Based on interview, observation and record review, the facility failed to provide appropriate care for an indwelling urinary catheter to prevent infection in 1 of 4 residents (R45), reviewed for catheters in the sample of 37. Findings include: On 7/23/24 at 9:05 AM, R45 was observed lying in bed with an indwelling urinary catheter in place draining cloudy yellow urine. The catheter drainage tubing was touching the floor and the drainage bag was in a privacy bag. On 7/24/24 at 1:50 PM, catheter care was observed on R45 with V12 (Certified Nursing Assistant/CNA) and V15 (CNA). V12 completed hand hygiene and donned clean gloves and removed R45's incontinence brief. There were incontinence wipes that had been removed from the package and were sitting on top of the package with no barrier between them. V12 then took one of the wipes and wiped down the catheter tubing, then using the same wipe, wiped down the catheter tubing again touching the urethra. V12 then disposed of the wipe and attempted to get another wipe from the top of the wipe package, V12 was unable to grab the wipe and turned the wipes over several times trying to get the wipe to pull away from the others, contaminating the wipes. Then wearing the same gloves and using the contaminated wipe, V12 wiped down the outside of R45's labia. V12 then using the same contaminated gloves and not maintaining a clean/dirty field, grabbed another wipe and wiped again down the center of R45's labia, touching the urethra. V12 removed her gloves, performed hand hygiene, donned clean gloves and R45 was turned onto her left side and then her right side, cleansing her buttocks and anal area. R45 was then placed on her back and using the same contaminated gloves, V12 placed a clean incontinence brief and mesh underwear on R45, repositioned her in bed and covered her up with a blanket. R45's Face Sheet, undated, documents R45 has a diagnosis of UTI (Urinary Tract Infection) and Retention of Urine. R45's MDS (Minimum Data Set), dated 7/2/24, documents R45 has a BIMS (Brief Interview for Mental Status) score of 3, which indicates R45 has severe cognitive impairment. The MDS goes on the document that R45 is dependent with toileting, utilizes an indwelling urinary catheter and is always incontinent of bowel. R45's Care Plan, dated 1/4/24, documents R45 has the potential for UTI's due to the use of an indwelling urinary catheter. R45's Progress Note, dated 1/1/24 at 8:26 AM, documents the following: During med pass Resident was observed to be flushed, diaphoretic, and un-alert. Resident could not open eyes or take medication and her face was bright red. After assessing Resident VS (vital signs) were 104.0-100.8, 104, 22, 113/55, 93%-95%. Resident was negative for COVID and BS (blood sugar) was 185. Resident was given (acetaminophen) to help with fever and air condition was turned on, then this nurse reached out to on call NP (Nurse Practitioner) who advised to send resident out for further assessment. Emergency contact, on call nurse, and DON (Director of Nurses) was made aware. Report was called to ER (Emergency Room) nurse. R45's Progress Note, dated 1/2/24 at 7:45 AM, documents the following: Call placed to (local) hospital. Resident admitted with dx of UTI and Sepsis. R45's Progress Note, dated 3/1/24 at 9:30 AM, documents the following: Resident continues on MED A. Alert with confusion this shift. Yelling out most of this shift. I have to Pee. Resident has had no urine noted in bag this AM. Resident laid down and assessed, Foley (indwelling urinary catheter) intact. Foley flushed with 60cc (cubic centimeters) of NS (normal saline) x (times) 2. Foley now patent and draining, yellow cloudy urine 900cc noted. The resident has had U/A (urinalysis) recently collected, awaiting the final results. No voiced pain. Vitals are stable. Fluids are encouraged and at the bedside. Resident now resting in bed call light within reach. R45's Progress Note, dated 3/5/24 at 11:44 AM, documents the following: FNP (Family Nurse Practitioner) responded to UA results from 3/2. Contaminated specimen. May need to change Foley and then send urine sample after clean Foley placed. Made all parties aware. R45's Progress Note, dated 3/8/24 at 1:45 PM, documents the following: Received urine C&S (culture and sensitivity) results from (facility contracted) lab. Copy faxed to (doctor) and called to verify receiving. Explained specimen taken straight from catheter and urine is cloudy with sediment. Office to call new orders to facility. R45's Progress Note, dated 4/4/24 at 7:06 PM, documents the following: Resident returned to nursing station after being lethargic @ (at) the dinner table, she responds to name and able to state her name. Responds to tactile stimulation. Blood pressure 98/62-p82-sat 97. Blood sugar at 430p was 182 now 274. No indication of pain. In bed sleeping, respiration even and non-labored. Called placed to doctor's office, message was left on the voicemail @ 7:24p.m. Will continue to assess the resident for changes in respiration and level of consciousness. R45's Progress Note, dated 4/5/24 at 1:39 PM, documents the following: (Doctor's) office notified resident sleeping more than usual. Quiet most of day. Poor appetite at meals. Urine output less than normal thru Foley catheter. Difficult to arouse. Waiting on response from (doctor). VS 97.5-81-18 122/78. R45's Progress Note, dated 4/5/24 at 4:33 PM, documents the following: ADON (Assistant Director of Nurses) called with orders that was given from MD (medical doctor) to get stat labs CBC (complete blood count), CMP (comprehensive metabolic panel), Troponin, and UA. R45's Progress Note, dated 4/6/24 at 9:54 AM, documents the following: Stat lab result received; made aware to on-call NP; received a new order for Rocephin 1gm (gram) IM (intramuscular) daily x 5 days, sub-q (subcutaneous) 1 liter of NS, RUN 100ml (milliliters)/hr (hour), repeat BMP (basic metabolic panel) and CBC in the AM; lab order carried out; made aware to on-call nurse and left (voicemail) to family. R45's Progress Note, dated 5/8/24 at 11:30 PM, documents the following: Resident returned from the hospital via ambulance transport. Resident transferred into bed 2 assist via ambulance service. Resident is sleeping w/o (without) signs of discomfort or distress. Resident returned with a new order for Cefdinir 300 mg, take 1 cap po BID (twice daily) for 7 days. Resident also returned with a newly inserted Foley 16F/10mL. R45's Progress Note, dated 5/9/24 at 2:33 PM, documents the following: Resident has increased confusion after lunch, leaning forward unable to assist herself back to position. Resident has had x2 loose stools with a moderate amount of mucous noted. Resident POA (Power of Attorney) was contacted and made aware. Requested resident to be sent to (local) hospital ED (emergency department). EMS was contacted to transfer resident to ED. MD contacted and made aware via fax. Resident clean and dry, resting in bed at this time. No s/s (signs/symptoms) of pain or distress, call light in reach. R45's Progress Note, dated 5/9/24 at 3:15 PM, documents the following: Resident transferred to (local hospital) ED via (local) EMS in stable condition. R45's Progress Note, dated 5/9/24 at 9:19 PM, documents the following: Resident returned to facility via EMS. NNO (no new orders) at this time. Abx (antibiotic) administered as prescribed. Resident afebrile. Resting comfortably in bed at this time, call light in reach. No c/o pain, discomfort, or distress noted. R45's Progress Note, dated 5/13/24 at 11:57 AM, documents the following: Remains on ABT (antibiotic) for UTI. Fax received from (local) hospital related to recent ED visit on 5/9/24. Fax showed E-Coli (Escherichia coli) in the urine with Bactrim DS and Doxycycline being two of the PO (by mouth) meds resident's results are susceptible to. Results sent to (doctor's) office and to FNP with explanation and present order for Cefdinir. Awaiting return call or fax. R45's Progress Note, dated 5/13/24 at 2:31 PM, documents the following: New order related to results from (local) hospital for urine C&S received. Doxycycline 100 BID x 7 days ordered. R45's Urine Culture, dated 3/11/24, documents R45 had Escherichia Coli and Enterococcus Faecalis in her urine. R45's U/A, dated 4/5/24, documents R45's urine was abnormal, and no culture was performed. R45's Urine Culture, dated 5/8/24, documents R45 had Escherichia Coli in her urine. On 7/26/24 at 10:00 AM, V2, DON (Director of Nurses), stated they utilize a catheter competency that goes through the steps of how catheter care should be performed. V2 stated staff are to wash their hands and put on clean gloves. Staff can perform hand hygiene with alcohol hand gel three times and then after the 3rd time, they are to wash their hands and put on clean gloves. V2 stated they are to utilize one wipe per swipe and change their gloves twice during catheter care. The Foley Catheter Care Policy and Procedure, undated documents the following: All staff will adhere to the evidence-based guidelines for the performance of routine catheter care utilizing the proper procedure to prevent urinary tract infections. Procedure: #4 - Wipe around area where catheter enters meatus in a downward motion. Use wipe only once, change wipes between each swipe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure Physician Orders were followed and the physician was notified if the orders could not be carried out for 1 of 4 residents (R65) reviewed for physician orders in the sample of 37. Findings include: R65's Physician Order Sheet (POS) for July 2024 documents a diagnosis of Rhabdomyolysis; Unspecified superficial injury of unspecified great toe, subsequent encounter; Unspecified hemorrhoids (History of); Anemia, unspecified; Benign prostatic hyperplasia with lower urinary tract symptoms; Chronic kidney disease, unspecified; Chronic metabolic acidosis; Depression, unspecified; Rheumatoid arthritis, unspecified; Testicular hypofunction; Unilateral primary osteoarthritis, left knee; Unspecified fall, subsequent encounter; Pain, unspecified; and Constipation. R65's Minimum Data Set (MDS) dated [DATE] documents R65 was moderately impaired for cognition for activities of daily living. R65's Care Plan does not address weight loss and/or nutrition. R65's Nurse's Notes dated 5/17/2024 at 5:34 AM, documents, resident seen in clinic today by (V16 Medical Director) during routine rounds. New order received for Marinol 2.5mg (milligrams) by mouth twice daily. Resident & family both notified. Order processed & carried out. R65's Dietary Note dated 5/28/2024 at 10:31 AM, Dietitian weight note. [AGE] year-old male triggering for significant (-9#; -8.5%) weight loss x 30 days. BMI (body mass index). R65'S Nursing Notes dated 5/30/2024 at 2:00 PM, IDT (Intradisciplinary Team) weight meeting held. Resident noted with 9.4% loss in 3 months. Resident had order for Marinol for appetite, but medication is on backorder with pharmacy unsure of availability date. Pharmacy recommendation sent to MD (Medical Director). Supplements ordered, alternatives and snacks offered. Resident will request item, take 1-2 bites and then state he is done. R65's Progress Notes dated 5/31/2024 at 11:41 AM, documents, Fax sent to (V16's) office regarding new order received to start Remeron 7.5 mg. New order was to replace Marinol 2.5 mg, but resident is already prescribed Remeron. Awaiting response. R65's dietary notes dated 5/31/2024 at 11:41am, Dietitian weight note: 84 YOM (year old male) triggering for significant (-9#; -8.5%) wt (weight) loss x 30 days. CBW 97# (5/7/24), BMI 13.15 underweight for age, weight history [DATE]#, [DATE]#, [DATE]#, [DATE]#, [DATE]#, [DATE]#. Diet/Meds reviewed, Marinol 2.5mg BID, prednisone BID. No recent uploaded labs to review. Continue with current nutrition therapy General/Regular with House supplement 60ml/4x per day (480kcal/19gm protein) and (nutritional supplemental dessert) (270kcal/9gm protein per serving) with meals. Noted poor meal intakes and refusing supplements, nutrition therapy as ordered will exceed needs if consumed. Recommend continue with nutrition therapy as ordered, assistance with meals and encourage fluids throughout the day. Continue to monitor nutritional parameters and refer to RD (Registered Dietician) prn (As needed). R65's Dietary Notes dated 2/20/2024 at 10:54 AM, Dietitian weight note: (R65) who triggers for significant (-12#; 10.2%) weight loss x 90 days. BMI 14.37 underweight for age. Weight history November 2023 112# On 7/26/2024 at 9:03 AM, attempted to call Medical Director and left a message but no message was returned. The Medication Administration Policy with a revision date of 12/2020 documents, (Facility) will administer medications per a standardized liberal schedule except when the physician's order dictates it to be given another time. Manufacture's recommendations will be considered when scheduling certain medications. Residents' preferences and quality of life issues will be considered in medication administration schedules as much as is safe and practicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to monitor medications to ensure the resident is not receiving unnecessary medications for one of five residents (R67) reviewed for unnecessary medications in the sample of 37. Findings Include: R67's MDS (Minimum Data Set) dated [DATE] documents R67 has moderately impaired cognitive skills for decision making. R67's EHR (Electronic Health Record) dated [DATE] documents R67's Unspecified Dementia Unspecified severity without behavioral disturbance, mood, disturbance, and anxiety. Vascular Dementia Unspecified Severity with behavioral disturbance, Restlessness and Agitation, and Major Depressive Disorder Single Episode Unspecified. Consultant Pharmacist's Medication Regimen Review dated [DATE] documents Regarding Previous Pharmacy Recommendation from [DATE] (V30 Consulting Psychiatrist) marked, signed and dated [DATE] to discontinue PRN (as needed) Haldol however this order is still active on the POS (Physician Order Sheet) Please discontinue as PRN antipsychotics can only be ordered for 14 days. Haldol was Scheduled (not PRN) on [DATE]. Note to Attending Physician/Prescriber dated [DATE] documents this hospice resident continues to have a PRN order for the antipsychotic Haldol. Resident (R67) also has routine Haldol order. However, CMS (Central Management Service) considers the PRN use of antipsychotics inappropriate as of [DATE]. The Maximum order for an antipsychotic is 14 days and a new order can only be written with a) Direct physical assessment by the Physician b) documents clinical rationale for the new order which includes what is the benefit of the medication to the resident and has the resident's expressions or indications of distress improved as a result of the PRN. Agree discontinue Haldol PRN. Consultant Pharmacist's Medication Regimen Review dated [DATE] V30 Consulting Psychiatrist marked, signed, and dated [DATE] to discontinue PRN Haldol please discontinue as PRN Antipsychotic orders can only be ordered for 14 days. Haldol was scheduled [DATE]. R67's Medication Administration History (MAR) dated [DATE] documents that R67 is receiving Buspirone 15mg (milligrams) twice a day for Major Depressive Disorder, Quetiapine 100mg twice a day for restlessness and agitation. Sertraline 100mg twice a day for Major Depressive Disorder, Haloperidol Lactate concentrate 2mg/ml 1ml (milliliter) every 8 hours for Vascular Dementia unspecified severity with other behavioral disturbances, Lorazepam 1mg at bedtime for Restlessness and agitation. R67's July MAR documents R67 is receiving the same medications. R67's Behavior/Intervention Monthly Flow Record dated [DATE] to [DATE] documents depression was only completed 4 times on the day shift with no behaviors, twice on evening shift with no behaviors, and thirteen times on the night shift with one behavior with redirection. R67's Behavior/Intervention Monthly Flow Record dated [DATE] through [DATE] was only completed 15 days with her being returned to her room [ROOM NUMBER] times for restlessness. The monthly Flow sheet also documents that she was behavior tracked 10 times on the night shift for restlessness and she was redirected twice. R67 Hospice Plan of Care Note dated [DATE] documents Pt (patient) is awake with confusion answers some questions appropriate awoke to follow commands anxious trying to get out of her chair. She was refusing medications yesterday and throwing things. R67 Hospice Plan of Care Note dated [DATE] documents patient increase somnolence Ativan given prior to shift. R67's Hospice Plan of Care Note dated [DATE] patient confused poor to fair appetite intermittent restlessness no agitation. R67's Hospice Plan of Care Note dated [DATE] documents patient sleeping prior to visit some restlessness noted easily redirected. R67's Hospice Plan of Care Note dated [DATE] documents patient alert to self-able to follow commands can track with eyes. R67's Hospice Plan of Care Note dated [DATE] documents patient alert to self-patient can answer questions that are simple patient follows commands. R67's Hospice Plan of Care Note dated [DATE] documents patient sleeping 16 to 18 hours in 24 hours patient alert to self-tracks with eyes follow commands. R67's Hospice Plan of Care Note dated [DATE] documents patient will become anxious with care at times. R67's Hospice Plan of Care [DATE] documents appetite poor patient sleeping addition of Haldol more effectively manage symptoms. R67's Facsimile Sheet dated [DATE] she has a diagnosis of severe vascular dementia with behaviors disturbances. R67's Electronic Health Record documents R67's medications are Buspar 15mg BID ordered on [DATE], Haldol Concentrate 1ml po QD ordered on [DATE]. Seroquel 100mg BID ordered on [DATE]. Ativan 2mg Q4 HR PRN ordered on [DATE]. Ativan 1mg PO QD 8 PM. On [DATE] at 1:50 PM V25 (Certified Nursing Assistant/CNA) stated I assist her (R67) with feeding I assist her with incontinent care. Her husband just recently died, and sometimes she will call out for him. She is not violent. She does not cause any problems. She does not hallucinate. On [DATE] at 1:55 PM V15 (CNA) stated sometimes she sees things that are not there. She reaches for things on the floor. Sometimes she sleeps a lot sometimes no. On [DATE] at 2:00PM V27 (Licensed Practical Nurse/LPN) stated she was sleeping a lot, easy to arouse. She took her medications. Sometimes she is in bed. Sometimes she is in the Geri chair with no issues. On [DATE] at 2:00 PM V28 (LPN) stated we mostly monitor her for safety. She sleeps throughout the night on low bed. On [DATE] at 2:02 PM V26 (CNA) stated she's a feeder, not with it. We do what we know she needs. No, she does not see things. Sometimes she can feed herself. The Facility Policy Psychotropic Drug Orders undated documents in order to ensure Psychotropic drugs are used appropriately according to physician's order and to protect residents' rights. (The Facility) will follow uniform procedures. Psychotropic drugs are used for documented resident's need and not staff convenience. Residents will not be given unnecessary drugs including excessive dose, duplicative therapy, for excessive duration without adequate monitoring, without adequate indication for it's use or in the presence of adverse consequences that indicate the drug should be reduced or discontinued. Informed consent will provide for dosage changes to establish the lowest effective dose that will achieve the desires outcome. The informed consent will include benefits and side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure there was a RN (Registered Nurse) working in the facility for 8 consecutive hours a day, 7 days a week. This has the potential to affect all 82 residents living in the facility. Findings include: On 7/23/2024 at 9:00 AM, Schedules were requested for the past 14 days, including Registered Nurse (RN). The schedule coverage did not document any RN working on 7/13/2024 and 7/14/2024. The PBJ (payroll-based journal) Report for the second quarter (January 1- March 31) of 2024 documents concerns for RN coverage and one star rating for fiscal quarter 2, 2024 for the facility. On 7/23/2024 at 10:11 AM, V3 (Assistant Director of Nursing) stated, I am a Registered Nurse along with the Director of Nursing. I know we are currently trying to hire more RNs and we struggle on the weekends. I know we are supposed to have a RN on duty every day for 8 consecutive hours every day. On 7/23/24 at 11:34 AM V1 (Administrator) stated I am going to be honest we did not have a Registered Nurse (RN) for 7/13/2024 and 7/14/2024. We are in the process of attempting to hire more Registered Nurses. I hired two RNs, and they did not even last a day. I am not going to lie I know the weekends are where we are getting hit. I am just having issues finding staff. The Facility assessment dated [DATE] documents, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Nursing Services, RN. Great need for RN's and continued struggle. Areas Facility Assessment Informed, Action to be taken/already taken this year, Need RNs to stabilize nursing department. On 7/24/2024 at 4:18 PM, V2, Director of Nursing stated there was no staffing policy. The 672 Long Term Care Facility Application for Medicare and Medicaid form dated 7/24/2024 documents, there are 82 residents living in the facility.

Based on observation, interview, and record review the facility failed to have an air gap present for the ice machine in the kitchen. This has the potential to affect all 82 residents living in the facility. Findings include: On 7/23/2024 at 4:24 PM, the ice machine in the kitchen had no air gap present. The white drainage hose from the ice machine went directly into the round drain hole with no air gap present. This allows for potential backflow into the ice machine from the sewage drain. On 7/23/2024 at 4:28 PM, V11 (Dietary Manager) stated, I see the hose going into the drain I did not realize or think about any backflow. We use this ice for all of the residents' drinks during meal services. The State Plumbing code Section 750.290 document, Ice Dispensing Ice for consumer use shall be dispensed only with scoops, tongs, or other ice-dispensing utensils or through automatic self-service ice-dispensing equipment. Ice-dispensing utensils shall be stored on a clean surface or in the ice with the dispensing utensil's handle extended out of the ice. Between uses, ice transfer receptacles shall be stored in a way that protects them from contamination. Ice storage bins shall be drained through an air gap. Section 750.1080 Backflow, The potable water system shall be installed to preclude the possibility of backflow. Devices to protect against backflow and back siphonage shall be installed at all fixtures and equipment where an air gap at least twice the diameter of the water inlet is not provided between the water outlet from the fixture and the fixture's flood-level rim and wherever else backflow or back siphonage may occur. A hose shall not be attached to a faucet unless a backflow prevention device is installed. Section 750.1100 Drains a) Commercial dishwashing machines, dishwashing sinks, pot washing sinks, pre-rinse sinks, silverware sinks, bar sinks, soda fountain sinks, vegetable sinks, potato peelers, ice machines, steam tables, steam cookers, and other similar 29 30 30 30 29 30 30 29 29 Installed Cross-connected Siphonage Backflow Installed Backflow Back-siphonage Installed *Keyed to IDPH Retail Food Establishment Inspection Report 67 fixtures shall be indirectly connected in compliance with 77 Ill. Adm. Code 890.1410(a). The only exception shall be when such fixtures are located adjacent to a floor drain, the waste may be directly connected on the sewer side of the floor drain trap provided the fixture waste is trapped and vented as required by the Illinois Plumbing Code (77 Ill. Adm. Code 890) and the floor drain is located within four feet horizontally of the fixture and in the same room. The indirect piping from the fixture to the air gap shall not exceed five (5) feet developed length. All indirectly connected fixtures shall discharge to a vented trap located in the same room in compliance with 77 Ill. Adm. Code 890.1410(a). In the case of direct connection, no other fixture waste shall be connected between the floor drain trap and the fixture protected. b) Drain lines from equipment shall not discharge wastewater in such a manner as will permit the flooding of floors or the flowing of water across working or walking areas or into difficult-to-clean areas, or otherwise create a nuisance. The 672 Long Term Care Facility Application for Medicare and Medicaid form (CMS 671) dated 7/24/2024 documents, there are 82 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 ensure staff had passed their required licensure exam for Licensed Practical Nurse before allowing them to work in the facility in the capacity of a license-pending graduate practice nurse. This has the potential to affect all 82 residents in the facility. Findings include: On 7/25/24 at 9:00 AM V29 (Assistant Administrator) provided employee files for V10 (Graduate Practice Nurse/GPN) and V23 (GPN). According to their files, V10 and V23 were hired for the positions of Licensed Practical Nurse (LPN) but their employee files did not include confirmation by the Illinois Department of Financial and Professional Regulation that either V10 or V23 have a valid LPN license or a copy of their license. On 7/25/24 at 9:50 AM V2 (Director of Nursing/DON) stated V10 and V23 are working as license pending LPNs. She stated they have passed some medications under the supervision of the LPNs who are working the floor. She stated they have not taken their test to obtain their LPN license yet and never work independently. She stated that she only schedules them to work when either she or V3 (Assistant Director of Nursing/ADON) is working because V10 and V23 have to work under the supervision of a Registered Nurse (RN). On 7/25/24 at 9:55 AM V1 (Administrator) stated they hired V10 and V23 to work as license pending because it is very difficult to hire nurses so they hired them so they will fill in LPN slots when they are licensed. V1 stated until V10 and V23 are licensed, they are being orientated and doing observations with other nurses. V1 stated she was not aware V10 or V23 had not already taken their tests for LPN licensure, or that they were not even scheduled to take their tests. V1 stated she was not aware that V10 or V23 had administered medications to residents because they were only supposed to be shadowing V2 or the other nurses and should not be passing medications. V1 stated she does not have a job description for GPN position and does not have a policy regarding GPNs, but just goes by what the regulations say. On 7/25/24 at 11:30 AM V10 (GPN) was observed in the facility wearing a Staff Identification Badge that identified her as Licensed Practical Nurse (LPN). V10 stated she is a GPN and has not taken her test to become an LPN and stated she has no plans to take the test yet. V10 stated she is not going to take the test until she is ready and stated she is not ready. V10 stated she has administered medications to some of the residents in the facility and signs out the medications she administers in the residents' electronic Medication Administration Records (e-MARs). V10 stated she does not do any other LPN duties besides passing medications which she does under the direct supervision of V2. She stated she is mostly doing observations with other nurses. V10 stated she has been working in the facility for a few weeks. On 7/25/24 at 3:30 PM V10's employee file was reviewed. V10's Payroll Authorization and Employee Pay Change & History form documents V10's job description as LPN and documents the effective date as 6/27/24 as a new hire. V10's Emergency Contact Form dated 6/27/24 documents her position as LPN. On 7/25/24 at 11:33 AM V23 (GDR) stated she has administered medications to residents under the supervision of V2. V23 stated when she passed medications, she passed to 7 or 8 residents in the dining room, and she signed out the medications in the residents' e-MARs. V23 stated she has not registered to take her test to obtain her LPN license because she stated she does not feel like she is ready to take the test yet. She stated she has been working in the facility as a GPN for about a month. V23 was wearing an employee ID badge that identifies her as an LPN. V23's Application for Employment dated 6/19/24 documents GPN under the question, What job are you applying for? V23's Payroll Authorization & Employee Pay Change & History form documents, under job description: LPN, with effective date of 6/24/24 as a new hire. On 7/25/24 at 3:27 PM V29 (Administrative Assistant) stated she does background checks on all the new hires in the facility. V29 stated she has asked V10 and V23 when they are planning to schedule their tests to obtain their LPN license and they have never given her a definite answer. She stated the facility has never hired any GPNs before while she has been employed, and if someone did not have a license they had to work as a Certified Nursing Assistant (CNA) until they could provide a license. V29 stated the only information she received from V10 and V23 was what is on their applications. She stated she does not have any documentation that they completed LPN schooling. V29 stated she did bring up her concerns regarding V10 and V23 working as GPNs but was told by V1 (Administrator) that it was fine. V29 stated they do not have a job description for the position of a GPN. V29 confirmed V10 and V23 are paid LPN wages. On 7/25/24 at 3:33 PM V2 stated both V10 and V23 graduated from (local school of nursing) and they showed her emails that confirmed they are eligible to take the test to obtain their LPN license. She stated they got the letter after they graduated, and they have time before they have to take their tests, and neither of them are ready to take the test yet. V2 stated, I messed up. I gave my permission for them to pass medications under the supervision of the other nurses. I didn't know this was not allowed. The other nurses who are orienting V10 or V23 log into the e-MARS and when V10 or V23 administer a medication, they check them off, but it is under the LPN's log in. V2 stated V10 and V23 do not have accesses of their own to log into the e-MARs. V2 stated she was not aware that the regulations do no allow GPNs to work as license pending. until they take and pass their LPN test. V2 confirmed that V10 and V23 were supervised by herself, V3 (ADON) or one of the LPNs who were orientating V10 and V23. She stated they were not always directly supervised by her, but either she or V3 were in the facility when V10 and V23 were working. The Illinois General Assembly Public Act [PHONE NUMBER], Section 55-10(d)1, 2,3,4 documents, (d) A licensed practical nurse applicant who passes the Department-approved licensure examination and has applied to the Department for licensure may obtain employment as a licensed-pending practical nurse and practice as delegated by a registered professional nurse or an advanced practice registered nurse or physician. An individual may be employed as a license-pending practical nurse if all of the following criteria are met: (1) He or she has completed and passed the Department-approved licensure exam and presents to the employer the official written notification indicating successful passage of the licensure examination. (2) He or she has completed and submitted to the Department an application for licensure under Section as a practical nurse. (3) He or she has submitted the required licensure fee. (4) He or she has met all other requirements established by rule, including having submitted to a criminal history records check. The CMS form 671, Long Term Care Facility Application for Medicare and Medicaid, dated 7/24/24 documents there are 82 residents residing in the facility.

Based on observation, interview, and record review the Facility failed to follow CDC Infection Control Guidelines during an COVID outbreak and staff providing patient care were not wearing the proper PPE (Personal Protective Equipment). This has the potential to affect 82 residents living in the facility. Findings include: On 7/24/24 at 8:12 AM, R36's room had PPE (Personal Protective Equipment, Gowns, Gloves, Face shields and mask), on the outside of his door. On 7/24/2024 at 8:15 AM, V10 (Licensed Practical Nurse/LPN) entered R36's room and was only wearing a N95 mask. V10 was not wearing any gown or any eye protection. On 7/24/2024 at 8:18 AM, V10 left R36's room and walked into the main dining room and began assisting with breakfast meals. V10 was carrying trays to the residents in the main dining room. On 7/24/2024 at 9:02 AM, V10 stated I did not realize (R36) was on droplet precautions. I found out later he was COVID positive. I guess I was not looking at the door and did not see he was on contact isolation. I should have been wearing a gown and eyewear. On 7/26/2024 at 10:12 AM, V2 (Director of Nursing) stated, I would expect any staff in COVID positive rooms to be in full PPE, N95 mask, gown and faces shield or goggles. On 7/24/24 at 8:05 AM V1 (Administrator) stated R23 tested positive for COVID this morning along with 2 other residents. On 7/24/24 at 8:10 AM R23's door had PPE (Personal Protective Equipment) caddy hanging on her door with gloves, face masks, gowns and N95 masks on it. V9 (Housekeeper) was in R23's room cleaning and was observed walking in and out of the room to grab items off her housekeeping cart which was parked right in front of the door. V9 was wearing a gown, gloves and N95 mask, but no eye protection. After she went back in room to wipe off table and walked back to cart, she looked at the sign on R23's door indicating R23 is on droplet and contact isolation. V9 stated, Yes, I should be wearing a face shield also when I am in R23's room. R23 was in her bed in the room while V9 was cleaning her room. R23's Physician Order dated 7/24/24 documents: COVID positive charting, s/s (signs and symptoms) of COVID, respiratory assessment, and full set of vitals every 4 hours while on isolation. Contact and droplet isolation precautions for COVID 19. On 7/26/24 at 12:45 PM V1 (Administrator) provided the following policies when asked for their most up to date policies regarding infection control practices and use of PPE: The facility's undated policy, Droplet Precautions, documents, Objective: Droplet Precautions will be used for residents known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident during coughing sneezing, talking, etc. Transmission of the droplets require close contact between source and recipient because droplets do not remain suspended in the air and generally travel short distances (3 feet or less). Droplet transmission involves contact of mucous membranes of the nose or mouth of a susceptible person with the infectious droplets. The facility's policy, Infection Control--Fundamentals of Isolation Precautions revised 5/19/04 documents, Policy: In order to decrease the transmission of pathogenic microorganisms, (facility) will follow fundamentals of isolation precautions according to CDC (Centers for Disease Control) guidelines and IDPH (Illinois Department of Public Health) regulations. Personal Protective Equipment-Masks, Respiratory Protection, Eye Protection, Face Shields: A mask that covers both nose and mouth, and goggles or a face shield will be worn by staff during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, excretions, or secretions to provide protection of the mucous membranes of the caregiver's eyes, nose, and mouth from contact transmission of pathogens. A mask which covers both nose and mouth will be worn to provide protection for the caregiver when a resident is on droplet precautions. This provides protection against spread of infectious large particles droplets that are transmitted by close contact and generally travel only short distances (up to three feet). The CMS form 671, Long Term Care Facility Application for Medicare and Medicaid, dated 7/24/24 documents there are 82 residents residing in the facility.

Based on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 78 residents living in the facility. Findings include: The facility's schedule for 9/20/23 through 10/3/23 documented that the facility did not have a RN in the facility for at least 8 consecutive hours a day on 9/20/23, 9/21/23, 9/24/23, 9/25/23, 9/26/23, 9/27/23, 9/28/23, 9/29/23, 9/30/23, 10/1/23, 10/2/23 and 10/3/23. The facility's schedule dated 9/1/23 through 9/14/23 documented the facility did not have a RN in the facility for at least 8 consecutive hours a day on 8/2/23, 8/3/23, 8/6/23, 8/12/23 and 8/14/23. On 10/5/23 at 2:30 PM, V1 (Administrator) stated, we have applications, and we will start interviewing soon for RNs. On 10/5/23 at 2:35 PM, V7 (Minimum Data Set Coordinator) stated, We are trying to get RNs, but it is hard. The facility policy entitled Direct Care Staffing dated 12/2012 documents the facility will comply with staffing requirements set forth by the state and federal requirements to meet the needs of its residents. The facility's Room Roster/census dated 10/3/23 documents there are 78 residents in the facility.

5. R2's Physician Order dated 02/21/22 documents repeated falls. R2's Care Plan dated 03/28/19 documents Problem: At risk for falls due to decreased strength and balance, decreased safety. Is independent with bed mobility, transfers, ambulation, locomotion, uses her rollator walker, educated on wearing non-skid socks. Res (resident) has been educated from staff to use call light and ask for help prior to walking in room and res refuses to use call light and ask for help. 6/9/22 fall no injuries, R2 refuses to wear non-skid slippers. Son stated he will be in on 6/10 to bring up new non-skid sole slippers/shoes. 6/10/22 fall educated to press call light and wait for assistance. 7/11/22 slid while trying to stand. Intervention: R2 was educated multiple times from staff to use call light for assistance, wear gripper socks. 4/17/23 res found on floor in front of toilet, no injuries noted. Tennis shoes on but, came off during fall. Resident is non-compliant with all safety interventions. 5/29/23 Res found sitting on floor in front of bathroom door, shearing noted to buttock. Intervention, educated to use call light. R2's Care Plan dated 03/28/19 documents Problem: Continued, resident is at risk for falls d/t (due to) decreased strength, balance and decreased safety awareness. 8/23/22 R2 slid out of bed onto the floor no injuries. Intervention R2 re-educated on use of call light for assistance. 8/29/22 R2 slid out her recliner and on to her bottom. No injuries, wearing regular socks at this time. Intervention R2 was re-educated on proper footwear of gripper socks, or non-skid footwear. 9/19/2022 resident fall, intervention CBC and BMP ordered. 9/20/2022 UA and CNS ordered. 10/29/22 unwitnessed fall in bathroom, no injuries, R2 was not wearing non-skid socks at time. Intervention R2 re-educated on wearing non-skid footwear. 11/5/22 slid out of chair on to floor, no injuries. Intervention re-educated on wearing gripper socks, and shoes. 11/7/22 resident slid out of chair onto floor, no injuries. Intervention educated R2 on importance of proper footwear and calling for and waiting for assistance. R2 is refusing to have the (nonskid material), in her chair which is an intervention for a fall. 11/18/22 slid out of recliner, no injuries. Intervention staff re-educated R2 on importance of using call light and waiting for assistance and proper footwear. 11/19/22 found on floor no injuries, did not have shoes on. Intervention staff re-educated about the importance of wearing shoes. 01/09/2023 resident found on the floor in her room in front of recliner, plain socks on. Resident educated regarding keeping tennis shoes on feet, fall had no injury. 01/21/23 slide off recliner onto the floor. Intervention education to keep shoes on until transfer complete. 01/25/23 slide off recliner onto the floor, plain socks. Continues to not follow instructions given by staff. 03/06/23 fall from recliner, slide out, no injuries. 03/30/23 found on floor in front of chair, no injuries. 04/2/23 found sitting on floor in front of recliner, no injuries. R2 continues to be non-compliant. R2's MDS (Minimum Data Set) dated 04/27/23 documents, a BIMS (Brief Interview of Mental Status) score 15 out of 15. Resident has no impairment. The MDS documents, that R2 is independent with setup help, only for bed mobility, transfer, walk in room, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Resident is not steady, but able to stabilize without staff assistance. R2's Fall Investigation dated, 07/10/22 documents, Resident fall. Spoke with resident concerning leaving (nonskid material) in her recliner and not covering it up with a blanket, also educated resident to use her call light and not to transfer without assistance. R2's Nursing Note dated, 07/11/22 at 4:22 PM documents, CNA (Certified Nurses Assistant), notified this nurse that resident was on the floor. When this nurse entered residents' room, resident observed sitting on her buttocks with her legs stretched out in front of her, reclining chair. When this nurse asked resident what happened, resident states, she slipped, when she got out of her chair, to go to the bathroom. Resident denies hitting head. ROM (range of motion), WNL (within normal limits). Denies pain with ROM. 0 (no) shortening or rotation noted to BLE (bilateral lower extremities) 0 injuries noted at this time. Resident assisted to her feet by this nurse and 2 CNAs. Resident encouraged to have on gripper socks or shoes when self-transferring, and to utilize call light for assistance. Resident expressed understanding, resident observed in bathroom an hr. (hour) later and resident had not utilized call light for assistance or put on shoes for transfer. MD (Medical Director), Family, and DON (Director of Nursing) notified of INC (incident). R2's Fall Investigation dated, 07/11/22 documents, spoke with resident concerning wearing the shoes, that are non-slip that her son bought for her, resident voiced understanding. R2's Nursing Note dated 08/03/22 at 2:22 AM documents, CNA notified this nurse, that resident was on the floor. When this nurse entered residents' room, resident observed sitting on her buttocks with her legs stretched out in front of her, in front of her reclining chair with W/W (wheeled walker) at feet. When this nurse asked resident what happened, resident states, she slipped, when she got out of her chair to go to the bathroom. Resident denies hitting head, ROM WNL. Denies pain with ROM, 0 shortening or rotation noted to BLE. 0 injuries noted at this time, resident assisted to her feet by this nurse and 1 CNA. Resident had tennis shoes on at the time of fall. Resident encouraged to utilize call light for assistance, resident expressed understanding. MD, Family, and DON notified of INC. R2's Fall Investigation dated, 08/03/22 documents Unwitnessed fall without injury, intervention in place, continue current care plan. R2's Nursing Note dated, 08/23/23 at 7:10 PM documents, CNA notified writer that resident was in room on floor. Upon entering room writer found resident sitting in room upright on coccyx with back against bed and leg stretched out in front of her and arms to her side. Staff assisted resident up off ground and back onto her bed. When asked how the fall occurred resident stated, I was attempting to get up off bed when my foot slipped from under me, and I fell onto my bottom. Resident denies any pain at this time, no injuries or bruising found at this time residents ROM is WNL per her baseline. Resident's Son notified of fall and call placed to (V33) exchange to make aware of fall. R2's Fall Investigation dated, 08/23/22 documents, Fall in bedroom, resident slid off of the side of the bed to the floor. No injuries, educated to utilize call light when needing assistance. Care plan updated and continued. R2's Nursing Note dated, 08/29/22 at 3:38 PM documents, CNA notified, this nurse that resident is on the floor, upon entering, resident was on the floor on her buttocks, resident stated, that she slid from her recliner when she was trying to get up, resident had plain socks on her feet, nurse educated resident to wear gripper socks or shoes before she transfer, resident stated, she did not hit her head, denies for any pain or discomfort, no injury noted, helped resident onto her chair, made aware to resident son and NP (V30). R2's Fall Investigation dated, 08/29/22 documents, Fall from recliner, no injury. Investigation completed, resident slid out of recliner onto her bottom, no injuries. Resident was wearing plain socks at the time. Educated to wear gripper socks or non-skid footwear, Care plan updated and continued. R2's Nursing Note dated, 09/19/22 at 2:07 PM documents, Resident found on the floor in her room, on the floor by her recliner. Resident stated that she fell while attempting to go to the restroom. ROM completed and WNL, proper footwear in place. Resident assisted from the floor and back into her recliner, no injury apparent. Resident currently resting quietly in recliner with call light in place. Scheduled pain medication as well as Tylenol administered and tolerated well. No current c/o, (complaint of), pain or discomfort voiced, and no acute s/s, (signs and symptoms), of distress noted, monitor for change. R2's Fall Investigation dated, 09/19/22 documents, Fall in bedroom. Investigation completed, resident slid down from recliner to bottom when attempting to transfer, no injuries. Intervention, decrease Tramadol and U/A. Continue current care plan. R2's Nursing Note dated, 09/20/22 at 4:08 AM documents, This nurse was doing rounds and resident call light was on. Upon entering room, resident was noted sitting on buttocks, in front of recliner with pants down. Assessed resident immediately, no injuries noted, no c/o pain or discomfort when asked. Resident stated that she was trying to go to the bathroom and had pulled pants down before going. She stated that she lost her balance when trying to pull pants up. Resident was wearing regular socks and wheeled walker wasn't locked. Resident educated on using call light when needing assistance and spoke with resident about transitioning to a wheelchair vs wheeled walker, due to recent falls, resident agreed, and stated son suggested that she do the same. Resident was assisted off the floor and into bed by this nurse. NP (V30), DON, and son made aware. R2's Fall Investigation dated, 09/20/22 documents Fall in bedroom. Investigation completed; resident slid down to bottom when attempting to get out of her recliner. No injuries. Intervention: Labs. R2's Nursing Note dated, 10/29/22 at 9:17 AM documents, CNA notified, (V22), that resident was on the floor in her bathroom at 8:30am. Resident was transferring self-off of the toilet & slipped onto her bottom. Resident noted to be in regular socks with no shoes. VS (vital signs), BP (blood pressure), 110/68, HR (heart rate) 70, RR (respiration rate) 16, O2 (oxygen saturation) 97%, RA (room air), T (temperature) 97.6, PERRLA (pupils equal, round, reactive to light, accommodation) and no new complaints of pain, related to fall. Reported to NP (V30), NNO (no new orders). POA (Power of Attorney) notified as well and (V18) (on-call) notified. Resident educated on importance of asking for help with transfers and either gripper socks or shoes at all times. Resident voiced understanding, however, is noncompliant & unaware of safety guidelines & needs. Resident resting in her recliner at this time with call light within reach, no other concerns at this time. R2's Fall Investigation, 10/29/22 documents, Unwitnessed fall, resident fell while in the bathroom. Resident had plain socks on, no shoes or gripper socks. Resident educated on proper footwear and voiced understanding. R2's Nursing Note dated, 11/05/23 at 10:44 PM documents, resident turned on call light and CNA went to answer, and resident was on floor in front of her chair. R2 stated just slipped out of chair, CNA help her back up in chair, nurse went down to assess. Resident stated, did not hit head & no bumps or red areas seen. PERRL, BP 134/82, T 97.3, P 100, R 18, O2 sats 96%. Stated, did not hurt anything just twisted her neck a little no red/open areas noted. Resident remains up in chair with call light within reach, POA called & made aware. No fall investigation for fall on 11/05/22. R2's Nursing Note dated, 11/07/22 at 10:13 AM documents, CNA informed this nurse, that resident was on floor, upon observation resident was sitting in front of the bed with legs outstretched in front of her. Resident informed this nurse that she slid out of recliner, resident noted to have plain socks on with no shoes or gripper socks. Resident informed of the importance of proper footwear, to stop further incidents or injuries. Resident assessed to have ROM to all extremities without difficulty, no other injury noted, resident denies hitting head. VS assessed, T 97.6, P 94, R 18, 02 99% on room air; Resident assisted back to recliner and proper footwear put in place. (V30) NP notified of incidents; no new orders; son notified of new incident. No fall investigation noted for fall on 11/07/22. R2's Nursing Note dated, 11/18/22 at 10:23 PM documents, Staff was answering residents call light at 9:50PM, resident sitting on buttock on the floor stated, to staff that she slid off recliner and landed on her bottom. Denies hitting head or injuries. Tennis shoes were off and in front of resident. Resident states, that they came off when she slid down. Resident was assisted back off the floor by staff and into recliner. (V30) NP for (V33) notified, son was notified, and ADON was notified. R2's Fall Investigation dated, 11/18/22 documents Slid off chair in room. Resident slid out of chair while returning from the restroom, reminded resident to wear shoes and socks and push call light for help. R2's Nursing Note dated, 11/19/22 at 4:41PM documents, resident picked up off floor, no injuries noted. Denies hitting her head, VS, WNL, help into bed after assessment. Made sure call light within reach, resident was not wearing shoe. Reminded to put shoes on for all transfers, POA call & left message. (V30) NP, made aware with no new orders. R2's Fall Investigation dated, 11/19/22 documents, Fall from bed, Therapy referral. R2's Nursing Note dated, 01/09/23 at 7:20PM documents, Answered resident's call light and resident was noted on the floor sitting on her buttocks, in front of her recliner. Resident was assessed immediately, no injuries noted, no c/o pain or discomfort when asked. Asked resident what happened, and she stated, she was trying to pull her pants up and slipped. Resident had on regular socks only, no shoes on before she slipped. Resident educated on putting shoes on before standing and using call light if needing assistance. Resident understood and stated, she didn't hit her head. Son, NP (V30), and (V15) made aware. R2's Fall Investigation dated 01/09/22 documents unwitnessed fall in room. Found on the floor in front of her recliner. Resident had taken her tennis shoes off and only had her plain socks on. [NAME] was in front of resident. Attempted to place (nonskid material) to the floor in front of resident's recliner but, resident removes it off the floor. Intervention is resident teaching; resident is alert and responsive oriented to know that she needs to leave her shoes on. Despite all safety measures taken and in place, resident continues to remove her tennis shoes and walk around her room in plain socks. R2's Nursing Note dated, 01/21/23 at 1:18PM documents, Resident had an unwitnessed slide in room. Resident was found sitting on bottom leaning against recliner. Resident did not have gripper socks on, resident had normal black socks on. Call light in use, alarm on. CNA answered light and informed this nurse that resident was on the floor. Resident was assessed, no injuries noted, no s/s of shock. VS: T:97.8, R: 20, P:96, BP:154/81, O2:98% RA, Pain: 0, Resident denies any pain. Resident is A&O x4 able to make needs known. When asking resident what happened she stated, I was trying to get out of my recliner and slide onto the floor. When asking resident if she hit her head she stated, no, I did not hit my head. Resident was transferred off the floor with two staff members, using gait belt into recliner per resident's request. Intervention was put into place, gripper socks applied and rest. Neuro checks initiated; resident is currently sitting in recliner with call light in place. NP contacted, note was made in 24hr nursing report to call POA in the AM. On call nurse contacted, statements made. No fall investigation noted, for fall on 01/21/23 R2's Nursing Note dated, 01/25/23 at 3:25 PM documents, Was notified by staff that resident had a fall. Resident was sitting on buttocks in front of recliner. She stated that she was trying to stand and slid to the floor. No injuries noted, no c/o pain or discomfort. Educated resident on using call light and waiting for staff assistance, when needing to stand during the night, she stated she would. NP (V30), DON and family made aware. R2's Fall Investigation dated, 01/26/23 documents Fall investigation, resident slipped while transferring self from recliner chair. Resident very non-complaint with safety devices/interventions. Resident given night light for safety. R2's Nursing Note dated, 03/06/23 at 1:22AM documents, Resident had an unwitnessed fall; found on floor on bottom by CNA. Resident A&O (alert and oriented) X3; able to make needs known. Resident stated she slid out of her reclining chair attempting to go to the restroom. Resident stated, she did not hit her head and was not in pain. 0 s/s of distress or discomfort, VS WNL; BP 137/82, P 77, RR 12, O2 at 98%, room air, T 97. Resident assessed by this nurse and reoriented on importance of call light use. Resident is resting in bed at this time call light within reach, will continue to monitor during shift. R2's Fall Investigation dated, 03/06/23 documents, Fall investigation. Resident slid to floor from chair with no injuries. Resident remains non-complaint with safety devices/inventions. R2's Nursing Note dated, 03/06/23 at 7:42PM documents, Resident had an unwitnessed fall at 7pm. Resident was found on the floor next to bed. Resident said she fell while getting off the toilet. VS, T 97.6, P 83, R 20, O2 96%, RA, BP 122/63. A&O x4, she reached for her walker and the walker breaks were not locked in place, the walker went the opposite direction and the resident slid and fell. The resident denies hitting her head, when the nurse first assessed the fall, the resident said, she was in pain and hurting; she was on the floor crying, and she appeared to be in distress. When the nurse discussed the possibility of her going to the ER r/t (related to) 2 falls in one day, the resident began to deny pain and plead not to be sent to the hospital. No signs of bleeding noted, no changes in skin condition. NP (V30) contacted, NP suggest we ask the POA for instruction r/t hospital and to begin Neurological Checks. The nurse contacted POA son, POA chose not to send resident to the ER stating, if she says she's not in pain, she not in pain. I know it may seem concerning, but I'm ok with her not going to the hospital. The nurse will initiate Neuro-checks. Resident last seen in recliner, call light in reach. R2's Fall Investigation dated, 03/06/23 documents, Unwitnessed fall. Incorrect documentation. R2's Nursing Note dated, 03/30/23 at 9:10PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttocks, in front of her chair. She stated, she slid trying to get up to hold on to walker, and she didn't fall or hit her head. Resident did have shoes on. Resident was assessed immediately, no injuries, no c/o pain or discomfort. Educated resident on using call light when needing assistance, she stated she would. Family, NP (V30), and on-call nurse (V15) made aware. R2's Fall Investigation dated, Fall investigation. Resident fall, attempting to transfer from recliner chair, no injury. Resident remains non-complaint with safety interventions. R2's Nursing Note dated, 04/02/23 at 10:30PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttock, in front of her recliner. When asked what happened resident stated, she was trying to get up and go to the bathroom and slid out of her recliner. Resident educated on using her call light when needing help, resident agreed and stated, I know I am just embarrassed to ask for help. Resident was assessed immediately, ROM WNL, hand grips strong, no injuries noted, denies having pain. Resident had shoes on, lighting in room was adequate, floor was dry, no items in pathway. Call light and personal belongings within reach. POA, on call nurse (V18) and NP (V30) notified. Resident was assisted to the bathroom and is currently resting in bed with call light within reach. R2's Fall Investigation dated, 04/02/23 documents, Fall investigation. Resident fall, attempting to transfer from recliner chair, no injury. Resident remains non-complaint with safety interventions, continues to remove (Nonskid material) from chair. R2's Nursing Note dated, 04/14/23 at 10:04PM documents, Resident had an unwitnessed fall. Resident was observed on the floor, sitting on bottom in front of chair. Resident states, I was trying to get up to use the bathroom and my feet slipped from under me. [NAME] breaks were not locked prior to fall, call light was within reach, tennis shoes and non-slip socks were on. VS, T 98, P 78, R 16, BP 102/77, O2 98% RA. Resident denies hitting head and pain, no injuries noted. POA notified, NP (V30) notified, no new orders at this time. Resident is currently laying down in bed resting, call light in reach. R2's Fall Investigation dated, 04/14/23 documents, Fall investigation. Fall during self-transfer from recliner chair. Wheeled walker brakes not locked, no injury. Resident educated/reminded to lock brakes before transferring. Resident continues to remove, (nonskid material), from recliner chair. Resident remains non-complaint with safety interventions/devices. R2's Nursing Note dated, 04/17/23 at 8:52AM documents, This nurse was going to the 200 hall and heard voice calling for help; upon entering in the room, observed resident on the floor on her buttocks in front of the toilet; resident states she slipped when she was trying to get up from commode; resident denies hitting her head; no injury noted; denies for any pain or discomfort; ROM, WNL; walker breaks were not locked; resident stated, she did had tennis shoes on but, when she slipped her shoes came off; bp 145/84, temp 98.3, pulse 90, resp 20; POA notified; NP (V30) notified, no new order received. R2's Fall Investigation dated, 04/17/23 documents, Fall investigation. Resident stated, she fell when shoes fell off during transfer from commode. Brakes to rollator not engaged. Resident non-complaint with safety devices/interventions. Refuses to ask for assistance. R2's Nursing Note dated, 05/29/23 at 9:30PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttock in front of the bathroom door. When asked what happened resident stated, I was coming out of the bathroom and slid. Resident educated on the risks and benefits of using call light when needing assistance, resident stated, I know baby. Resident was assessed immediately. VS: T 97.3, B/P 116/68, P 73, R 18, O2, 96% RA. Shearing noted on buttock; SWM nurse made aware, resident to be evaluated. ROM, WNL, hand grips strong, denies having pain, resident had shoes on prior to fall, lighting in room was adequate, floor was dry, no items in pathway. POA, DON (V2), and NP (V30), notified. Resident currently resting in bed, call light in reach. R2's Fall Investigation dated, 05/29/23 documents, Fall investigation. Resident fall when leaving bathroom, no injury. Resident remains non-complaint with safety interventions. Will not use call light for assistance. R2's Nursing Note dated, 06/03/23 at 11:30PM documents, This writer was alerted by CNA, that the resident was on the floor, upon entering the room this writer observed the resident sitting in an upright position, in front of her recliner and her rollator position in front of her, her shoes was noted her the side of the chair and she had on regular socks. The resident stated that her rollator did not brake and she lost her balance and slide to the floor from her recliner. She does not voice any c/o new pain, nor did she hit her head. This writer assessed the resident from head to toe, no visible injuries noted at this time, ROM, WNL for resident, and neuro checks initiated. Resident transfer x2 up to recliner and assisted to the bathroom. VS stable, MD (V33) notified, no new orders, resident son notified. R2's Fall Investigation dated, 06/03/23 documents, Fall investigation. Resident slid from recliner chair, no injury. Resident was wearing regular socks, shoes beside her. Resident removes (nonskid material) from chair. States rollator brakes not engaged at the time. Resident non-complaint with safety interventions and does not use call light for assistance. 6. R54's Physician Order dated, 07/18/22 documents, repeated falls. R54's Physician Order dated, 01/26/23 documents, Alzheimer's disease with late onset. R54's Care Plan dated, 06/15/22 documents, Problem: At risk for falls due to: Unsteady gait, Dementia, unaware of safety needs, non-compliant with safety instructions, Dementia. (R54) had a fall on 6/18/22 and was sent to ED for further evaluation and TX. W/C changed out and anti-rollback device put on w/c. Fall on 6/28/22 no injuries. Staff to ensure proper footwear on at all times, non-skid socks. 07/17/22 Resident fell out of bed, no injuries. Resident did not use call light to ask for assistance. (R54) moved her bed to a very high position. (R54) is unaware of safety awareness; (R54) was re-educated on using call light from staff to call for assistance. Intervention: bed control to be placed out of reach of resident. 07/26/22 Unwitnessed fall out of bed no injuries. Intervention: Bolster mattress placed on bed. 08/16/22 unwitnessed fall while transferring self from bed to w/c c/o leg pain. Intervention: mats on the floor next to bed and STAT X-ray ordered. 09/2/22 (R54) fell trying to get out of w/c, by herself and fell and hit head on door. Intervention: Sent out to ED for further evaluation and Tx, and anti-thrust cushion placed in wheelchair. 10/28/22 Unwitnessed fall. Interventions: order to Send out to ER from NP, POA refused, NP notified of refusal. (R54) placed on Restorative Program for transfers and AROM. 11/25/22 Fall taking self to bathroom, no injuries. Intervention: UA /CS 12/31/22 - resident had a self-reported fall. Resident stated, she had fallen out of her wheelchair and assisted herself back into her wheelchair. The fall is questionable because, resident is unable to assist herself back into her wheelchair without assistance. No injuries were noted. Resident will be beginning therapy to assist with transfer. 3/6/23 Fall without injury attempting self-transfer. Intervention: Bed in low position while in bed. 3/17/23 Fall found sitting on floor with injuries, received laceration to forehead sent to ER and returned with N.O. (no orders), Intervention: Non-compliant with safety interventions. R54's Care Plan dated 04/20/23 documents Problem: Resident is at risk for falls due to: Unsteady gait, Dementia, unaware of safety needs, non-compliant with safety instructions. 4/19/23 res was self-transferring from w/c to bed and pants caught on w/c and res was found on right side laying on floor mat, received S/T, (skin tear), to right forearm. R54's MDS dated , 06/16/23 documents, a BIMS score of 10 out of 15. Resident is moderately impaired. The MDS documents, that R54 requires supervision of one person of bed mobility, transfer, locomotion on unit, locomotion on one person, dressing, eating, toilet use, and personal hygiene. Resident is not steady, but able to stabilize without staff assistance. R54's Nursing Note dated, 07/17/22 at 8:19PM documents, At 7:45pm this nurse was at the nurse's station when I heard someone yell for help. This nurse went down the hallway by residents' room and noticed resident sitting on the floor by her bed, yelling I fell out of bed. This nurse asked the CNA to come help assist with getting resident up off the floor. Resident when asked if anything hurt stated, Nothing hurts get me up. Resident was assessed head to toe, bandage noted to middle of back and pain patch noted to back and old bruise noted to lateral side of left lower leg. No new visible injuries noted. Residents bed was all the way up. CNA stated that bed was in normal position and not that high when she just left residents room after putting her to bed and went to the restroom. Resident was taken to the bathroom and toileted. VS, WNL, 98.9, 84, 18, 112/60, SPO2 94% RA. DON notified, and NP notified of fall. POA called and VM (voice message), left, awaiting a call back. Resident placed on neuro checks since fall was unwitnessed. R54's Fall Investigation dated, 07/18/22 documents, resident fall from bed. Resident fall from bed, using remote raising the bed and then tried to self-transfer. Intervention to keep bed remote out of reach. R54's Nursing Note dated, 07/26/22 at 1:27AM documents, Resident had an unwitnessed fall at 1:00am. Resident was yelling for help. This nurse walked into resident's room where I found her sitting on the side of her bed. Resident was stable. A&0 x4. When asked what happened resident stated, I was trying to get up to use the bathroom and fell. When asking resident if she hit her head she stated no. When asking resident if she was in pain she stated no. When asking resident if she used the call light that was in reach resident stated no. Resident was assessed and VS were taken and WNL. No skin tears, no bruising nor bleeding was noted. Immediate intervention was putting gripper socks on and reinforcing the importance of using the call light. Resident was then transferred into wheelchair using gait belt with two nurses and CNA in room. CNA then assessed resident into bathroom. Resident was then transferred in bed. Resident is in bed stable with call light in place. MD, DON, contacted. POA will be contacted in the morning. R54's Fall Investigation dated, 07/26/22 documents, Unwitnessed fall in bedroom. Slid out of bed onto floor. Call light in reach, resident fall from bed, Bolster mattress. R54's Nursing Note dated, 08/16/23 at 9:27PM documents, Resident starts IFU, (investigation follow-up), r/t post fall no c/o pain no injuries noted found on floor by bed trying to transfer w/o, (without), assistance denies hitting head fall unwitnessed neuro checks started POA called, MD aware and DON notified VSS will continue to monitor. R54's Fall Investigation dated, 08/16/22 documents, Fall in bedroom. Intervention: Floor mat to bedside for safety, continue current care plan. R54's Nursing Note dated, 09/02/22 at 7:51AM documents, CNA notified this nurse that resident is on the floor; upon entering to room found resident on the floor by the door on her buttock; resident stated, she did hit her left side of her head; denies for any pain at this time; no bleeding, swollen noted; helped resident on her chair with help of staff; made aware to NP, (V30), and received order to send resident to ER for evaluation; made aware to family as well as ADON; (local ambulance service) contacted for emergency transfer. Report given to nurse at (Hospital). R54's Fall Investigation dated, 09/02/22 documents, Fell and sent to ED, (Emergency Department), for eval and treatment. Resident fell out of wheelchair landing on her left side. Was sent to the hospital for evaluation and treatment. X-ray negative and resident returned same day. Intervention: Anti-thrust cushion added to wheelchair, continue current care plan. R54's Nursing Note dated, 10/28/22 at 11:12 AM documents, Resident fell this shift; unwitnessed, Neuros in place per MAR, (medication administration record). VS stable/WNL for resident; BP: 1[TRUNCATED]

Based on interview and record review the facility failed to provide a Registered Nurse (RN) for eight consecutive hours in a day. This failure has the potential to affect all 66 residents in the facility. The facility Nursing Schedule dated, Monday June 12th through June 29th documents. The facility has three RNs (V4, V10, and V25.) The facility did not have a RN for eight consecutive hours in a day on June 16th, 24th, 25th. On 6/29/23 at 11:00 AM V3 Director of Nursing stated our night nurse just walked in and resigned. We just don't have the RN coverage. The facility policy entitled, Direct Care Staffing dated, 12/2012 documents, the facility will comply with staffing requirements set forth by the State and Federal requirements to meet the needs of its residents. The Residents Census and Conditions of Residents Form dated, 6/27/23 documents the facility has a census of 66.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 66 residents living in the facility. Findings include: On 6/27/23 at 7:58 AM, on the bottom shelf of the preparation table, beside the large steam table, there were 4 clear containers with various dry cereals that were not labeled or dated. On 6/27/23 at 8:08 AM, in the standing freezer, there was a brown paper bag containing an unknown food. The bag was sealed, but not labeled or dated. There was a bag of snicker doodle cookies, inside a cardboard box. The plastic bag inside the cardboard box had been opened, but was not resealed or dated, and the cookies were open to air. There were two trays of individual ice cream cups covered with sheets of wax paper, but not sealed. The wax paper was labeled ice cream and 6/27/23 in black marker. On 6/27/23 at 8:07 AM, in the walk-in refrigerator, there was a bag of shredded yellow cheese and a bag of parmesan cheese that were previously opened and resealed but were not dated. On 6/27/23 at 8:12 AM, in the dry storage room, there was a dented 108 ounce can of pinto beans on the rack. There was a plastic bag containing an opened box of baking soda on a shelf that was not sealed up or dated. There were two bins, each approximately three feet high, containing white powdery substances, labeled sugar and flour that were not dated. On 6/27/23 at 8:23 AM, V7 (Cook) was serving food from the small steam table. The entire scoop and handle of the scoop fell into the scrambled eggs. On 6/27/23 at 8:25 AM, V7 (Cook) served toast using the tongs that were used for the bacon. On 6/27/23 at 8:26 AM, V7 (Cook) resumed serving scrambled eggs with the scoop that was inside the bin on top of the food. On 6/27/23 at 8:28 AM, V6 (Cook) and V8 (Dietary Aid) were serving food at the larger steam table. V6 was wearing a loose, unzipped sweatshirt that brushed the inside of the scrambled egg container when she reached forward to place the plate on the counter to be served. V8 had a mustache and goatee approximately one inch long and was not wearing a beard net. V8 used the tongs for the French toast, then the tongs fell into the French toast container. V6 then used the tongs that were in the sausage and bacon container for the French toast. On 6/27/23 at 8:30 AM V6 touched the French toast with her bare hand while reaching for the tongs inside the container. On 6/27/23 at 8:33 AM, V9 (Dietary Aid) was running the dish machine. He stated, he has been working in the facility for 1 or 2 months and has never tested the dish machine. He stated, he was never told he should be testing the machine. During the final rinse, the final rinse temperature dial did not move from 0 degrees Fahrenheit (F). On 6/27/23 at 8:39 AM, V5 (Dietary Supervisor) stated, they check the dish machine twice weekly and asked if she should be testing it more often. V5 removed a test strip from a plastic bag. The text on the test strip stated, If center is black then correct temperature has been achieved. V5 placed a test strip on a coffee cup, placed the cup in the dish machine, and started the dish cycle. After the cycle was complete, the test strip remained white and did not change color. V5 stated, when the machine is tested, it usually takes a few cycles to get to the correct temperature, but she will be contacting the person who maintains the dishwasher. On 6/27/23 at 8:37 AM, after the last resident tray was served, the pureed sausage, from the assisted dining room steam table measured 94.4 degrees Fahrenheit on a metal calibrated thermometer. V7 (Cook) stated, It should have been on the hot plate. On 6/29/23 at 7:55 AM, V7 stated, the pureed food on her steam table is used for all pureed diets in the facility. The Facility's Resident Orders for Dietary documents, R4, R9, R10, R19, R30, R32, R39, R40, R52, R54, and R56 have pureed diets. On 6/30/23 at 8:19 AM, V1 (Administrator) stated, she expects staff to follow all of the Facility's food service and sanitation policies. The Facility's Food Storage Policy revised 8/2017 documents, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled. Food should be dated as it is placed on the shelves. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. All foods should be covered, labeled and dated for refrigerated and frozen foods. The Facility's Food Safety and Sanitation Policy dated 2017 documents, All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. All staff will be in good health, will have clean personal habits and will use safe food handling practices. Beard nets are required when facial hair is visible. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. The Facility's Cleaning Dishes/Dish Machine dated 2017 documents, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Prior to use, verify proper temperatures and machine function. Note: Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot but, cannot verify actual temperatures. The Facility's Resident Census and Conditions Form (CMS-672) dated 6/27/23 documents there are 66 residents living in the Facility.

Based on interview and record review, the facility failed to establish and implement an infection control program which analyzed trends of infection. This has the potential to affect all 66 residents living in the facility. Findings include: 1. R3 was listed on the undated Infection Control Log for a Urinary Tract Infection (UTI). The Infection Control Log documented; a urine specimen was collected 01/26/23. No organisms were listed but, the antibiotic Macrobid (Nitrofurantoin) was prescribed. On 6/29/23 at 3:30 PM, V3 (Director of Nurses) presented Lab results dated, 5/11/23 documenting, the organisms as (1) Escherichia Coli ESBL >100,000 CFU/mL (2) Mixed Skin Flora, no sens, (Sensitivity), done >100,000CFU/ml. The Prescription Order Sheet dated, 5/17/23 documents, Macrobid 100 mg, 1 tab twice a day between 7:00 AM-10:00 AM and 7:00-10:00 PM. Start date documented as 5/16/23 and end date 5/21/23. Electronic Medical Record, (eMAR), dated, May 2023 documents, R3 received a dose of Macrobid at 4:00 PM and the order was discontinued. Another prescription order was issued on 5/17/23 with a start date of 5/17/23 and end date of 5/21/23. On 6/30/23 at 8:45 AM V3 Director of Nursing stated, charts are audited to ensure accuracy of orders to eliminate any medication errors. It is her expectation that staff will adhere to the facility's policy and procedures. 2. R8 is on the undated Infection Control Log for Urinary Tract Infection (UTI), no test was listed; no test results were listed, and no antibiotics were listed. On 6/29/23 at 3:30 PM V3 provided lab results dated 5/11/23 which documents, lab results as (1) Escherichia Coli > 100,000 CFU/mL (2) Mixed Skin Floras, no sens done 50-60,000 CFU/ml. The facility received an order for Macrobid 1 tab by mouth twice a day by mouth for 7 days. Start date documented, as 5/16/2023 and end date documented, as 5/23/2023. (eMAR) dated, May 2023 documents. On 5/16/23 R8 was given a dose of Macrobid at 4:00 PM. On 5/17/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/18/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/19/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/20/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/21/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/22/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM and On 5/23/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. Instead of 14 doses of Macrobid received 15 doses. On 6/29/23 at 3;30 PM V3 also provided Labs results dated, 6/7/23 documents a urine specimen was collected, and the organisms were documented, (1) Escherichia Coli >100,000 CFU/mL and (2) Mixed Skin Flora, no sens done 40-50,000 CFU/mL and no antibiotics were started. 3. R39 is listed on the undated Infection Control Log with a Urinary Tract Infection. The Infection Control Log documents, a urine specimen was collected 10/24/22. In the test results column, the note documents, spoke with NP, hospital results received from Hospital, Macrobid ordered. eMAR dated, 10/2022 documents, Ciprofloxacin suspension microcapsule recon 500 mg/5 ml; amount to administer 5 mL oral daily. R39 was given 5 ml of Ciprofloxacin on 10/28/22. R39 was given 5mL of Ciprofloxacin on 10/29/22. R39 was given 5 mL of Ciprofloxacin on 10/31/22 and R39 was given 5 mL of Ciprofloxacin on 10/31/22. R39 was not listed on the undated Infection Control Log again but, an (eMAR) dated, November 11/2022 documents, an order for Macrobid 100 mg 1 tab twice a day with a start date of 11/6/22 and end date of 11/11/22 for a urinary tract infection. On 11/6/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/7/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/8/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/9/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/10/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/11/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 6/30/23 at 8:45 AM V3 stated, she was the ICPC but does not have certification as an Infection Control Preventionist Program. 4. R58 was listed on the undated Infection Control log as having a Urinary Tract Infection. The specimen collection dated was documented, as 5/19/23 no organism(s) were documented, and the antibiotic Bactrim DS was ordered. On 6/29/23 at 3:30 PM supplied lab results dated, 5/15/23 documenting, the organisms as (1) Proteus Mirabilis (2) Enterococcus Faecalis-Unable to isolate organism for definitive susceptibility due to swarming properties of Proteus. The organism was sensitive to Bactrim (<=0.5/9.5). eMAR dated 5/1/23-5/31/23 documents R58 was given Bactrim-DS 1 tab twice a day x 7 days. R58 was given Bactrim-DS on 5/22/23 at 4:00 PM. R58 was given Bactrim-DS on 5/23/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/24/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/25/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/26/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/27/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/28/23 at 8:00 AM and 4:00 PM R58 did not receive a dose of Bactrim on 5/29/23 at 8:00 AM, however did a total of 13 doses instead of 14. The Facility's Policy and Procedure undated Mercy Rehab & Care Center Antibiotic Stewardship documents the policy establishes directives for antimicrobial stewardship at Mercy Rehab & Care Center to develop antibiotic use protocols and a system to monitor antibiotic use.

Based on interview and record review, the facility failed to utilize the services of an Infection Preventionist (IP), at a minimum part time basis, to track facility infections and resident vaccinations in order to prevent the spread of infectious disease. This has the potential to affect all 66 residents living in the Facility. Findings include: On 06/30/23 at 9:00 AM, V1 (Administrator) stated, (V3) is our Infection Preventionist, but she is not certified. She is working on it but, has not completed the training. On 06/30/23 at 8:45 AM V3 (Director of Nursing) stated, I have been doing the job but, I am not certified. The Facility's Infection Control log undated but, covers the months June 2022 to June 2023 for Urinary Tract Infections, (UTI), have 12 entries with no organisms documented, as source of infection. Additionally, there are 6 residents with antibiotics with no organisms listed. The Facility's QAPI Meeting Attendees list does not document (V3) as the Infection Control Preventionist. The Facility's Policy and Procedures undated documents, The infection Preventionist, (IP), will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP's primary professional training is in nursing, medical technology, microbiology, or epistemology, or other related field. the IP is qualified by education, training, experience or certification and by November 28th, will have completed specialized training in infection prevention and control. The IP works at the facility full-time/part-time. Resident Census and Conditions of Resident form dated 6/27/23 document. The facility has a census of 66.

Based on interview and record review, the facility failed to provide consecutive 8-hour Registered Nurse coverage in the facility. This has the potential to affect all 65 residents in the facility. Findings include: On 5/1/2023 at 11:00 AM V1 (Administrator) stated, that the facility Census is 65. V1 stated that the facility received a citation from a previous complaint on RN (Registered Nurse) coverage and have submitted their plan of correction that has been accepted. On 5/3/2023 at 2:15 PM, the Nursing Working staffing schedule from 3/25/2023 through 5/1/2023 was reviewed with V2 (Director of Nurses/DON). There was no consecutive 8-hour RN coverage in 24 hours for the following dates: 4/20/23, 4/21/23, 4/24/23, 4/29/23, and 4/30/23. On 5/2/2023 at 12:20 PM V10 (Assistant Director of Nursing/ADON) stated that she is new to the facility. V10 stated that she has been only at the facility for a week. V10 stated that her start date at the facility was on 4/24/2023. On 5/3/2023 at 2:00 PM V1 stated, that the facility is trying to get RN in the facility. V1 stated, that the facility hired an assistant (ADON) and have a weekend RN. V1 stated, that they are getting close but knows that they are not there yet. On 5/3/2023 at 2:15 PM V2 (DON) verified that the facility did not have RN coverage on dates listed above. V2 stated, that facility is actively trying to recruit staff. V2 stated, that they have hired an RN for the ADON position, and they did not show. V2 stated, that currently they have a new ADON that is an RN. V2 stated, that they have assured that they have nurses in the building to provide the care needs of the residents in the facility. The facility's Direct Care Staffing policy, dated December 2012, documents that the facility will comply with staffing requirements set forth by stated and federal requirements to meet the needs of its residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the integrity of each resident's skin is maintained for 1 of 4 (R3), residents reviewed in a sample of 4. This failure resulted in R3 sustaining 3 pressure ulcers to her sacrum, 1 pressure ulcer to posterior left thigh and 1 pressure ulcer to anterior right thigh. Findings include: R3's Face Sheet, not dated, list Cerebral Infarction, Hemiplegia and hemiparesis following cerebral infarction affecting dominant side as diagnosis. R3's Care Plan, dated 7/3/22, documents Problem: Resident is at risk for pressure ulcer due to friction and shear. It continues Approach: Minimum of 2 people plus draw sheet to lift resident while in bed. It also documents Problem: Resident is at risk for pressure ulcer due to activity and chairfast. Approach: Pad bony prominences with foam wedges, rolled blankets, or towels prn, (as needed). Consider PT consult for conditioning and w/c (wheelchair), assessment. Instruct resident to reposition frequently in chair. Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair. It also documents Problem: Resident is at risk for pressure ulcer due to bedfast/mobility, resident often refuses to get up out of bed, daughter likes resident to remain in bed in the evening time. Resident has history of pressure ulcers. It continues Teach or do frequent small shifts of body weight, assist as needed. Elevate heels off bed or use heel protector's prn. Position with pillows to elevate pressure points off the bed. Position prone if appropriate or elevate HOB (head of bed) no more than 30 degrees. R3's Braden Scale, dated 1/26/23, documents that R3 is High Risk for obtaining pressure ulcers. R3's Specialized Wound Management note, dated 2/14/2023, documents left buttock pressure ulcer. Plan: promote healing and comfort-Met Plan: 1. Left buttock closed- staff will use house barrier per protocol. Nursing is assisting with peri care and repositioning q (every) 2 hours and PRN (as necessary). R3's Shower Sheet, dated 3/4/23, documents that a bed bath was given. R3's Shower Sheet, dated 3/8/23, documents that shower refused. No reason indicated. R3's history, dated 7/4/22-3/10/23, documents that on 3/5/2023 at 10:18 AM to 10:19 AM R3 was moved in bed, transferred, and dressed. On 3/6/2023 at 6:44 AM R3 was moved in bed. On 3/8 at 7 AM R3 was moved in bed, toileted and dressed. From 9:54 AM to 10:01 AM R3 was moved in bed, transferred, dressed and personal care. On 3/10/2023 at 7:05 AM R3 was moved in bed and toileted. No further documentation of resident being repositioned every 2 hours, toileted, dressed, bathe and personal care provided by the facility. No documentation provided by the facility of ADL, (activity of daily living), care performed on 3/11/2023. R3's Wound Assessment from local hospital, dated 3/11/2023, documents 3 pressure ulcers to R3's sacrum. Areas measured, approximately, facing resident 1. left 1.2 cm x 0.6 cm. 2. middle 1.1 cm x 1.2 cm 3. right 0.6 cm x 0.5 cm. On 3/21/2023 at 1:15 PM V10 (Certified Nurse Assistant/CNA) stated that she works for the facility since December and works the same hall, working with R3. V10 stated that the last time she provided care for R3 was 2 days before she went to the hospital. V10 stated she provided everyday care, and she did not remember R3 having any open areas to her buttock. R3 had swelling on her left side but, not aware of her having swelling to the right side. V10 stated she had given R3 bed baths and cleaned her feet as well, R3's feet were ashy but not flaky. V10 stated R3 could not reposition herself independently in the bed, she needed help to turn and reposition, but R3 would help by grabbing rail and pulling when staff is pushing but could not fully reposition self. On 3/21/2023 at 3:44 PM V23 (CNA) stated she has taken care of R3, and that R3 needed help with repositioning and could not reposition herself without help. V23 stated in the past when she cared for R3 she did not have an area to her buttocks. On 3/21/2023 at 3:30 PM requested documentation of care provided for R3 up until discharge on [DATE]. Receiving on 3/22/23 at 9:00 AM from V24 (Administrator) R3's Point of Care History, dated 7/4/2022 to 3/10/2023. V24 stated she is not sure why on 3/11/2023 R3 was not provided care and they must not have been documented. On 03/22/23 at 11:55 AM V20 (CNA) stated she works at the facility part time and works every other weekend. V20 stated, that the last day she worked with R3 was on 03/05/23. V20 stated she was not assigned to R3, but did help with incontinent care, on 03/05/23. V20 stated, that R3 was incontinent of bowel. V20 stated, that R3 did have a small area that was open to her buttocks, that area was small and did not cause for concern to V20. V20 stated she applied barrier cream to the area; she puts barrier cream on all of her residents to help prevent areas to their bottoms from breaking down. On 3/22/2023 at 12:39 PM V21 (Licensed Practical Nurse/LPN) stated, she is an employee of the facility and works every other weekend and was the nurse assigned to R3's hall. V21 stated the only care she had provided for R3 was administering her medications and then left R3's room. V21 stated she was called to R3's room by her daughter (V9) who had voiced concerns about R3's swelling and showed V21 an area to R3's buttocks that area was red with bleeding, the blood looked fresh. V21 stated it looked like the area was sheared, like someone had pulled her across the mattress. V21 stated she was not aware of a new area prior to this and had not seen R3's buttocks before this time. V21 stated she was aware when R3 came to the facility with areas that was like scar tissue. V21 stated V23 (CNA) and V22 (CNA) cleaned R3 up prior to R3 going to the hospital. On 3/22/2023 V22 stated she had not provided care to R3, except for the day R3 left for the hospital. V22 helped V23 clean R3 up. V22 stated V23 cleaned R3 up and she assisted with holding R3 over. V22 stated at that time V23 told her to get the nurse because there was an area on R3's buttocks. V22 stated, that R3 had previously had an area to her bottom, but she never saw the actual wound, because it had a dressing over it. V22 stated she had not provided care to R3 that day, this was the first time she had interacted with R3. On 3/23/2023 at 9:44 AM V25 (Physician) stated she had an opportunity to view the photos from Hospital and documentations, that those areas were old and not obtained at the hospital. V25 stated that the facility may have missed documented, but the areas are pressure and old. On 3/23/2023 at 2:25 PM V25 (Physician stated) she was aware of R3 having an area to her buttocks previously, that this area had healed. V25 stated R3 did have the area that reopened, and that once there is an area that has closed it is prone to reopening, this puts R3 at a higher risk of obtaining pressure areas and would require more focus and monitoring to assure the area doesn't reopen or new ones doesn't occur. V25 stated depending on how long R3 laid in the emergency room the area may have been obtained there. When notified that R3 was transported to the hospital, per facility documentation, R3 left at 6pm and the hospital documentation, with pictures which were time stamped, as was time being at 8:11 PM. V25 then stated, that there was no way R3 could have obtained the pressure areas documented by the ER in that short of time. The facility's Skin Care Prevention of Pressure Ulcers, dated 3/03, documents Policy: To ensure the integrity of each resident's skin is maintained, [NAME] Care Center will utilize specific care protocols for those residents identified at risk for pressure ulcers. Procedure: The Nurse will: 4. Implement appropriate protocols to prevent impairment of skin integrity, based on the Pressure Ulcer Risk Assessment scores.

Based on interview and record review, the facility failed to provide 8 consecutive hours a day Registered Nurse coverage, 7 days a week. This has the potential to affect all 63 residents in the facility. Findings include: On 03/20/2023 at 11:00 AM, the Nursing Working staffing schedule from 01/01/2023 through 03/20/2023 was reviewed with V2 (Director of Nurses/DON). There were no consecutive 8-hour Registered Nurse/RN coverage in 24 hours for the following dates: 01/21/2023, 01/22/2023, 02/05/2023, 02/18/2023, 02/19/2023, 02/24/2023, 02/26/2023, 02/27/2023, 02/28/2023, 03/02/2023, 03/04/2023, 03/05/2023, 03/09/2023, 03/12/2023, 03/13/2023, 03/14/2023, 03/17/2023, and 03/18/2023. On 03/20/2023 at 9:00 AM V1 (Administrator) stated that the facility census is 63. On 03/20/2023 at 2:34 PM when asked if the facility was having staffing problems V2 (DON) stated that the answer is yes and no. V2 stated that when the facility doesn't have adequate staff, they utilize the staffing agency. V2 stated that they have a couple of agencies that are reliable. V2 stated that she is new to the DON roll and was originally hired as the Assistant Director of Nursing/ADON and started as the DON February 24, 2023. V2 stated, currently they have 1 RN on day shift. V2 stated, that she has hired a RN for midnights, and this nurse would work the opposite days of the day shift RN giving the facility RN coverage 7 days a week. V2 stated, that the RN has not started yet, but will start on Tuesday 03/21/2023. On 3/21/2023 at 9:00 AM, V2 verified that the facility did not have RN coverage on dates listed above. The facility's Direct Care Staffing policy, dated December 2012, documents that the facility will comply with staffing requirements set forth by stated and federal requirements to meet the needs of its residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely report and investigate an injury of unknown origin for one of three residents (R2) reviewed for resident injuries in the sample of seven. Findings Include: R2's Minimum Data Set, dated [DATE] documents R2 is moderately cognitively impaired. R2's Progress Note dated 1/14/23 documents resident was discharged at 7PM. She was released to her niece (V12). Resident (R2) is A&Ox2 (alert and oriented) w (with)/ behavior. Resident (R2) was DC (discharged ) home w/ meds (medications) and PT (physical therapy)/OT(occupational therapy) orders, and to follow up w/ PCP (primary care physician). VS (vital signs) WNL (within normal limits). Resident niece (V12) got all of her belongings including meds gave education on meds. She was escorted by her niece (V12) via personal vehicle. On 1/19/23 at 8:35 AM, V12 (R2's niece and Power of Attorney/POA), stated, My aunt had bruising to her right breast from her nipple all the way back to her arm pit, and a lump in her left breast. I found the bruise on Sunday when I gave her a shower. I went to the facility, but they could not tell me how she (R2) got the bruise. On 1/19/23 at 8:45 AM, V1 (Administrator) stated (R2) was discharged on Saturday, and her niece spoke with me on Sunday on the telephone. Saying she (V12) had found a bruise to her aunt's (R2's) breast, but the resident had been discharged for over 14 hours. R2's Progress Note dated 1/12/23 at 7:04 PM documents skin assessment completed. No skin issues noted. Right side near breast has purplish bruising. Bilateral arms and legs intact. Peri area and buttocks are clean and intact. Heels clean and intact. Skin dry and warm to touch. Resident (R2) denies any pain. Fluids encouraged. Resident is currently laying in low bed with call light in place. On 1/19/23 at 2:13 PM, V13 (Licensed Practical Nurse/LPN), stated, I just made the skin assessment. I didn't know if it was previously reported. I didn't report it to anyone. R2's Event Final Report dated 1/15/23 documents on 1/12/23 a skin assessment was completed by the nursing staff. Bruising was noted to the right side near her breast on that date. The resident denied anyone hurting her. The physician stated that bruising of unknown origin is to be expected considering the diagnoses of Thrombocytosis and a low platelet count. The resident was discharged to her niece's home at 7:00 PM on 1/14/23. The staff assisted the resident into her niece's (V12) car to go home. On the following day 1/15/23, the niece (V12) came to the facility, concerned about a bruise that she had noticed on the resident's right side under her breast. The administrator spoke with the niece via the phone. The niece (V12) stated that she had not undressed the resident on 1/14/23 and noted the bruise when she showered (R2) on 1/15/23. All staff that cared for (R2) was interviewed by the administrator. The resident had no complaints of any staff hurting her. The administrator interviewed several alert residents on the hall that (R2) resided. All residents interviewed stated that no staff had been rude or rough with them during care. The administrator spoke with the physician regarding the bruise. The physician stated that the resident has a diagnosis of thrombocytosis and a low platelet count. (R2) also receives Aspirin as an anticoagulant with the diagnosis it is to be expected that the resident will bruise easily and could develop bruising without trauma causing it. The resident left the facility over 12 hours prior to the niece (V12) questioning the bruise. It is difficult for the facility to determine if an incident occurred when the resident was not in the facility. No abuse could be substantiated. The facility policy Incidents/Accidents dated 8/2022 documents, (the facility) will take every precaution to prevent the occurrence of accidents. When an incident/accident does occur, the facility will document it in the Events section of (documentation system), and in the Nurses Notes. An incident may be defined as, but not limited to falls, resident injuries of known or unknown origin, or any occurrence of an unusual nature that requires investigation. The Administrator will 1.begin investigation per facility abuse prevention policy, 2. send the initial report of the event to Illinois Department of Public Health (IDPH) via the smartsheet, 3. conduct the investigation, 4. Final report of event to IDPH, 5. inform the family.

Based on interview and record review, the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This failure has the potential to affect all 61 residents living in the facility. Findings Include: The facility Nursing Schedule dated 1/6/23 through 1/19/23 documents the facility did not have a Registered Nurse (RN) eight hours a day for three days on January 7, 14, and 15. On 1/19/23 at 8:45 AM, V1 (Administrator), stated, We are trying to hire RNs (Registered Nurses). On 1/19/23 at 4:05 PM, V14 (Certified Nursing Assistant/CNA),stated, No, we don't have enough staff. On 1/19/23 at 8:15 AM, R3 stated, I would like my chair turned around, but I bet they won't come until tomorrow they need more nurses. On 1/19/23 from 3:45 PM through 3:50 PM, R4 through R6 all stated the facility did not have enough staff. The facility policy Direct Care Staffing dated 12/2012 documents the facility will comply with staffing requirements set forth by state and federal requirements to meet the needs of its residents. The facility's Resident Census and Conditions form dated 1/19/23 documented the facility had a census of 61 residents.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure affects the entire facility. Findings include: Facility's Nurses Staffing Schedule dated 10/3/22 to 10/30/22 and 10/31/22 to 11/27/22 documents that no RNs were scheduled to work on 10/09/22, 10/15/22, 10/16/22, 10/22/22, 10/23/22, 10/30/22, 10/31/22, 11/06/22, 11/12/22, and 11/13/22. On 11/15/22 at 3:30 PM, V2 (Director of Nursing) stated, (V3 Assistant Director of Nursing) does sometimes work the weekends. She worked a double on the 5th. We don't always have a RN. It's hard to get RNs to come here and work. On 11/16/22 at 12:28 PM, V7 (Licensed Practical Nurse/LPN) stated, There isn't an RN that works my weekend. I don't think they have one that works on the other weekend. On 11/16/22 at 12:30 PM, when asked if there is a RN at the facility every day, V8 (LPN), stated, I don't think so. Resident Census and Conditions of Residents dated 11/15/22 documents a census of 61 residents.