility's Weekly Wound Tracking, dated October 2022, documents on 10/4/2022, R14 acquired a Deep Tissue Injury (DTI) measuring 2 centimeters (cm) by (x) 1.1 cm to her left medial foot. R14's Minimum Data Set (MDS), dated [DATE], documents R14's cognitive skills are moderately impaired, requires extensive assistance for bed mobility, and has one stage 3 pressure ulcer. R14's Treatment Administration Record (TAR), dated December 2022, documents, 11/23/2022-Heel protectors on at all times. The initials are circled for the whole month of December 2022. On 1/03/23 at 1:55 PM, V4, Licensed Practical Nurse (LPN), was asked the meaning of circling initials on the TAR. V4 stated, I think they (heel protectors) would get dirty and sent to laundry. I just circled them on the TAR if they weren't on her. R14's Physician's Order Sheet (POS), dated 12/13/2022, documents, Apply Medi-Honey to left foot/heel and cover with dry dressing every day. On 12/28/2022 at 2:45 PM, V1, Administrator, stated R14 was admitted to the facility in July 2020, with no open areas/impaired skin. V1 stated R14 acquired the open area to R14's left heel while at the facility. On 12/29/2022 at 11:15 AM, R14 was not wearing heel protectors. There was no dressing on R14's left foot pressure ulcer. V6, Certified Nursing Assistant (CNA), verified there was no dressing to R14's left medial foot. V6 stated, There's nothing on it, just a hole. V6 did not know how long R14's dressing had been off. On 12/29/2022 at 1:15 PM, V9,LPN, stated, I have not done treatments yet today. I have had order upon order, and now I'm getting an admit. R14's left heel treatment had not been completed. On 1/4/2023 at 9:09 AM, V1 stated she would expect staff to follow doctor's orders regarding the heel protectors and treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to revise resident's care plans to address resident's current needs for 5 of 12 residents (R1, R4, R11, R21, R23) reviewed for Care Plan revision in the sample of 21. Findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE]. R1's Care Plan, dated 1/24/19, documents (R1) Mobility, impaired physical related to: diagnosis Osteoarthritis, history of multiple fractures to BLE (Bilateral Lower Extremities). Resident ambulates in wheelchair propelled by self. The Care Plan Interventions document Assist to transfer with (full body mechanical lift device), dependent, use gait belt for all transfers. The Care Plan documents (R1) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include developmental delay, early onset dementia. Resident is non-weight bearing at this time. Other resident specific information, resident is non-weight bearing, (full body mechanical lift device) for transfers, uses an immobilizer for left leg. Interventions: Review quarterly and PRN (as needed) resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Fall Risk Assessment quarterly and as needed with change in condition or fall status. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status is 15), and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1's MDS documents R1 requires extensive assistance from two staff members for toilet use. On 12/27/22 at 10:25 AM, R1 stated, It takes two staff members to assist me in using the sit-to-stand device. On 1/3/23 at 2:00 PM, R1 stated, When I first came back from the hospital a long time ago, they were using the (full body mechanical lift device). I didn't really like it because it felt like I was just swinging, and it scared me. Now they are using the sit-to-stand device to get me up. They do have problems with it sometimes because I can't really put any weight on my legs, so I just sit in the sling. There have been times when it doesn't get me up enough, so they have to use the emergency button to put me back down. On 1/3/23 at 2:45 PM, V8, CNA (Certified Nursing Assistant), stated, We always use the Sit-To-Stand with (R1). I have only been here about a month, and we have used that since I have been here. I have noticed that she has been deteriorating lately while trying to use the sit-to-stand. She hasn't been as strong with it as she has before. I'm not sure why the Care Plan says to use the (full body mechanical lift). On 12/28/22 at 10:42 AM, R1 was assisted by V5, CNA, and V10, CNA, with a transfer from her bed to her wheelchair using a sit-to-stand device. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. R1 appeared to be sitting in the sling as her legs were bent and not supporting her during the transfer. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. There was no gait belt used on R1 as documented as required in the Care Plan. R1 confirmed they do not use a gait belt on her, just the sling with belt around her. R1's Care Plan, dated 1/24/19, documents a full body mechanical lift device and a gait belt should be used for transfers. The Care Plan has not been updated since 2019. 2. R4's Face Sheet, undated, documents R4 was admitted to the facility on [DATE]. R4's Care Plan, dated 5/10/22, documents (R4) has risk factors that require monitoring and intervention to reduce potential for self-injury. (R4) has periods of weakness, does not understand need for safety and will attempt to transfer self. As evidenced by attempts to transfer self from chair to bed and bed to chair. Interventions: Review quarterly and PRN (as needed). Resident's ADL, mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed (5/10/22). IDT review of function and referral to PT (Physical Therapy) as needed for change in function (5/10/22). IDT review and referral to OT (Occupational Therapy) as needed for change in function (5/10/22). Remind resident to lock wheelchair brakes (5/10/22). Attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own (5/10/22). Fall Risk Assessment quarterly and as needed with change in condition or fall status (5/10/22). It continues (R4) has mobility, impaired physical related to history of TIA (Trans Ischemic Attack). As evidenced by need for extensive assist with most ADL's and use of wheelchair for locomotion (5/10/22). Self-Care deficit: needs supervision and/or assist to complete ADL's. History of TIA (5/10/22). It continues (R4) has alteration in transfer ability. Unable to transfer independently related to diagnosis of TIAs, weakness. as evidenced by inability to stand independently (12/20/22). Interventions: Assess ability and need of adaptive/assistance equipment in safe and efficient manner, assist with transfer as necessary with staff assist of one, pivot with gait belt. Use gait belt with every hands-on transfer (12/20/22). R4's MDS, dated [DATE], documents R4 is cognitively intact (BIMS 15) and requires extensive assistance from one staff member for bed mobility, transfers, dressing, and personal hygiene and bathing. R4's MDS documents R4 requires extensive assistance from two staff members for toileting. R4 is always incontinent of both bowel and bladder. R4's admission Fall Risk Assessment, dated 4/26/22, documents R4 is a high fall risk (score of 12 with greater than 10 indicating a high fall risk). This is the only fall risk documented in R4's medical record. R4's Nurse's Note, dated 10/12/22 at 2:45 AM, documents, Resident observed on floor next to low bed at 2:00 AM. Resident obtained hematoma to right forehead. Ice pack applied for ten minutes, ROM (Range of Motion) WNL (Within Normal Limits) for resident. PERRLA (Pupils Equal Round Reactive Light Accommodation), grips equal. Vital Signs Temperature 97.9, Blood Pressure 132/80, Pulse 108, Respirations 18, SpO2 (Oxygen Saturation) 95% on 2 liters via NC (nasal cannula). The Facility's Fall Log, dated September 2022 and October 2022, documents R4 had falls on: 9/29/22, 10/6/22, 10/12/22, 10/16/22. The Facility's Quality Improvement Review, dated 10/7/22 at 10:00 AM, documents, QA (Quality Assurance) team met and reviewed previous fall. Root Cause: Attempting to ambulate, weakness. Intervention: Call don't fall sign. The Facility's Quality Improvement Review, dated 10/17/22 at 10:05 AM, documents, QA team met and reviewed previous fall. Root Cause: Attempting to self-transfer from wheelchair, slid off edge of wheelchair. Intervention: (Non-slip pad) under wheelchair cushion. On 12/27/22 at 10:15 AM, R4 stated, I have fallen a couple of times here. On 12/27/22 at 10:20 AM, a Call Don't Fall sign was seen posted on a wall in R4's room, R4 was sitting in his recliner, with his walker and wheelchair sitting next to his bed. R4's Care Plan was updated on 5/20/22. Since then, R4 has had four falls (as documented on the Fall Log) without any updates to the care plan or fall interventions until 12/20/22. There are no other nurse's notes regarding R4's falls seen in his medical record. The Facility's Comprehensive Care Planning Policy, dated 7/20/22, documents, It is the policy of (this Facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. It continues 9. The resident Care Plan may be kept electronically or in hard copy printed format. a. Problems, Goals, and Interventions should include the date initiated for ease of reference. b. All intervention entries should include the date the care intervention was initiated by the staff as well as the date the interventions was added to the care plan if added after the original Care Plan date. The Facility's Fall Prevention Policy, dated 10/2007, documents, Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and continue to honor each resident's wishes/desires for maximum independence and mobility. Procedure: 1. Conduct fall assessment upon admission, quarterly, with a significant change and after a fall. 2. Identify, on admission, the resident's risk for falls. Initiate appropriate individual intervention to prevent falls (e.g., 15 min visuals, body alarm, education, call light within reach, education, etc ), in accordance with why the resident may be at risk for falls. It continues 6. Documentation of any new interventions will be placed on the CNA assignment worksheet by the charge nurse. 3. R23's MDS, dated [DATE], documents R23 is cognitively impaired and requires extensive assistance from staff for transfers. R23's Fall Risk Assessment, dated 12/7/21, documents R23 is at a high risk for falls. R23's Care Plan undated documents, Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Resident has low cognitive score and does not understand safety needs. Risk factors include resident attempting to transfer self, as evidenced by past falls. It continues to document a low bed and tab alarm (an alarm to alert staff of resident attempting to self-transfer) was added as a fall prevention on 12/9/2022. The Facility's Fall Log, dated November 2022, documents R23 fell on [DATE] and 11/27/2022. It continues to document on 11/27/2022, R23 sustained an injury to her left forehead, elbow, and knee. R23's Progress Notes, dated 11/27/2022 at 2 AM, documents, (R23) on floor in room lying on back. Noted to have area to left forehead bleeding. 911 called at this time. R23's Progress Notes, dated 11/27/2022, further document R23 returned to the facility with a noticeable hematoma/laceration to her left orbital area and left elbow both of which had to be glued at the Emergency Room. R23's Care Plan does not include interventions for the falls on 11/16/2022 or 11/27/2022. 4. R21's admission Profile, undated, documents R21 was admitted on [DATE]. R21's Physician Orders, dated December 2022, documents R21 has diagnoses of Alzheimer's Dementia and Anxiety. R21's MDS, dated [DATE], documents R21 is moderately cognitively impaired, and is totally dependent on 2 staff members for bed mobility and transfers. The Facility Fall log documents the following falls on the following dates: R21 fell on 7/2/22 at 940 in the common area; R21 fell on 8/6/22 at 1600 in the hallway and sustained a laceration to her left eyebrow and she was sent to the hospital; R21 fell on 8/28/22 at 12:15 in her room; R21 fell on 8/30/22 at 1535 in the hallway; R21 fell on [DATE] at 2030 in her room; and R21 fell on [DATE] at 160 in the dining room and sustained an injury to her left knee and forehead and she was not sent to the hospital. R21's Quality Assurance (QA) Progress Notes, dated 7/5/22, documents, QA team met and reviewed previous fall. Root cause: Restless, unaware of physical limitations, reaching forward. Intervention: Encourage activities while up. R21's QA Progress Notes, dated 8/9/22, documents, QA team met and reviewed previous fall. Root cause: Restless, reaching to floor nothing observed on floor during assessment. Intervention: Resident to remain at nurses' station or in view of staff while up in wheelchair. R21's QA Progress Notes, dated 8/29/22, documents, QA team met and reviewed previous fall. Root cause: Reaching for drinks across table, impulsiveness. Intervention: Nothing placed on table until meal tray is ready. R21's QA Progress Notes, dated 8/31/22, documents, QA team met and reviewed previous fall. Root cause: leaning forward in wheelchair. Intervention: Therapy to eval (evaluate) for positioning. R21's QA Progress Notes, dated 11/4/22, documents, QA team met and reviewed previous fall. Root cause: Attempting to self-transfer from bed. Intervention: therapy to screen for positioning. R21's QA Progress Notes, dated 11/30/22, documents, QA team met and reviewed previous fall. Root cause: Unaware of physical limitations; leaning forward in wheelchair. Intervention (non- slick pad) placed in w/c under cushion; (click) alarm placed. R21's Fall Care Plan, initiated on 9/16/21, documents, Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. This care plan has not been revised since 12/23/21 with the new interventions put into place for R21 for the falls that R21 has had since 7/2/22 - 11/29/22. On 1/3/22 at 3:55 PM, V1, Administrator, stated the Care Plans are not updated as they should be. The Comprehensive Care Planning policy, dated 7/20/22, documents, 9. The Resident Care Plan may be kept electronically or in hard copy printed format. a. Problems, Goals and Interventions should include the date initiated for ease of reference. b. All intervention entries should include the date the care interventions was initiated by the staff as well as the date the intervention was added to the care plan if added after the original CP (Care Plan) date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R30's New admission Information, dated 12/1/22, documents R30 was admitted to the facility on [DATE]. R30's Care Plan, dated 12/13/22, documents (R30) is known to wander, may seek to leave the home. Related to diagnosis include Dementia. Resident specific information: resident attempts to leave facility several times daily. Interventions: IDT (Inter-Disciplinary Team) review behavior plan quarterly and PRN (as needed) for changes in exit seeking/wandering. Share plan and risks factors with responsible party. IDT to assign risk level after assessment and resident will wear a (Security Anklet/Bracelet). Seek alternative/diversional activities for exit seeking behaviors. 1:1 close and constant or continuous visual monitoring when resident is agitated and not easily redirected from exits or wandering. Provide towels/washcloths to fold to allow feeling of usefulness and participation. It continues (R30) has impaired cognition results in wandering behavior. Related diagnosis Dementia. Behavior exhibited: walking through facility with no set destination, going into other rooms and elopement attempts. Interventions: Provide supervision, approach calmly, offer assistance and attempt to redirect. Assess level of elopement risk by identifying reason for leaving the unit, destination, and ability to return unassisted. Resident attempts to leave facility several times daily. Provide regular opportunities to go outdoors with supervision, assist as needed. Redirect when enters room of another resident. Intervene as needed with other residents to prevent altercation. Ask all staff to notify nursing if resident is found in other areas of the building and requires assistance to return. [NAME] the room with name, familiar object or picture. It continues (R30) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include resident being unaware of safety limitations related to diagnosis/condition/history includes Dementia. R30's MDS, dated [DATE], documents R30 has severe cognitive impairment and requires supervision for walking. R30's admission Fall Risk Assessment, dated 12/1/22, is not fully complete, however, the scores that are completed, documents R30 is a high fall risk. R30's admission Elopement Evaluation, dated 12/1/22, documents R30 is a high elopement risk. Interventions: visual checks every fifteen minutes, door alarm/bracelet/anklet, redirect common areas. Haldol 5 MG (milligram) IM (Intramuscular) and Ativan 2 MG IM ordered on 12/26/22 for agitation. R30's Nurse's Note, dated 12/2/22 at 2:00 PM, documents, At 5:30 AM, Resident pushed staff member who was attempting to escort her out of another resident's room. R30's Nurse's Note, dated 12/4/22 at 12:09 PM, documents, Resident refused AM (morning) medications, resident spit medications out at writer. Resident continues to be exit seeking, (Security Anklet/Bracelet) working. No s/s (signs/symptoms) of pain voiced/noted. R30's Nurse's Note, dated 12/10/22 at 1:58 PM, documents, Resident pulled fire alarm on Center Hall at approximately 9:50 AM. All protocols performed. Resident pulled fire alarm again at 1:43 PM, all protocols performed. Administrator and RCC (Resident Care Coordinator/V3) aware. Resident educated on importance of not using/pulling fire alarm. R30's Nurse's Note, dated 12/13/22 at 3:20 AM, documents, Resident pulled fire alarm around 11:40 PM. Resident exit seeking/anxious/agitated this shift. Resident complaint of back pain, at 2:35 AM writer administered PRN (as needed) Tylenol and was effective. Resident resting in room at this time. R30's Nurse's Note, dated 12/14/22 at 1:00 PM, documents, Resident attempts to leave facility several times and redirected. R30's Nurse's Note, dated 12/17/22 at 9:00 AM, documents, Resident up and about. She has gone out the doors numerous times, redirected. Resident takes items (cups) off of med cart, tears papers off doors (Christmas decorations), continuous redirection. R30's Nurse's Note, dated 12/20/22 at 10:20 AM, documents, Resident continues to be exit seeking and aggression continues towards staff when redirected. Resident spit out AM medications at writer. No s/s of pain noted. R30's Nurse's Note, dated 12/23/22 at 5:20 AM, documents, Resident noted to be combative with care (toileting) this shift. Resident noted to be exit seeking times four this AM and combative when staff redirects. Staff tried redirecting, re-approaching, and changing staff members multiple times. Resident appears very anxious/wandering and pacing hallways. Resident currently resting in resident's room. R30's Nurse's Note, dated 12/24/22 at 12:13 PM, documents, Resident continues to be exit seeking and combative towards staff when being redirected. Resident with family member at this time and resident continues exit seeking behaviors. Resident c/o pain, PRN offered, and writer educated resident on med and what it was for and resident spit it out at writer. Resident took AM medications without difficulty but refused to use Flonase per order, writer re-approached multiple times in AM and refusal remains. On 12/27/22 at 11:35 AM, V6, CNA (Certified Nursing Assistant), stated, (R30's) ankle bracelet only goes off with the front door. Most of the time (R30) only gets to the sidewalk outside before we get her back in. We try to do one-on-one with her and then redirect her. I remember there was one Saturday where (R30) got out about eight or nine times, but usually it is only a couple times a day. On 12/28/22 at 1:25 PM, V1, Administrator, stated, The only thing we can do for (R30) is one-on-one with her. We are lucky and have an abundance of CNAs so we can assign one person to be with her each shift. She is still getting out a door, she is a handful. We have an anklet on her, but it does not work for all of the doors. I plan on calling one of our sister facilities to see if they would be willing to take her in a locked unit. I also plan on having a care plan meeting with (R30's) daughter and see if she is willing to transfer her. At this point, it is becoming a safety issue. I have nightmares about her disappearing and every time my phone rings I worry that it is the facility calling me about her. On 12/29/22 at 10:45 AM, V15, CNA, stated, I have been with (R30) all morning. At about 10:30 AM, (R30) was walking towards the front door, I was trying to stand in her way, but she pushed her way through me and opened the front door, setting off the alarm and other staff came to help me get (R30) back into the building. On 12/27/22 at 10:12 AM, Facility's North Hall door alarm went off, and R30 was seen walking quickly out the door to the outside with multiple staff running towards the door and was able to get to R30 and bring her back inside within a minute or two. On 12/27/22 at 11:30 AM, R30 was wandering around the facility, entering other resident's rooms and back out, has a (exit alarm anklet) around her left ankle. On 12/27/22 at 12:45 PM, R30 was wandering around the facility, walking in/out other resident rooms, up and down the halls. No staff member was walking with or supervising R30. On 12/28/22 at 10:40 AM, R30 was wandering the halls and went into her room to sit down. V11, CNA, was assigned to be a one-on-one with R30; however, V11 came from the opposite hall and entered R30's room to check on her. On 12/28/22 at 12:18 PM, R30 pushed the Facility's front door open, and alarm went off. Staff quickly stopped R30 from exiting. On 12/29/22 at 1:49 PM, R30 was seen walking through a door at the end of her hallway which goes to another section of the building. There was no staff with R30. The alarm went off, but that alarm shuts itself off as soon as the door is closed. R30 walked around the back area, which is located by the Therapy Department, and then went straight to the outer door which exits to the outside and was next to the conference room the IDPH (Illinois Department of Public Health) Surveyors were in. R30 pressed open the outside exit door and the alarm sounded. There were no staff seen in the area at the time, so for resident safety reasons, the Surveyors stopped R30 from exiting out of the building. V16, PTA (Physical Therapist Assistant), arrived and came over to assist with R30. Once R30 pressed open the outside exit door and the alarm sounded. V6, CNA, came running into the area in a panic, and escorted R30 back to her hallway. On 12/29/22 at 2:20 PM, V1, Administrator, stated, Well, (R30) is supposed to have one-on-one and I'm not sure where that person is right now. I have already called (R30's) daughter and we have a Care Plan meeting with her tomorrow (12/30/22) at 11:00 AM, with regards to all of this, so hopefully we can do something for her. On 1/3/23 at 9:30 AM, V1, Administrator, stated, We had the Care Plan meeting last Friday (12/30/22) with (R30's Daughter) and we are all in agreement that (R30) needs to be transferred to a more secure facility. I sent three referrals to local area facilities and the first one said no, that (R30) would not be a good fit for them. I am still waiting for the other two to get back with me. I will follow-up today on these. For now, we are just doing one-on-one with (R30). On 1/3/23 at 9:40 AM, R30 sitting in her room by herself. There was no staff present supervising R30. The Facility's Elopement Prevention Policy, dated 10/2006, documents It is the policy of (Facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. It continues 8. Revision of the Elopement Risk Assessment will be completed quarterly, after an isolated elopement attempt, monthly for residents who attempt elopement more than five times per week, upon a resident's significant change in condition and as needed, determined by the IDT (Inter Disciplinary Team). 9. The plan of care for minimizing elopement risks will be reviewed each time the risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. The Facility's Missing Resident Policy, dated 10/2006, documents It is the policy of (Facility) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, staff interventions, staff education regarding response to door alarms, and individual resident intervention. It is the policy of (Facility) to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing. 5. R1's Face sheet, undated, documents R1 was admitted to the facility on [DATE]. R1's Care Plan, dated 1/24/19, documents, (R1) Mobility, impaired physical related to: diagnosis Osteoarthritis, history of multiple fractures to BLE (Bilateral Lower Extremities). Resident ambulates in wheelchair propelled by self. Interventions: Assist to transfer with (full body mechanical lift device), dependent, use gait belt for all transfers. IDT (Inter-Disciplinary Team) to review for need for Physical Therapy, allow resident to actively participate in turning, repositioning, and transfers. Non-Ambulatory. Wheelchair for mobility, self-propels wheelchair. It continues (R1) has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include developmental delay, early onset dementia. Resident is non-weight bearing at this time. Other resident specific information, resident is non-weight bearing, (full body mechanical lift device) for transfers, uses an immobilizer for left leg. Interventions: Review quarterly and PRN (as needed) resident's ADL (Activities of Daily Living), mobility, cognitive, behavior and overall medical status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Discuss fall related information to review and revise plan as needed. Fall Risk Assessment quarterly and as needed with change in condition or fall status. R1's MDS, dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status is 15) and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1 requires extensive assistance from two staff members for toilet use. On 12/27/22 at 10:25 AM, R1 stated, It takes two staff members to assist me in using the sit-to-stand device. On 1/3/23 at 2:00 PM, R1 stated, When I first came back from the hospital a long time ago, they were using the (full body mechanical lift device). I didn't really like it because it felt like I was just swinging, and it scared me. Now they are using the sit-to-stand device to get me up. They do have problems with it sometimes because I can't really put any weight on my legs, so I just sit in the sling. There have been times when it doesn't get me up enough, so they have to use the emergency button to put me back down. On 1/3/23 at 2:45 PM, V8, CNA, stated, We always use the Sit-To-Stand with (R1). I have only been here about a month, and we have used that since I have been here. I have noticed that she has been deteriorating lately while trying to use the sit-to-stand. She hasn't been as strong with it as she has before. I'm not sure why the Care Plan says to use the (full body mechanical lift). On 12/28/22 at 10:42 AM, R1 was assisted by V5, CNA, and V10, CNA, with a transfer from her bed to her wheelchair using a sit-to-stand device instead of a full body mechanical lift as documented in R1's Care Plan. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. R1 was sitting in the sling as her legs were bent and not supporting her during the transfer. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. There was no gait belt used on R1 as indicated in the Care Plan. R1 confirmed they do not use a gait belt on her, just the sling with belt around her. The Facility's Specific Best Practice Transfer Guidelines, undated, documents Transfer Status: The transfer status will be noted on the Care Plan. A caregiver has the ability to increase the level of assistance at anytime if that caregiver feels that the resident is not safe to perform the noted transfer method on the Care Plan. It continues Combative and Mentally Impaired Residents: It is expected that in most situations, a combative or mentally impaired resident requiring a lift based on dependency needs can be lifted using the appropriate mechanical lifting aid device. Combative or uncooperative residents may require a particular resident due to their mental condition or behavior, that determination should be made by a member of the facilities professional staff and noted in the accessible records for that resident. Under such circumstances a specific plan for lifting and transferring that resident should be developed in advance, specifying the number and type of caregivers needed to assist. 3. R23's MDS, dated [DATE], documents R23 is cognitively impaired and requires extensive assistance from staff for transfers. R23's Fall Risk Assessment, dated 12/7/21, documents R23 is at a high risk for falls. R23's Care Plan undated documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Resident has low cognitive score and does not understand safety needs. Risk factors include resident attempting to transfer self, as evidenced by past falls. Start Date: 11/11/22. The Care Plan Intervention, with start date of 11/11/22, documents Review quarterly and PRN (as needed) Resident's ADL, mobility, cognitive, behavior and overall medial status. IDT review of changes and needs with resident and/or responsible party (when choose to attend) during car plan. Discuss fall related information to revie and revise plan as needed. R23's Care Plan continues to document a low bed and tab alarm (an alarm to alert staff of resident attempting to self-transfer) was added as a fall prevention on 12/9/2022. The Facility's Fall Log, dated November 2022, documents R23 fell on [DATE]. R23's Care Plan was not revised after R23 fell on [DATE] The Facility's Fall Log documented R23 fell on [DATE]. It continues to document on 11/27/2022, R23 sustained an injury to her left forehead, elbow, and knee. R23's Progress Notes dated 11/27/2022 at 2 AM documents, (R23) on floor in room lying on back. Noted to have area to left forehead bleeding. 911 called at this time. R23's Progress Notes, dated 11/27/2022, further document R23 returned to the facility with a noticeable hematoma/laceration to her left orbital area and left elbow both of which had to be glued at the Emergency Room. R23's Care Plan was not revised after R23 fell on [DATE] with progressive interventions to prevent her from future potential falls/injury. The Facility's Fall Log, dated December 2022, documents R23 fell on [DATE], once at 3:45 AM, and again at 6:30 PM. On 12/27/2022 at 10:15 AM, R23 was observed in her wheelchair. R23 did not have a tab alarm attached to her person. On 12/27/2022 at 12:00 PM, V5, CNA, stated R23 has had a lot of falls. On 12/28/2022 at 12:00 PM, R23 was observed in the dining room in her wheelchair and did not have a tab alarm attached. On 12/28/2022 at 2:31 PM, R23 was observed in her room in her recliner and did not have a pull tab alarm attached. On 12/28/2022 at 2:45 PM, V5 verified R23 did not have a pull tab alarm attached or a low bed. At this time, V5 stated, I'll find her one. I think the battery stopped working. I think the pressure pad alarms are better because they alert you to their movement. These pull tabs just let you know when they fall. V5 then located a pull tab alarm attached to R23's bed and when tested, it alarmed, but very faintly. V5 also verified R23's bed was not a low bed. On 12/28/22 at 3:08 PM V5 stated, Just so you know, she (R23) now has a low bed in her room and a pressure pad alarm. Based on observation, interview, and record review, the facility failed to investigate to determine a root cause of the falls, failed to implement progressive interventions based upon root cause to prevent future falls, failed to provide supervision to prevent elopement, and failed to provide safe transfer techniques to prevent injury for 5 of 13 residents (R1, R20, R21, R23, R30) reviewed for accidents/supervision in the sample of 21. Findings include: 1. R20's admission Sheet, undated, documents R20 was admitted on [DATE]. R20's Physician Orders, dated December 2022, documents R20 has diagnoses of Dementia, falls, aggressive behaviors, diabetes, and seizures. R20's Minimum Data Set (MDS), dated [DATE], documents R20 is severely impaired cognitively, requires supervision of 1 staff member for transfer and bed mobility. R20's Care Plan, dated 9/13/22, documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Risk factors include unsteady gait and inability to understand safety limitations, will transfer self and walk independently. Interventions, dated 9/13/22, Observe for unsteady / unsafe transfer or ambulation and provide stand by or balance support as needed. Intervention, dated 12/16/22, Resident will have a Call don't Fall Sign in room. Intervention, dated 12/20/22, (non-slip pad) in wheelchair. Intervention, dated 12/28/22, Resident in low bed with side rails. The Facility Fall log documents R20 fell on [DATE] at 10:10 AM in the hallway, resulting in a bruise to the scalp and she was sent to the hospital. R20's Initial Report with Final Investigation, dated 10/3/22, documents R20 pinched R28, R28 shoved R20, and R20 fell backwards and hit her head. The root cause was confusion and unaware of resident's boundaries. The Facility Fall log documents R20 fell on [DATE] at 10:42 AM in her room. R20's Nurse's Note, dated 12/16/22 at 5:36 PM, documents, Res (resident) fell at 10:42 AM in bedroom (room #). Res was found sitting on buttocks on the floor with back facing the legs of reclining chair. It continues, As an intervention, (nonslick pad) will be put in reclining chair seat to help res. from sliding off seat. R20's Quality Assurance (QA) notes, dated 12/19/22, documents, QA (Quality Assurance) team met and reviewed previous fall. Root cause: Attempting to self-transfer; weakness; unaware of physical limitations. Intervention: Call don't fall sign. The Facility Fall log documents R20 fell on [DATE] at 3:18 PM in her room. R20's Nurse's Note, dated 12/20/22, documents, Res. fell at 3:18 PM in room (room number). Res on buttocks on ground in middle of floor. R20's QA notes, dated 12/22/22, documents, QA team met and reviewed previous fall. Root cause: Slid from wc (wheelchair). Intervention: (Non-slip pad) in wc. This had been a previous intervention which was implemented on 12/16/22 to address the fall she had on that date. On 12/28/22 at 11:05 AM, V8, Certified Nurse's Aide (CNA), and V10, CNA, attempted to transfer R20 with a full mechanical lift from her recliner to her wheelchair. R20 would not cooperate, and V8 and V10 decided transferring her with a partial mechanical lift would be safer. V10 placed the transfer belt around R20's waist. The belt was attached to the machine. R20 placed her hand on the transfer arms to hang on. V10 raised the machine. R20 was not supporting her own weight. The transfer belt raised up into R20's underarms. R20 was hanging from the transfer belt. On 12/28/22 at 2:00 PM, R20's room was entered. R20 is lying on the floor next to the bed. V18, Social Service Director, was notified. V18 got V13, MDS nurse, and V5, Certified Nurse's Aide (CNA), entered the room and assessed her. R20 was lifted with a mechanical lift and put in bed. On 12/28/22 at 2:10 PM, V5, CNA stated, I just put (R20) to bed not long ago. R20's QA notes, dated 12/29/22, documents, QA team met and reviewed previous fall. Root cause: Attempting to self-transfer; weakness; unaware of physical limitations. Intervention: Low Bed. R20's Nurse's Note, dated 1/2/23, documents, Res found in hallway on floor sitting up on bottom in front of wheelchair. No injuries noted. R20's QA notes, dated 1/3/23, documents, QA team met and reviewed previous fall. Root cause: Attempting to ambulate in wheelchair; slid out of wheelchair. Intervention: Offer to lay down between meals. On 1/3/23 at 9:46 AM, V4, Licensed Practical Nurse (LPN), stated R20 has had a decline recently. V4 stated R20 had a fall, and she has not been the same since then. V4 stated R20 does need help with transfers and eating. On 1/3/23 at 12:38 PM, V13, MDS/Care Plan Coordinator, was questioned about why she had not done a significant change MDS for R20. V13, stated R20 has had a significant decline recently. V13 stated, Well, I guess I could but, she was just up walking on Christmas. It was the Christmas miracle. On 1/4/22 at 9:11 AM, V1, Administrator, stated the partial mechanical lift transfer should be done only when the resident can bear at least partial weight on their legs. V1 further stated if staff feel a mechanical transfer is unsafe, it should be stopped. On 1/3/22 at 4:00 PM, V3, Resident Care Coordinator, (RCC), stated she agrees the fall investigations do not look at last time resident seen and when care when was provided last. V3 also stated she understands why the root cause should not be poor safety awareness or physical limitations. 2. R21's admission Profile, undated, documents R21 was admitted on [DATE]. R21's Physician Orders, dated December 2022, documents R21 has diagnoses of Alzheimer's Dementia and Anxiety. R21's Minimum Data Set, (MDS), dated [DATE], documents R21 is moderately cognitively impaired and is totally dependent on 2 staff members for bed mobility and transfers. R21's Fall Care Plan, initiated on 9/16/21, documents Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. R21's Care Plan Goal, dated 12/15/21, documented (R21) will follow safety suggestions and limitation with supervision and verbal reminders for better control of risk factors thru next 90 days. The following Care Plan Interventions were initiated on R21's Care Plan as of 9/16/21: Discuss fall related information to review and revise plan as needed; Review quarterly and as needed during daily care and services of Resident's plan for safety , giving verbal cues as needed to gain resident participation in minimizing risk factors and injury, IDT (Interdisciplinary Team) review of function and referral to physical therapy as needed for change inf unction; IDT review of function and referral to Occupational therapy as needed for changes in function; Keep call light within reach at all times. Answer promptly and notify that help is coming; remind of safety precautions and limitation as necessary; Observe for non-verbal sings of restlessness that may precipitate movement and attempt to stand/walk unattended. The following Care Plan interventions were implemented on the following dates: 11/06/21 Slipper socks at HS (time of sleep); 11/22/21 Keep in high traffic area when up; 11/22/21 Place dycem in wheelchair (w/c); 11/26/21 Anti rollback place on w/c; and 12/23/21 Keep in visual while in dining room. There have been no further revisions to this care plan since 12/23/21. The Facility Fall log documents R21 fell on 7/2/22 at 9:40 AM in the common area. R21's Nurse's Note, dated 7/2/22 at 1:32 PM, documents, Res. (resident) found on buttocks in front of w/c (wheelchair) in TV (television) room at 9:47 AM. Res opened scab on L (left) elbow. R21's Quality Assurance (QA) Progress Notes, dated 7/5/22, documents, QA team met and reviewed previous fall. Root cause: Restless, unaware of physical limitations, reaching forward. Intervention: Encourage activities while up. There was no documentation available regarding if R21 was in an area of high traffic during the incident on 7/5/22. There was no documentation regarding if this was a witnessed event. The Facility's Fall Log documented R21 fell on 8/6/22 at 1600 in the hallway and sustained a laceration to her left eyebrow, and she was sent to the hospital. R21's Abnormal Skin Report, dated 8/6/22, at 4:00 PM, documents, Post Fall ER (Emergency Room). Findings: 9 sutures L (left) eyebrow line (above), bruising L eye, bruising L elbow, bruising Left inner upper arm. There was no documentation in R21's Nurse's Notes R21 was sent to the hospital. There was no documentation if R21's fall was witnessed, what occurred, and if she was in an area of high traffic where she was being observed by staff. R21's QA Progress Notes, dated 8/9/22, documents, QA team met and reviewed previous fall. Root cause: Restless, reaching to floor nothing observed on floor during assessment. Intervention: Resident to remain at nurses' station or in view of staff while up in wheelchair. The Facility's Fall log documented R21 fell on 8/28/22 at 12:15 in her room. R21's Nurse's Note, dated 8/28/22 at 12:15 PM, documents, Resident in DR (dining room) in chair awaits staff to assist feed. Resident then 'falls to floor' per a witness. Resident falls forward, does not hit head. R21's QA Progress Notes, dated 8/29/22, documents, QA team met and reviewed previous fall. Root cause: Reaching for drinks across table, impulsiveness. Intervention: Nothing placed on table until meal tray is ready. The Facility's Fall Log documented R21 fell on 8/30/22 at 3:35 PM in the hallway. R21's Medical Record fails to document a Nurse's note for R21's fall on 8/30/22, what occurred, was staff present, and was she in within view of staff when this incident occurred. R21's QA Progress Notes, dated 8/31/22, documents, QA team met and reviewed previous fall. Root cause: leaning forward in wheelchair. Intervention: Therapy to eval (evaluate) for positioning. The Facility's Fall Log documented R21 fell on [DATE] at 8:30 PM in her room. R21's Nurse's Note, dated 11/3/22 at 8:30 PM, documents, On floor sitting upright on buttocks beside bed. R21's QA Progress Notes, dated 11/4/22, documents, QA team met and reviewed previous fall. Root cause: Attempting to self transfer from bed. Intervention: therapy to screen for positioning. The Facility's Fall Log documented R21 fell on [DATE] at 4:00PM in the dining room and sustained an injury to her left knee and forehead and she was not sent to the hospital. R21's medical record had no documentation how the fall occurred and if staff were present at the time R21 fell on [DATE]. R21's QA Progress Notes, dated 11/30/22, documents, QA team met and reviewed previous fall. Root cause: Unaware of physical limitations; leaning forward in wheelchair. Intervention Dycem pad placed in w/c under cushion; (click) alarm placed. R21's Care Plan documented the Dycem should have been an intervention implement as of 11/22/21. The Facility's Fall Prevention Policy, dated 10/2007, documents Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and continue to honor each resident's wishes/desires for maximum independence and mobility. Procedure: 1. Conduct fall assessment upon admission, quarterly, with a significant change and after a fall. 2. Identify, on admission, the resident's risk for falls. Initiate appropriate individual intervention s to prevent falls (e.g., 15 min visuals, body alarm, education, call light within reach, education, etc ), in accordance with why the resident may be at risk for falls. It continues 6. Documentation of any new interventions will be placed on the CNA assignment worksheet by the charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R1's MDS, dated [DATE], documents R1 is cognitively intact (BIMS/Brief Interview for Mental Status of 15) and requires extensive assistance from one staff member for bed mobility, transfer, dressing, and bathing. R1's MDS documents R1 requires extensive assistance from two staff members for toilet use. On 12/28/22 at 10:42 AM, V10, Certified Nursing Assistant (CNA), and V5 (CNA) assisted R1 with a transfer from her bed to her wheelchair using a sit-to-stand device. V10 donned clean gloves, while V5 had no gloves on. V5 and V10 put the device's sling around R1, attached the straps to the lift device, and lifted R1 off her bed as R1 held the handles of the device. V10 operated the lift device as V5 held R1 as they moved her to her wheelchair. R1 was then lowered to her wheelchair. V10 and V5 did not perform hand hygiene before or after transferring R1. 5. R18's Care Plan, dated 12/2/21, documents, (R18) has an alteration in bladder elimination as skin will remain intact X 90 days, related to incontinence. Interventions: Pad appropriately for dignity and comfort, toilet and/or change padding and give proper hygiene before/after meals, upon rising, upon request, before retiring for the evening, after napping, and PRN for incontinence. It continues (2/3/20) (R18) new environment and routine may affect resident ability to complete ADLs and/or maintain continence effectively. Interventions: Observe and assess toileting routine and pattern of incontinence using monitoring log if necessary. Refer to Restorative Nursing for scheduled toileting program or bladder/bowel retraining. Brief while up, pad on bed when sleeping. Provide assist as needed for changing brief, accomplishing peri-care, use of barrier cream as needed and appropriate. Keep call light in reach and answer promptly. Encourage to ask for help until safe toileting ability is established. R18's MDS, dated [DATE], documents R18 has a severe cognitive impairment (BIMS 6) and requires extensive assistance from two staff members for most of her ADL's. R18's MDS documents R18 is frequently incontinent of both bowel and bladder. On 12/28/22 at 11:35 AM, V5 and V12, CNAs, went into R18's to perform perineal care on R18. V5 and V12 donned gloves. R18's dirty linen was removed and put into a bag. V5 and V12 both doffed gloves and donned clean gloves, with no hand hygiene done. V12 wiped once to R18's left groin, once down middle of R18's vagina, and once to R18's right groin. V12 wiped once from front to back including anal area, changed the glove on the hand that was performing the wiping, then wiped R18's buttocks off. R18 rolled and the other side of her buttocks wiped off. V12 doffed her soiled gloves and donned clean gloves, clean linen was put on the bed, and a clean incontinent brief was applied to R18 and R18 was then dressed. V5 and V12 did not perform hand hygiene in between any glove changes. Based on observation, interview, and record review, the Facility failed to perform hand hygiene before and after donning gloves and during medication administration, and failed to perform glove changes when gloves were visibly soiled for 6 of 14 residents (R1, R4, R5, R10, R11, and R18) reviewed for infection control in the sample of 21. Findings include: 1. On 12/28/2022 at 8:00 AM, V9, Licensed Practical Nurse (LPN), administered R10's pills, nasal spray, and insulin injection. V9 did not perform hand hygiene or use alcohol-based hand rub (ABHR) prior to or after the procedure. 2. On 12/28/2022 at 8:15 AM, V9 administered R5's medications. V9 did not perform hand hygiene or use ABHR prior to or after assisting/administering R5's medications, including an injection as well as a nasal spray. 3. On 12/28/2022 at 8:30 AM, V9 administered R4's medications, without the benefit of hand hygiene or using ABHR prior to or after administering R4's medications. The Facility's Medication Administration,, dated 11/18/2017, documents, 12. Appropriate hand washing is to be completed and or alcohol-based gel rub or (brand name hand sanitizer) must be used, throughout the medication pass. This should occur: Before and after medication pass, after any contact with mucous membranes, blood or bodily fluids, secretions or excretions. It continues to document, Handwashing between every resident is not required according to CDC (Centers for Disease Control) guidelines. It is acceptable to use an antiseptic gel type solution between residents. 6. On 12/27/22 at 1:15 PM, V5 and V12 entered R11's room to provide incontinent care and to take him to the shower room for a shower. R11 had been incontinent for urine and stool. R11's bed pad was saturated in urine and R11's top sheet was wet with urine.V5 and V12 both washed their hands and donned gloves. V5 cleansed R11's penis and scrotum with a wet cloth that had peri-wash on it. V5 cleansed R11's rectal area, V5 flipped the cloth and wiped again. The cloth had a moderate amount of stool on it. V5 dried R11's rectal area. V5 then sat R11 up and placed her gait belt around his waist. V5 and V12 both assisted R11 up to a standing position and pivoted him into his wheelchair. V5 then removed her gloves and gown and washed her hands with soap and water. V12 removed her gloves and gown and washed her hands. R11 was then taken to the shower room. On 1/3/22 at 4:00 PM, V1, Administrator, stated she expects staff to change gloves when the gloves are soiled. V1 further stated staff should wash hands before donning gloves and after removal of gloves and between residents. The Facility's Hand Hygiene Policy, dated 12/7/18, documents Policy: All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. The Facility's Perineal Cleansing Policy, dated 12/2017, documents Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items.

Based on observation, interview, and record review, the Facility failed to provide a full time Director of Nursing (DON) and failed to provide a Registered Nurse (RN) 8 hours a day 7 days a week. This has the potential to affect all 29 residents in the facility. Findings include: During the survey, there was no Director of Nursing (DON) and no RN coverage. The Facility's Nursing Schedule for November and December 2022 were reviewed and documents there was no RN on duty the entire month of December. On 12/28/22 at 1:15 PM, V1, Administrator, stated, Our staffing matrix right now is one LPN (Licensed Practical Nurse) for Days and one LPN for Nights. We usually run with four to five CNAs (Certified Nursing Assistant) on each shift. On 12/28/22 at 1:20 PM, V1 stated, On the November Nurses Schedule, from the first through the fifteenth, the DON was the only RN working Monday through Friday. Our DON quit on us around 12/5/22. Since then, we have not had an RN working here, and we are having a hard time finding RNs. All of our current nurses are LPN's. We do have a Regional Nurse who will come in every now and then to help out, but as of now, we only have an LPN schedule because we only have LPN's. On 1/4/23 at 9:12 AM, V1 stated, I have tried to use Social Media, texts, emails and other means to ask nurses if they wanted to work here, and as of today, I still can't find anyone. We do use an agency to provide nurses when needed. I feel like if we had a strong DON, things will turn around here. The Facility's Nurse Staffing Policy, undated, documents, It is the policy of (Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The Resident's Census and Conditions of Residents, CMS 672, dated 12/27/22, documents the facility has 29 residents living in the facility. The CMS 672 documented 4 residents receive Hospice Care, 1 resident has an ostomy, 2 residents have catheters, one resident has tube feeding, one resident has a pressure ulcer, and 20 residents are receiving psychoactive medications.