Based on interview and record review, the facility failed to coordinate services between the facility and resident's oncology provider for one of one resident (R3) reviewed for coordination of services to provide quality of care in the sample of 8. Findings include: R3's Care Plan, dated 10/10/2024, documents R3 is to have an individualized plan of care while at the facility. Staff to follow individualized plan of care to meet resident's needs. R3's Care Plan does not address her blood cancer or her seeing an oncologist, V8. R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). Testing.com website, documents the Jak2 Mutation test is used To help diagnose bone marrow disorders known as myeloproliferative neoplasms (MPNs) in which bone marrow produces too many or one or more types of blood cells. R3's Progress Note, 6/24/2024 at 3:51 PM, documents Res returned from (V8's), Oncologist, with findings of increase platelet counts, lab called with critical findings of 783 platelet count, (V10) MD notified. R3's Progress Note, dated 6/26/2024 at 8:52 PM, documents (V15, Nurse Practitioner), responded r.t (related to) R3 platelets for V10 to address at this time either via fax or at facility during his next rounding date. MUM (memory unit manager) (V16, Memory Unit Manger), aware. F/U (follow up) required in r.t results for further action required regarding plan of care moving forward. R3's Progress Note, dated 6/28/2024 at 10:46 AM, documents Spoke with MUM r/t high platelets & possible Hospice Referral. MUM to address this. R3's JAK-2 Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given. A stamp Scanned Date/Initials with unrecognizable date and initials. It also documents that R3 is positive for Jak-2. R3's Progress Note, dated 8/15/2024 at 11:17 PM, documents MD responded to fax sent regarding inquiry on if resident is currently seeing a hematologist specialist at this time d/t (due to) elevated H Platelet count. MD responded with new orders to have resident be referred to see a hematologist specialist for a consultation regards to lab results at this time. MUM notified r/t consult needing to be scheduled for specialist to be implemented on behalf of resident's account. F/U needed once appointment has been scheduled regarding this matter for time and date & w/ whom. R3's Progress Note, dated 8/20/2024 at 2:55 AM, documents Critical High Platelet level of 1167 called in from Lab. MD notified. NNO. MD wants res seen by Hematologist soon, questioning when appointment is. R3's Progress Notes, dated 8/20/2024 at 11:15 AM, documents Writer called (V8's) office, Oncology-Hematology, to schedule an appointment to be seen regarding the resident's recent critical platelet levels. Appointment has been scheduled for September 9th at 1:45PM at (City medical clinic) as the earliest available appointment. R3's Progress Note, dated 9/15/2024 at 10:43 AM, documents Nurses Note Text: Resident has appointment with hematology/oncology (V8) on September 27th, 2024, at 1:45 p.m. R3's Progress Note, dated 9/27/2024 3:17 PM, documents Nurses Note Text: (V8's) office called and scheduled a follow up appointment for after labs are drawn (they are waiting insurance approval). Appointment will be October 25th, 2024, at 10:30 a.m. Schedule person for facility notified. R3's Progress Note, dated 10/22/2024 at 11:20 PM, documents Nurses Note Text: F/U appointment with (V8) 10/25 @ (at) 1:45pm. R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: rec'd (received) call from (V8's) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab drawn prior to appt. Resident had a scheduled appointment for 10/25. F/U with office and asked would it be possible for lab to be drawn there. Nurse was unaware since resident resides at nursing home. Advised resident may have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this lab. Contacted (local hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would be sent out. (V8) office would like a f/u regarding if and when the lab will be drawn. Appointment for 10/25/24 has been canceled and need rescheduled. On 10/29/2024 at approximately 3:00 PM V3, Assistant Director of Nursing (ADON), provided documentation, dated 6/24/2024, that documents that Res returned from V8, Oncologist/Hematologist, with report of increase platelets, lab reported platelet count of 783. Please advise. On 10/29/2024 at 10:58 AM V5, V8's Oncology Registered Nurse, stated that R3 is a patient since August 2023. V5 stated that R3 has Myeloproliferative which is a rare blood cancer. V5 stated that R3 has not been seen by physician at the oncology office because the ordered lab work has not been completed. V5 stated that a Jak-2 lab was ordered on 6/24/2024. V5 stated that R3 was seen in the office when the lab was prescribed, and the order was sent with the resident and paper sent back to facility. V5 stated that the treatment for R3's diagnosis is Hydroxyurea. For this medication to be ordered and be effective the lab needs to be completed for dosing. This medication would decrease R3's platelet counts and prevent a stroke. This lab and medication are imperative. V5 stated that she has made multiple attempts to educate the staff on the importance of the lab and medication and nothing was done. V5 stated that she spoke the V3, ADON, on October 24th and stressed the importance of this lab and that R3 has not been seen and treated since June because the facility has not gotten the lab. V5 stated that they received the results with platelet count critical at 1410 from the hospital on October 25th. V5 stated that the have not received anything from the facility. V5 stated that they have called and talk with multiple people and nothing. V5 stated that at times they were not able to reach anyone. V5 stated that this lab is critical in R3's treatment. On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3 to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's office by V10. V3 stated that V8's office is a hematology and Oncology office. V3 stated that R3 was seen on 6/24/24 and with findings of increase platelets, splenomegaly, and weight loss. V3 stated that orders were received for boost, check Jak-2 mutation, continue ASA. V3 stated that R3 went to hospital and the Jak-2 lab was drawn. V3 stated that per the lab it was drawn 7/2/2024 and sent off. V3 stated that it takes about a week for the lab to be completed and results given. V3 stated that the lab then reported the results to the hospital 7/12/2024 and the facility received the lab 7/15/2024. V3 stated that there is a stamp on the lab with date and initials. V3 stated that she was not familiar with the initials. V3 stated that she spoke with V5 and informed her of this today. V3 stated that she was informed that the Oncology office did not receive the lab. V3 stated that she was unable to find confirmation that the lab was sent to the office or that it was received by the oncology office. On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find verification that the lab was communicated with the prescribing physician's office. On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday (10/29/24) and notified them that they just became aware that the Jak-2 lab was previously drawn and had not notified them. On 10/30/2024 at 3:37 PM V17, Oncology Nurse, stated that V10 only sees R3 because he is the house physician. V17 stated that R3 has been a patient of V8 since 2023. V17 stated that V10 does not handle her platelets that the results and treatment are handled by V8 not V10. V17 stated that V10 is only seeing R3 because he is the house physician. The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1. Guideline for notification of physician/responsible party f. Abnormal lab findings.

Based on interview and record review, the facility failed to ensure the Oncologist and the Attending Physician were notified of a significant lab value for 1 of 8 residents (R3) reviewed for reporting of laboratory results in the sample of 8. Findings include: R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). R3's Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given. A stamp Scanned Date/Initials with unrecognizable date and initials. R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: received call from (V8's, Oncology Physician) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab drawn prior to appt. Resident had a scheduled appointment for 10/25. F/U (follow up) with office and asked would it be possible for lab to be drawn there. Nurse was unaware since resident resides at nursing home. Advised resident may have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this lab. Contacted (local hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would be sent out. (V8) office would like a f/u regarding if and when the lab will be drawn. Appointment for 10/25/24 has been canceled and need rescheduled. On 10/29/2024 at 10:58 AM V5, Oncology Registered Nurse, stated that R3 is a patient since August 2023. V5 stated that R3 has Myeloproliferative which a rare blood cancer. V5 stated that R3 has not been seen by physician because ordered lab work has not been completed. V5 stated that a Jak-2 lab was ordered 6/24/2024. V5 stated that R3 was seen in the office when the lab was prescribed, and the order was sent with the resident and paper sent back to facility. V5 stated that the treatment for R3's diagnosis is Hydroxyurea. For this medication to be ordered and be effective the lab needs to be completed for dosing. This medication would decrease R3's platelet counts and prevent a stroke. This lab and medication are imperative. V5 stated that she has made multiple attempts to educate the staff on the importance of the lab and medication and nothing was done. V5 stated that she spoke the V3, ADON, on October 24th and stressed the importance of this lab and that R3 has not been seen and treated since June because the facility has not gotten the lab. V5 stated that they received the results with platelet count critical at 1410 from the hospital on October 25th. V5 stated that the have not received anything from the facility. V5 stated that they have called and talk with multiple people and nothing. V5 stated that at times they were not able to reach anyone. V5 stated that this lab is critical in R3's treatment. On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3 to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's office by V10. V3 stated that V8's office is a hematology and Oncology office. V3 stated that R3 was seen on 6/24/24 and with findings of increase platelets, splenomegaly, and weight loss. V3 stated that orders were received for boost, check Jak-2 mutation, continue ASA. V3 stated that R3 went to hospital and the Jak-2 lab was drawn. V3 stated that per the lab it was drawn 7/2/2024 and sent off. V3 stated that it takes about a week for the lab to be completed and results given. V3 stated that the lab then reported the results to the hospital 7/12/2024 and the facility received the lab 7/15/2024. V3 stated that there is a stamp on the lab with date and initials. V3 stated that she was not familiar with the initials. V3 stated that she spoke with V5 and informed her of this today. V3 stated that she was informed that the Oncology office did not receive the lab. V3 stated that she was unable to find confirmation that the lab was sent to the office or that it was received by the oncology office. On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find verification that the lab was communicated with the prescribing physician's office. On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday and notified them that they just became aware that the Jak-2 lab was previously drawn and had not notified them. The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1. Guideline for notification of physician/responsible party f. Abnormal lab findings. The facility's Laboratory Tests policy, dated 11/17, documents Procedure: 9. The physician or physician extender will be promptly notified of abnormal results according to facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to evaluate, monitor, and prevent a physical altercation from occurring for 1 out of 2 residents, (R86), reviewed for abuse in a sample of 68. Findings include: R91 was admitted to the facility on [DATE] with diagnosis of, in part, sequelae of cerebral infarction, anxiety disorder and depression. R91's Minimal Data Set (MDS) dated [DATE], documented she was cognitively intact. R86 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified dementia, unspecified severity and anxiety disorder. R86's MDS dated [DATE], documented she was severely cognitively impaired. On 10/15/2024, at 11:00 AM, R91 threw a brown liquid from her mug on R86 while sitting next to each other for lunch. R86 was sitting to the left of R91 and was visibly soaked by R91's beverage on her right arm and chest. R86 asked R91 why she would do that. R91 did not answer R86. R86 got up very quickly, shook her head in disapproval at R91 and then proceed to leave the cafeteria. On 10/15/24, at 11:10 AM, R66 stated to R91, so you got R86 to leave. R91 responded stating she wanted R86 to shut up. R66 stated R86 is frequently bothersome to all the residents, she repeats things over and over and doesn't stop when you ask her to. R66 stated staff do nothing to intervene or redirect R86 from upsetting the other residents around her. R66 stated R86 gets on everybody's nerves and people just get tired of it. On 10/16/24, at 11:03 AM, R86 was in her room. R86's previous shirt was lying on the bed. The front and sleeve was stained with a brown liquid. R86 stated that she was not hurt from having tea thrown on her but that she is very mad. On 10/15/24, at 11:08 AM, R86 returned to her same spot at the table in new clothes. R91 stated the tea she threw on R86 was not hot. On 10/15/24, at 11:11 AM, V2, Director of Nursing (DON), was notified of the incident. R91 and R86 were then separated from sitting at the same table next to each other. On 10/17/2024, at 9:40 AM, V16, Certified Nursing Assistant (CNA), stated R91 can frequently be grouchy, especially if she wants to smoke and even refuses care if she is not in a good mood; you have to be careful with how you approach her. On 10/17/2024, at 9:45 AM, V3, Social Services, stated R91 likes to hang out in her room a lot and she loves to smoke. She will occasionally mumble words under her breath when she is irritated with someone or something. She has depression and anxiety which she takes medications for and is seeing outside consultant services for psychiatry. On 10/17/2024, at 9:55 AM, V17, Registered Nurse (RN), stated R91 likes to smoke, it's usually what she gets up to do and gets irritated easily. V17 stated R91 has had multiple verbal arguments with the other residents. V17 is not aware of R91 having any friends at the facility. On 10/17/2024, at 10:00 AM, V18 (CNA) stated R91 will get up just for her smoke breaks. V18 stated R91 will be really sweet one minute but then talking about how much she hates you the next. V18 stated R91 likes to [NAME] a lot and she doesn't have any friends he is aware of at this time. V18 stated R91 had a relationship with another resident who left a short time ago. On 10/21/2024, at 9:50 AM, V1, Administrator, acknowledged more staff supervision on R91 and R86 should be occurring to prevent incidents of abuse. The facility's Abuse Policy, undated, documented, The facility is committed to protecting the residents from abuse by anyone. The policy further documented a prevention measure to identify, correct, and intervene in situations in which abuse, neglect and misappropriation of resident property is more likely to occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to administer medications as prescribed by the ordering Physician for 2 of 6 residents (R83,R103). This failure resulted in a medication error rate of 8%. Findings include: 1. On 10/16/24 at 8:15 AM, V12, Licensed Practical Nurse, (LPN), administered 1 Famotidine 10 milligram (mg) tablet to R103. R103's admission Record, print date of 10/21/24, documents that R103 was admitted on [DATE]. R103's Order Summary Report, dated 10/21/24, documents, Famotidine Oral Tablet 20 mg. give 1 tablet by mouth two times a day for GERD. (gastroesophageal reflux disease). Take 1 tablet PO (by mouth) BID (twice a day). 2. On 10/16/24 at 8:26 AM, V12 administered 4 Vitamin D3 2000IU (international units) 50 microgram (mcg) capsules to R83. R83's admission Record, print date of 10/21/24, documents that R83 was admitted on [DATE]. R83's Order Summary Report, dated 10/21/24, documents, Vitamin D3 Oral Tablet 25 mcg. Give 4 tablet by mouth one time a day related to Vitamin D deficiency. On 10/16/24 at 2:30 PM, V12, stated that she did not realize she gave the wrong dose of Famotidine to R103 or that she used the wrong Vitamin D3 capsules to R83 resulting in giving him a double dose of what the Physician had ordered. On 10/16/24 at 4:03 PM, V1, Administrator, stated that medication should be given as the Physician orders. The Medication Administration - general Guidelines, dated 1/15, documents, 18. Prior to administration, the medication and dosage, schedule on the residents' MAR /TAR (Medication Administration Record / Treatment Administration Record) is compared to the medication label. Information on the medication should be checked against the MAR / TAR at least 3 times during the med (medication) preparation and administration process.

3. R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI), SITE NOT SPECIFIED (N39.0) for 7 Days R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth three times a day for UTI for 5 Days R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days. R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders. R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI. The facility's infection control log, dated 09/2024, did not document the organism for R12's UTI 4. R46's Physician order, dated 8/13/2024, documented, Obtain UA with C&S if indicated. R46's Physicians order, dated 8/22/2024, documented, Cephalexin Cap 500 MG Give 1 capsule orally two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 08/29/2024. R46's McGreers Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R46's UTI. 5. R47's Physicians orders, dated 9/10/2024, documented, Levaquin Oral Tablet 500 MG (Levofloxacin) Give 1 tablet by mouth in the afternoon related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 5 Days R47's Physicians order, dated 9/22/2024, documented, Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth two times a day for infection related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 7 Days R47's Physician orders, dated 9/4/2024, documented, CBC bmp UA w/c and s one time only for pain while urinating for 1 Day. R47's McGreer's Criteria, undated, documeted, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R47's UTI. 6. R54's Physician order, dated 9/5/2024, documented, UA with C&S one time only for altered mental status for 1 Day R54's Physician order, dated 9/6/2024, documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI pending UA results for 7 Days Give 1 cap PO BID X 7 days. R54's McGreer's Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R54's UTI. On 10/21/2024 at 10:35 AM, V14, Infection Preventionist/RN, stated that she took over the infection tracking in June. She continued to state that she did not know what organisms were in the facility except what was on the rehab unit because she is the unit manger there. V14 stated that she would track and trend at the end of the month because that was when pharmacy would send her a list of residents and what antibiotics they were on but prior to that list coming she did not know what organisms were in the facility. She also stated that the McGreers criteria was completed after the resident was already placed on an antibiotic and that this should have been filled out when the resident was starting to have signs and symptoms. On 10/21/2024 at 12:47 PM, V1, Administrator, stated that she would expect that staff track and monitor all infections in the facility. The facility's Antibiotic Stewardship Program, dated 10/2022, documented, Tracking: Process measures: Track types and location of infections, and where the resident is located in the facility. It continues, Monitoring use: Facility will collect reports summarizing the antibiotic susceptibility patterns. It continues, Microbiology culture data will be used to assess and guide future antibiotic selection. The facility's Surveillance for Healthcare Associated Infections, dated 09/2029, documented, 8. Utilize you surveillance data to: a. Identify infections quickly. It continues, f. Compare unit by unit data. Based on interview, observation, and record review, the facility failed to perform hand hygiene, discard of potentially contaminated medications to prevent cross contamination. The facility also failed to have a system in place to monitor and track infections in the facility for 6 of 10 (R12, R16, R46, R47, R54 and R83) residents reviewed for infection control in the sample of 68. Findings include: 1. On 10/16/24 at 8:26 AM, V12, Licensed Practical Nurse, (LPN), prepared medication to be administered to R83. V12 obtained Tylenol 2 tablets, 1 tablet Magnesium Oxide 400 milligram (mg), 4 capsules of Vitamin D3 50 micrograms, and placed them into a medication cup. V12 donned gloves without hand hygiene, retrieved the Tylenol and Magnesium Oxide tablets, and placed them into a pill pouch so they could be crushed. V12 crushed the tablets, mixed them with pudding, added the Vitamin D3 capsules, removed her gloves. V12 then entered R83's room and administered the medications to R83. 2. On 10/16/24 at 8:39 AM, V12 opened R16's morning medication pass packet which include: Metoprolol 50 milligrams (mg), Losartan 100 mg, and hydrochlorothiazide 25 mg all 3 of the medications fell onto the top of V12's medication cart. V12 with her bare unsantized hands picked up the medications and placed them into a medication administration cup. V12 entered R16's room and administered the medications to R16. On 10/17/24 at 11:00 AM, V1, Administrator, stated that if medication falls onto the medication cart it should be discarded and not given to the resident. V1 further stated that staff should perform hand hygiene before putting gloves on and after removing them. V1 stated that the glove policy does not state hand hygiene before putting on gloves but it should be done. The policy hand Washing, dated 9/19, documents, Staff will use proper and washing technique to prevent the spread of infection. The policy Personal Protective Equipment Using Gloves, dated 2009, documents, 5. wash hands after removing gloves.

Based on interview and record review, the facility failed to have an effective antibiotic stewardship program to monitor and track antibiotic use and infections in the facility for 4 of 4 (R12, R46, R47 and R54) residents reviewed for antibiotic stewardship/ Infection control in a sample of 68. Findings include: 1 . R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI), SITE NOT SPECIFIED (N39.0) for 7 Days R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth three times a day for UTI for 5 Days R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days. R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders. R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI. The facility's infection control log, dated 09/2024, did not document the organism for R12's UTI 2. R46's Physician order, dated 8/13/2024, documented, Obtain UA (urinalysis) with C&S (culture and sensitivity) if indicated. R46's Physicians order, dated 8/22/2024, documented, Cephalexin Cap 500 MG Give 1 capsule orally two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 08/29/2024. R46's McGreers Criteria, undated, documents, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R46's UTI. 3. R47's Physicians orders, dated 9/10/2024, documented, Levaquin Oral Tablet 500 MG (Levofloxacin) Give 1 tablet by mouth in the afternoon related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 5 Days R47's Physicians order, dated 9/22/2024, documented, Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth two times a day for infection related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 7 Days. R47's Physician orders, dated 9/4/2024, documented, CBC (complete blood count) bmp (basic metabolic panel) UA w/c and s one time only for pain while urinating for 1 Day. R47's McGreer's Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R47's UTI. 4. R54's Physician order, dated 9/5/2024, documented, UA with C&S one time only for altered mental status for 1 Day R54's Physician order, dated 9/6/2024, documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI pending UA results for 7 Days Give 1 cap PO BID X 7 days. R54's McGreer's Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R54's UTI. On 10/21/2024 at 10:35 AM, V14, Infection Preventionist/RN, stated that she took over the infection tracking in June. She continued to state that she did not know what organisms were in the facility except what was on the rehab unit because she is the unit manger there. V14 stated that she would track and trend at the end of the month because that was when pharmacy would send her a list of residents and what antibiotics they were on but prior to that list coming she did not know what organisms were in the facility. She also stated that the McGreers criteria was completed after the resident was already placed on an antibiotic and that this should have been filled out when the resident was starting to have signs and symptoms. On 10/21/2024 at 12:47 PM, V1, Administrator, stated that she would expect that staff track and monitor all infections in the facility. The facility's Antibiotic Stewardship Program, dated 10/2022, documented, Tracking: Process measures: Track types and location of infections, and where the resident is located in the facility. It continues, Monitoring use: Facility will collect reports summarizing the antibiotic susceptibility patterns. It continues, Microbiology culture data will be used to assess and guide future antibiotic selection. The facility's Surveillance for Healthcare Associated Infections, dated 09/2029, documented, 8. Utilize you surveillance data to: a. Identify infections quickly. It continues, f. Compare unit by unit data.

Based on interview and record review the facility failed to provide a Registered Nurse (RN) for a least 8 consecutive hours a day for 7 days a week. This failure has the potential to affect all 106 residents residing at the facility. Findings include: On 10/17/24 at 10:30 AM V19, Licensed Practical Nurse, stated that the day shift for nurses was from 6 AM to 6 PM and the Night shift runs from 6 PM to 6 AM. The facility's Staff Assignments, for August 2024, September 2024 and October 2024 were reviewed and on these dates, 8/22/2024, 8/28/2024, 8/29/2024, 9/1/2024, 9/5/2024, 9/12/2024, 9/18/2024, 9/20/2024, 9/23/2024, 9/26/2024, and 10/3/2024, failed to document that there was a RN working the floor for 8 consecutive hours on these days. On 10/17/24 at 01:05 PM, V1, Administrator, stated that they have a new scheduler and that she may not understand that a new day starts at 12 midnight and that she did not know if the facility has a policy but they follow the federal guidelines for RN coverage. The facility's Long-term Care facility Application for Medicare and Medicaid, dated 10/15/2024, documented that there was 106 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 2 residents (R18, R36) reviewed for abuse in the sample of 58. Findings include: On 9/19/23 at 10:50 AM, V16, Registered Nurse, stated, (R36) is inappropriate for the Memory Unit, because of his behaviors. He is physically aggressive and sexually inappropriate with staff. He really hasn't hurt any residents, but he will grab them. V16 stated, I am very worried for the residents, safety when I am not here, because of him. A night nurse (V17, Licensed Practical Nurse, (LPN)) has told me that she caught (R36) in the bed of his roommate (R18) rubbing his chest and stuff. (V17) told me it has happened a few times. I guess it started around May. V16 stated she did not know if V17 had reported the incident to the Administrator. V16 was questioned if she had reported it to the Administration, V16 stated, No, it was hearsay. I never saw (R36) do anything, sexually inappropriate to any resident. That's why. I was friends with (R18's) daughter and she has passed away. All I think of is she is up in heaven saying, '(V16) why are you not protecting my Dad?' On 9/18/23 and 9/19/23, R36's Nurses Notes were reviewed, and there was no documentation of an incident between R36 and R18. On 9/19/23 at 1:30 PM to 2:30 PM, the abuse investigations involving R36 were reviewed. An abuse investigation involving R38 and R18 was not available for review. R38's abuse investigations did not document any sexually inappropriate behavior. On 9/19/23 at 2:40 PM, V1, Administrator, V2, Director of Nursing, and V27, Regional Nurse Consultant, all were notified of the allegation of abuse between R36 and R18. All three denied knowing about the allegation. V1 stated he will start an investigation immediately. V1 stated any staff member that sees, hears of, or suspects any type of abuse, must report it to him immediately. On 9/20/23 at 9:00 AM, V1, stated he has interviewed V16, and she had stated she did not report it, because it was hearsay. (V17) was interviewed and she has told different stories which I cannot make any sense out of. She told me that she had documented, it in the Nurses' Notes. I have gone back and reviewed his entire record of Nurses Notes and there was one very vague note, dated back in June, that I had found of hers documenting, that he is physically aggressive toward staff and sexually inappropriate as witnessed/experienced and reported. The note did not elaborate on anything else. I have one Certified Nurse Aide, (CNA), that said she had overheard (V16) and (V17) talking about it. All of the other staff members that I have interviewed have never observed or heard about (R36) being sexually inappropriate with other residents. On 9/21/23 at 8:20 AM, V2 stated all of R36's Nurses Notes are missing at this time. On 9/21/23 at 9:30 AM, V1 stated, (V17) has not given me consistent or reliable information. She has changed her story and dates three times. I have reviewed (R18's) Medical Record and there is nothing in his chart either, related to this. I have spoken to (V28, fomer Administrator), and she had no idea of what I was talking about. She told me that an allegation of sexual abuse was never reported to her. I also, have spoken to (V5, Interim Administrator). She began on July 10, 2023, and was in that position until September 13, 2023. I took over on the 14th. (V5) told me that she did not know anything about an allegation of sexual abuse, and nothing was reported to her. On 9/21/23 at 10:17 AM, V17, stated, There was an incident involving (R36 and R18). I was summoned into (R36's) room by 2 CNA's. I do not remember who they were. I saw (R18) lying on his back in his bed. He did not have a gown on, only an incontinent brief. (R36) had his pajama pants, down around his ankles and his incontinent brief on. (R36) was on his knees straddling (R18) and he was rubbing (R18's) chest, breast like you would a woman. It took all three of us to get (R36) off of (R18). (R18) did not seem to be traumatized by this behavior; I think he was enjoying it. I placed (R36) on one-to-one supervision. I contacted the Executive Director, (V28) and notified the Director of Nursing at that time who is (V3). I never actually spoke with (V28). I just left a message. She never reached out to me about it. So, I documented it on a paper Nurses Note. At that time, we had to do paper charting, because our computer system was hacked. We had to paper chart, from July 9th until the 17th. I did not write a note in (R18's) chart. (V3) told me that she would contact (R36's) Power of Attorney and explain it to her. I tried to contact (R18's wife), but she did not answer. (V3) told me she would tell (R18's wife) when she came to visit today. When I came to work on 9/19/23 (V1 and V2) questioned me about the incident, between (R36 and R18). I told them what had happened, that I had reported it and I charted it in (R36's) chart. (V1 and V2) both stated that they had reviewed the chart and could not find the note. (V1) handed me all (R36's) notes to review. I looked and I couldn't find it. After they left, I was thinking about it, and I knew that what they gave me for review could not have been all the notes. (V16) came up that night and we went and got his chart to look for my notes. My note was in the chart. (V16) took all the notes up to the office and made copies. I wanted a copy of my notes for myself. We put the notes back in his chart. V17 was asked what new intervention was put into place since she reported the incident, V17 stated, (V3) said we are getting rid of him. That's what we are going to do. On 9/21/23 at 11:20 AM, V3 stated she was never told about an incident between R36 and R18, and she never said they were getting rid of R36. On 9/21/23 at 11:25 AM, V2 stated she reviewed all of R36's computer notes and his paper Nurse Note right after they were told of the allegation. V2 stated there was not a paper Nurses Note, about the alleged incident between R36 and R18. On 9/21/23 at 11:30 AM, V1 stated, he reached out to IT (Information Technology) to find out when the computer system was down, and he was told it was only one day and it was July 7, 2023. On 9/21/23 at 3:10 PM, V5, Administrator from July 10, 2023, until September 13,2023, stated she was never told of an allegation of sexual abuse, between R36 and R18. On 9/22/23 at 9:19 AM, V28, former Administrator, stated V17 never told her about a sexual abuse, between R36 and R18. The Abuse Prevention - Illinois Only policy, dated 11/17/23, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Definitions: a) abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault or non-consensual sexual contact of any type with a resident. prevention: Staff members, volunteers, are to report and family members and others must report incidents of abuse. Identification: the Administrator must be immediately notified of suspected abuse or incident of abuse. If such incidents occur or are discovered after hours, the Administrator must be called at home or must be paged and informed of such incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete injury report, investigate an injury, and implement identified interventions for one of five residents (R20) reviewed for falls in the sample of 58. Finding include: 1. R20's face sheet, dated 8/28/2022, documents a history of falling. R20's Minimum Data Set, (MDS), dated [DATE], documents R20 requires extensive assistance and one-person physical assistance for bed mobility and transfers. R20's fall risk assessment, dated 8/3/2023, documents a score of 75, with a score of 46 or greater being high risk for falls. R20's Resident incident report, dated 9/17/2023 at 5:30PM, documents, resident was found on floor next to bed and noted purple and red area to right side of head. No open area or drainage noted. The report documents, immediate actions taken fall and a mats was put in place. The facility does not provide any witness statements in regard to R20's fall on 9/17/2023. On 09/18/23 at 11:00AM, V33, R20's wife, was in the dining room. V33 started crying and stated R20 had a fall a couple days ago, and R20 is not the same. V33 stated R20 cannot tell her where he got these bruises. V33 pointed to a bruise on top right side of V33's head and stated, (R20) has a bruise on his hip also. The facility called her and told me (R20) rolled out of bed and was fine. V33 stated R20 stated he did not have a mat beside his bed when he fell. On 9/21/23 11:37AM, V32, Registered Nurse, (RN), stated she was on call for the weekend of 9/16/2023. V32 stated she entered the facility on 9/17/2023 for a short period of time. V32 stated V33 was present at the facility and approached her, and reported to her R20 had fallen out of bed at 11:00PM the previous night. V32 stated V33 asked her if she had been notified as the on-call Nurse. V32 stated she initiated the injury report. The nurse who worked the night shift had notified the Physician, V33, and had started Neurological checks, but had not completed an injury report. V32 stated there were not fall mats in place, beside R20's bed, and she had to physically go find some to put in place. V32 stated R20 was to have fall mat beside his bed. On 9/21/2023 at 2:45PM, V2, Director of Nursing, (DON), stated she would expect staff to complete injury reports, investigate injuries and implement identified interventions for falls. The facility interdisciplinary fall reduction/injury prevention protocol, dated 7/12, documents, each fall is to be investigated as soon as possible post, fall, by all staff members working on that unit. The policy documents, an interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to prevent resident to resident abuse for 5 of 22 residents (R17, R19, R33, R36, R208) reviewed for abuse in the sample of 58. Finding include: 1. R36's Face Sheet, print date of 9/19/23, documents R36 was admitted on [DATE], and has diagnoses of Dysphasia, Convulsions, Major Depression, and Dementia. R36's Care Plan, dated 1/22, documents, Mental wellness/Mood. I have Schizophrenia and Dementia; I wander a lot. I walk with my head down at times. I will wander into other peers' rooms as well. I can be resistive to cares. I like to grab a hold of caregivers or other peers. I do this out of fear that I'm going to fall or just not used to my environment. It continues, I will take food off of other peers' plates. Please redirect me to my own food. I put random items in my mouth especially at mealtimes. Please observe me for this and redirect me. R36's Care Plan, dated 1/22, documents, Safety Notes. I am a risk for falls. I have diagnosis of Dementia. It continues, I am alert and oriented x 1. I know my name, but unaware of place and time. I am nonverbal due to diagnosis of aphagia. It continues, Please check on me during rounds. I like to wander up and down the halls. I am an elopement risk. Redirect me if I attempt to open doors. I require a locked facility for my safety. 2/8/23: I was involved in res, (resident), to res. without injury. staff to monitor me when I'm around other residents to make sure I have an object of choice in my hand as tolerated. 4/30/235 pm, res to res altercation with peer. No injury. res to be in assigned seating in DR, (dining room), and have tray delivered first. 5/16/23 I was involved in a res-to-res altercation with peer. No injury. Please redirect res away from other peers at table after supper and offer activity of choice as tolerated. 9/17/23 I was involved in a res-to-res altercation. No injury noted. Offer me a snack and music of choice after suppertime as tolerated. R36's September Behavior Tracking documents R36 has multiple incidents of Wandering into peers' rooms, grabbing at staff and peers, taking food from peers and wandering. R36's Minimum Data Set, (MDS), dated [DATE], documents R36 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. R36's MDS, dated [DATE], documents R36 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. R36's MDS, dated [DATE], documents, that R36 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. On 9/18/23 at 10:30 AM, V34, Certified Nurses Aid, (CNA), stated R36 requires redirection frequently because he wanders through the unit. V34 stated R36 will grab onto staff and you must redirect him to get him to let go of you. On 9/18/23 at 1:15 PM, R36 is observed walking up behind V35, CNA, and grabbing her sides. It appeared R36 was trying to pick V35 up. On 9/18/23 at 1:15 PM, V35 was telling R36 to let go of her and trying to redirect him. R36 did let V35 go, and he was redirected down the hall. On 9/19/23 at 10:50 AM, V16, Registered Nurse, stated, (R36) is inappropriate for the Memory Unit because of his behaviors. He is physically aggressive and sexually inappropriate with staff. He really hasn't hurt any residents, but he will grab them. V16 stated, I am very worried for the residents safety when I am not here because of him. On 9/19/23 at 11:30 AM, V1, Administrator, stated he is new here, but from what I have seen of (R36), (R36) is not your typical Dementia patient. I believe he has something else going on, but again I have only been here a few days and haven't really got into him yet. I am trying to find other placement for (R36) because (R36) would be better suited for a quieter place. V1 stated R36 does ambulate through the unit, and he will grab onto staff and other residents. On 9/19/23 at 12:45 PM, V3, RN/Memory Unit Manager, stated, (R36) is aggressive and sexually inappropriate with staff. (R36) will grab onto staff, and he has to be redirected to get him to let go. V3 stated he has had physical altercations with residents, but he is not sexually inappropriate with residents. V3 stated R36 reminds her of someone that is on the Autism Spectrum. He has the behaviors of someone who is Autistic, he is very tactile, and will stare off like he is not even looking at you. (R36) is basically nonverbal. 2. R17's Face Sheet, print date of 9/19/23, documents R17 was admitted on [DATE] and has diagnoses of Anxiety and Dementia. R17's MDS, dated [DATE], documents, that R17 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. The facility Abuse Investigation, undated, documents, Upon investigation through chart reviews, surveillance, and staff interview, on February 8, 2023, at approximately 4:00 PM, (R36) was walking around dining room where her walked up to (R17) who was coloring to observe her work. (R36) reached out to pick up a crayon at the same time (R17) reached out to pick up another crayon and (R36) grabbed onto (R17's) right arm instead. (R17) attempted to pull her right arm back creating a skin tear to her right forearm. (R17) then responded by contacting (R36's) arms with her left hand. 3. R208's Face Sheet, print date of 9/20/23, documents R208 was admitted on [DATE] and has diagnosis of Dementia. R208's MDS, dated [DATE], documents R208 is severely cognitively impaired and is independent with ambulation. R208's Care Plan, dated 6/2023, documents, Mental Wellness. I have a diagnosis of Dementia with behavioral disturbances. I have behaviors of exit seeking, combative and resistive to care, banging on exit doors, pacing and looking for my truck. The facility Abuse investigation, undated, documents, Upon investigation through chart reviews, staff interviews, and surveillance, on April 30, 2023, at approximately 5 PM, (R36) was sitting in the lounge area and (R208) was at a dining table waiting for mal trays. (R208) received his meal tray and staff walked over to (R36) to direct him to a dining table on the other side of the room. As (R36) walked past (R208), he saw a container of ice cream and quickly picked it up. (R208) reacted by striking (R36). Additional staff members responded, and the residents were immediately separated. No injuries occurred for either resident. 4. R33's Face Sheet, print date of 9/20/23, documents R33 was admitted on [DATE] and has a diagnosis of Dementia. R33's MDS, dated [DATE], documents R33 is severely cognitively impaired and that R33 requires extensive assistance of one staff member for locomotion and that he uses a wheelchair. R33's September Behavior Tracking documents multiple entries of R33 wandering. R19's Face Sheet, print date of 9/18/23, documents R19 was admitted on [DATE] and has diagnoses of Dementia and Anxiety. R19's MDS, dated [DATE], documents R19 is severely cognitively impaired. The facility Resident Incident Report, dated 9/17/23, documents, reported per CNA that this res (R33) and male peer (R36) had gone into female's peer's (R19) room. (R33) had a hold of (R19's) elbow while (R36) had a hold of (R19's) right wrist and fingers. CNA able to redirect (R33) and he let go. (R19) peer then reached up and slapped (R36). 5. R17's Face Sheet, print date of 9/19/23, documents R17 was admitted on [DATE] and has diagnoses of Anxiety and Dementia. R17's MDS, dated [DATE], documents R17 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. R19's Face Sheet, print date of 9/18/23, documents R19 was admitted on [DATE] and has diagnoses of Dementia and Anxiety. R19's MDS, dated [DATE], documents R19 is severely cognitively impaired. R17's Resident Incident Report, dated 9/15/23 at 4:20 PM, documents, (R19) had swung at (R17) over peer attempting to use the crayons. (R17) then grabbed (R19's) arm causing scratches and skin tears. 5 cm, (centimeters), scratch x 2 left forearm 1 cm scratch and 5 cm scratch left forearm and .2 cm skin tears left forearm. The Abuse Prevention- Illinois Only policy, dated 11/17/23, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Definitions: a) abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident.

Based on interview, observation, and record review, the facility failed to place a date on vial when a multi-use medication vial was opened, failed to maintain the medication refrigerator at the proper temperature, and failed to maintain a clean refrigerator and not store food in the medication refrigerator. This failure has the potential to affect 37 residents living in the Memory Unit. Findings include: On 9/20/23 at 10:00 AM, the Memory Unit Medication Room was observed. In the refrigerator there was 17 magic cup ice creams, the temperature was 32 degrees. The inside of the door had brown debris on the shelves, and there was an open undated bottle of Tubersol multi-dose vial. On 9/20/23 at 10:08 AM, V3, RN/Memory Unit Manager, stated food should not be kept in the medication refrigerator. They have been having trouble with the temperatures in that refrigerator, and any multi-use vial should be dated when opened. The policy Medication Storage, dated 1/15, documents, 18. Medications requiring refrigeration must be stored between 36 degrees F (Fahrenheit) and 46 degrees F in refrigerator. The policy Guidelines for Shortened Expiration Date, dated 11/10, documents, As a general rule, write the date opened on all multi-dose vials, ophthalmic, inhalers, nasal sprays and sublingual nitroglycerin tablets. Medication: Tubersol. Expiration Date after Opening: 30 days. The Resident Census and Conditions, CMS 672, dated 9/18/23, documents the facility has 37 residents on Memory Care Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement broad based testing or contact tracing and implement infection control to prevent the spread of COVID infection. This has the potential to affect all 103 residents at the facility. Findings include: 1. On 8/29/2023 at 7:29 AM, V10 (Licensed Practical Nurse/LPN) was passing meds on the rapid recovery unit with Covid positive residents. V10's surgical mask was on under her nose. 2. On 8/30/2023 at 9:32AM, V2 (Interim Director of Nursing/DON) stated V19 (LPN) had called her on morning of August 9th, and told her she was positive for COVID. V2 stated V19 worked the rapid recovery unit on 8/6/2023. V19's time sheet documents V19 clocked in at 6:25AM and clocked out at 7:16PM on 8/5 and 8/6/2023, working 12 hours from 6:30am- 7:15 pm on both days V2 stated there was no contact tracing done at that time. V2 stated, If someone had symptoms we would test. (R1) was having psych issues and was sent to local hospital for evaluation and tested positive there for Covid. (R1) resided on the rapid recovery unit. 3. On 8/30/2023 at 10:55AM, Memory unit lunch carts were being passed by staff; 2 family members were sitting at a table with their family with surgical masks on. Surveyor asked V4, Activities, if R9 was in the dining room eating, and V4 pointed him, R9, out at the table, who was sitting with 5 other table mates. R9 was positive for Covid. V4 stated V4 did not know why he was at the table. R9 was sitting at the table in the dining area with tablemates R10, R11, R12, R13 and R14. R15 and R16 had family members present in the dining area with surgical masks on. The facility Outbreak summary, dated August 2023, documents as of 9/2/2023, 26 residents have tested positive for Covid, and 13 staff, tested positive for Covid-19, with R1 being the first case. The outbreak summary documents R1 tested positive on 8/17/2023, during emergency room visit at the local hospital. The facility census list dated 8/28/2023 documents, a census of 103. On 9/5/2023 at 9:15AM, V3 (Director of Nursing/DON) stated she would expect staff to follow infection control and follow facility policy. The facility's Coronavirus (COVID-19) policy, dated 6/23, documents in part, Surveillance: 2. monitoring and testing of any current resident or staff member exhibiting signs or symptoms. 3.Monitoring coronavirus in the facility by the infection preventionist. This data will be utilized define threshold levels that would prompt additional investigating or enhanced control measures. 7. The identification of a single COVID-19 positive resident or staff triggers an outbreak investigation . Control Measures: 1. Any resident suspected of having coronavirus will be placed on standard, contact and droplet precautions as per CDC guidelines. The timeframe for precautions [NAME] be determined on a case-by-case basis. Such a decision will take into account the severity of the illness, comorbid conditions, resolution of fever and clinical status of resident . 5. While on transmission base precautions, residents are to be confined to their room as much as possible and should not attend communal activities/dining. 6. Personal protective equipment (PE) including gloves, gown, ace mask or respirator are to be utilized for any healthcare worker entering the resident's room for suspected or confirmed cases . Visitation: Signage is to be posted throughout the facility including entrances, regarding reporting symptoms of or exposure to someone with COVID and refraining from visiting if ill . Preventing Illness: 3. the CDC recommends the following core principles of infection prevention to help prevent the spread of respiratory diseases, including: perform hand hygiene before applying and removing PPE, including gloves . Avoid contact with people who are symptomatic. For residents suspected or with coronavirus, close contact includes being approximately 6 feet of the residents for prolonged periods of time or having direct contact with the resident infectious secretions .Testing Frequency: Follow instructions below for prioritization of testing: Asymptomatic health care provider (HCP) not wearing Personal Protective Equipment (PPE) that are exposed testing is recommended as soon as possible (but generally not earlier than 24 hours after exposure if known) on days 1, 3, and 5 unless recovered from Covid in the past 30 days . Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts- test all staff and residents on the affected unit (s), vaccinated and unvaccinated , that had high risk exposure with a COVID-19 positive individual. Testing is recommended as soon as possible (but generally not earlier than 24 hours after exposure if known) on days 1, 3, and 5 A new COVID-19 infection in any staff or any nursing home onset resident triggers an outbreak investigation .Asymptomatic with close contact who do not consistently wear mask or are immunocompromised, or reside near other who are severely immunocompromised or reside on a unit with ongoing COVID transmission, place in TBP (transmission based precautions) for 7 days ( count day of exposure as day 0) and negative test, test on days 1, 3, and 5. Discontinue TBP if negative. TBP for 10 days if no negative test, exposure day = day zero (0).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R43) reviewed for abuse in the sample of 67. Findings include: R43's Minimum Data Set, dated [DATE] documents she was alert with no disorganized thinking behavior present. R43's Care Plan, dated 4/26/2022 documents a communication/memory problem. Goal: to continue being able to make my needs known. Due to my diagnosis of TBI (traumatic brain injury) I do have troubles recalling things with some confusion. Please when I have my moments of confusion, please bear with me and explain things to me again or in another way so I can understand. I can make my needs know verbally. I do make false allegations towards staff at times. 6/27/2022 a report of an allegation of abuse skin assessment was completed with no negative findings. On 8/4/2022 at 12:10 PM R43 stated she was handled roughly by a male therapist (name unknown) a few weeks ago. She didn't have any injuries from it but it scared her and she felt it was abuse. facility's undated final investigation report documents on 6/27/2022 at approximately 10:30 AM staff reported an allegation of abuse. Investigation stated immediately, MD (physician), police, ED (Executive Director) and DON (Director of Nursing) notified immediately. The following were reviewed during investigation: face sheet, POS (physician's order sheet), care plan, resident interviews, staff interviews, police notification and interview, skin and pain assessment and surveillance. Upon investigation, resident expressed to a staff member that a male therapist was rough with her during treatment. When resident was interviewed by the DON, she expressed that she has never had a male therapist and maybe it was someone else. When resident was interviewed by the ED, she stated I didn't say that I just heard someone else say it. After staff interviews and surveillance resident was never cared for by a male during the shift, she expressed the allegation. According to resident's history, she has made false allegations in the past and in her previous home setting res stated, I just wanted someone to talk to. The allegation was concluded as unfounded. The following interventions were implemented: social services to follow up with resident to provide 1:1 as tolerated. Staff educated on abuse prevention including physical and verbal abuse. Resident states she feels safe in her environment. Care plan reviewed and updated. The facility's abuse investigation failed to include staff and resident interviews. On 8/4/2022 at 3:15 PM, V1, Administrator, stated she had provided the IDPH surveyor with the entire abuse investigation. She was not aware there were not staff or resident interviews documented in the abuse investigation, she expected abuse investigations to include staff and residents' statements. The Facility's abuse policy revised 5/2022 documents all cases of resident abuse must be thoroughly investigated and documented as required by state guidelines.

Based on interview and record review, the facility failed to obtain labs to monitor the efficacy of anticoagulant therapy and monitor need for dosage adjustments for 2 of 3 residents (R63, R99) reviewed for unnecessary medications in the sample of 67. Findings include: 1. On 8/02/22 at 1:05 PM, R63 stated she had had a bloody nose a couple weeks ago. R63 stated she has bruises on her arms, and she pulled up her sleeve and there were multiple purple-pink bruises noted up and down her right forearm. R63 stated she gets a bruise anytime she bumps her arms. R63 stated they usually check her blood every month because she is on Coumadin, but they didn't come last month to draw her blood. R63's Face Sheet documents her diagnoses to include Chronic Atrial Fibrillation. R63's Physician Order Sheet dated July 2022 documents the order, dated 4/12/21: Chronic Atrial Fibrillation, unspecified; Obtain PT (Protime) /INR (International Normalized Ratio) monthly. R63's Physician Order dated 1/14/22 documents: Coumadin 2 mg (milligram) by mouth daily There were no lab results for PT/INR in May 2022, June 2022 or July 2022. R63's Care Plan dated 5/9/22 documents, I take Coumadin to prevent blood clots. Please give me my Coumadin, obtain labs and notify my physician as needed. Please watch for me to have any abnormal bleeding and report to nurse/MD (medical doctor). On 8/03/22 at 11:06 AM, V1, Administrator, provided R63's Protime/INR tracker which documented her last PT/INR was done on April 7, 2022. V1 acknowledged R63 has not had any other PT/INR done since then; she stated R63 did not have a PT/INR in May, June or July as ordered. R63 did have a PT/INR drawn yesterday at 6:00 PM with the results of 29.7 and 2.53 which was within normal limits. V1 stated she has taken over since the last administrator left and the ball was dropped. She stated the Medical Director is working with the local hospital to have the facility's labs done there. V1 stated the MD is aware of the missed labs on R63 and gave the order to monitor her for adverse s/s (signs and symptoms). 2. On 8/03/22 at 2:20 PM, V1 stated there are two residents who received Coumadin and are required to receive PT/INRs to monitor this medication: R63 and R99. She stated she did medication error reports for both residents because their protime and INR was not done in May, June, or July. R99's Face Sheet documents her diagnoses to include Long Term (Current) Use of Anticoagulant and Atherosclerotic Heart Disease of Native Coronary Artery. R99's Physician Order Sheet documents an order dated 5/8/22: Long term (current) use of anticoagulants; Obtain a PT/INR monthly; call results to MD and fax results for his records. R99's Physician Order dated 1/11/22 documents: Coumadin 2.5 mg every Monday-Wednesday-Friday and Coumadin 5 mg every Tuesday-Thursday-Saturday-Sunday. There were no lab results documenting a PT/INR was done as ordered in June or July. R99's Care Plan dated 10/11/21 documents, under Health and Wellness: I have diagnoses of diabetes, dementia, atrial fibrillation, and coronary artery disease. Please administer my medications like my physician has ordered. I take Warfarin (Coumadin). Please monitor my PT/INR so that my physician can dose my medication accordingly. Obtain all labs my physician has ordered. The facility's policy, Laboratory Tests with review date of 11/17 documents, Policy: Laboratory tests are completed on all residents upon admission or re-admission if not already performed at the discharging facility. Lab tests are completed as ordered by the physician or physician extender (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist). Physician Orders supersede any guidelines listed in this policy. Under procedure: 1. Licensed Nurse, or designee, shall obtain the labs ordered by the physician or physician extender; or labs to be done routinely per policy and enter this information on the Lab Scheduling/Tracking Form, indicating resident, room number, month and approximate date lab work is due to be obtained.

Based on interview and record review, the facility failed to implement their Antibiotic Stewardship Program to monitor the use of antibiotics for 5 of 5 residents (R8, R21, R43, R50, R66) reviewed for Antibiotic Stewardship in the sample of 67. Findings include: 1. The facility infection control log, documents R8 had a Urinary Tract Infection (UTI) on 3/7/22. There was no documentation on the log that a culture was obtained, or the organism identified in the urine. R8's Physician Order Sheet (POS), documents an order dated 3/9/22 for Ciprofloxacin HCL 250 milligrams(mg) daily. 2. The facility infection control log, documents R21 had a UTI on 3/18/22. There was no documentation on the log that a culture was obtained, or the organism identified in the urine. R21's POS, documents an order dated 3/18/11 for Macrobid 100mg twice daily for UTI. 3. The facility infection control log, documents R43 had a UTI on 4/15/22. There was no documentation on the log that a culture was obtained, or the organism identified in the urine. R43's POS, documents an order dated 4/19/22 for Zyvox for UTI. 4. The facility infection control log, documents R50 had a UTI on 4/13/22. There was no documentation on the log that a culture was obtained, or the organism identified in the urine. R50's POS, documents an order dated 4/8/22 for Macrobid 100mg twice daily for UTI. 5. The facility infection control log, documents R66 had a UTI on 3/14/22 and 5/1/22. There was no documentation on the log that a culture was obtained, or the organism identified in the urine. R66's POS, documents the following orders: 3/14/22 - Keflex 500mg three times daily for UTI and 4/30/22 - Cephalexin 500mg twice daily for UTI. On 8/4/22 at 2:40 PM, V2, Director of Nurses stated R8, R21, R43, R50 and R66 were all admitted with the diagnosis of UTI and antibiotic orders from the hospital and there were no culture reports available. The Antibiotic Stewardship Program policy, dated 8/2017, documents the following: Monitoring Use: Microbiology culture data will be used to assess and guide future antibiotic selection.