Every finding on record at Alden Estates CTS of Huntley

Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 7 residents (R1) reviewed for transfers in the sample of 10. The findings include:On 7/7/26 at 8:50 AM, R1 was sitting in the dining room in his wheelchair with a mechanical lift sling underneath him. R1 was alert and oriented to person, place, and time and able to answer questions appropriately. R1 said he was at the facility after having surgery to get therapy. R1 said he is transferred by staff using a mechanical lift. R1 said usually there is two staff during the transfer with the machine but sometimes there is just one staff transferring him. R1 said this morning V7 Certified Nursing Assistant (CNA) transferred him via mechanical lift by herself. R1 said V7 said something about being shorthanded. On 7/7/26 at 8:54 AM, V7 said she got R1 up for breakfast and had used a mechanical lift. V7 said you are supposed to have two people with you when transferring using a mechanical lift. When asked if she had a second person with her during the transfer of R1, V7 hesitated and then said V8 helped her with the lift. On 7/7/26 at 9:01 AM, V8 CNA said she had not transferred anyone using a mechanical lift that morning yet. V8 said she had not helped V7 transfer R1. V8 said you are always supposed to have two people when using a mechanical lift. On 7/7/26 at 12:36 PM, V3 Director of Nursing said there is supposed to be two staff present when using a mechanical lift to transfer residents for safety. R1's Care Plan shows R1 has diagnoses of encounter for surgical aftercare following surgery on the digestive system, acute respiratory failure with hypoxia, presence of bilateral artificial knee joints, muscle weakness, dysphagia, and difficulty walking. This same Care Plan shows R1 requires the use of a mechanical lift for transfers: Provide 2 staff assistance for transferring. The facility's Total Mechanical Lift Policy dated 1/14/21 shows 2 caregivers are required to operate the mechanical lift.

Based on interview and record review, the facility failed to ensure a resident (R1) was free from a significant medication error. This applies to 1 of 3 residents reviewed for physician's orders in the sample of 5. The findings include:R1's electronic face sheet dated 6/12/26 showed R1 has diagnoses including but not limited to displaced fracture of right lower leg, subluxation of right ankle joint, type 2 diabetes, asthma, morbid obesity, muscle weakness, obstructive sleep apnea, hypertension, and osteoporosis. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment. R1's care plan dated 2/25/26 showed, (R1) has the potential for hypo/hyperglycemic reactions secondary to diagnosis of diabetes mellitus .administer medications for diabetes mellitus as ordered . R1's medication administration record for March 2026 showed R1 receives Insulin Glargine 20 units every evening at 8PM. R1's medication administration record for 3/9/26 showed R1's Insulin Glargine 20 units was not given due to Not available.On 6/12/26 at 11:37AM, R1 stated, I don't think they were giving me enough insulin, I know they were scared to give me too much, but I managed my medications before I came there so I know what I can handle. I think the hospital was doing it correctly, but I wasn't eating very well there either so I can't really remember.On 6/12/26 at 12:25PM, V11 (Registered Nurse) stated, Insulin is a critical medication for diabetics and should not be missed. We should be keeping an eye on the amount left for the residents and reordering with enough time to get the new supply in.On 6/12/26 at 11:02AM, V3 (Director of Nursing) stated, It would be my expectation that medications are ordered within enough time to be delivered so that the resident does not miss any doses. Insulin is a crucial medication for diabetics that cannot be missed.The facility's policy titled, Medication Administration dated 03/2021 showed, Policy: To ensure that medications are administered safely as prescribed .6. If the physician's medication order cannot be followed, the physician should be notified, depending on the situation .

Based on interview and record review, the facility failed to administer a resident's (R1) medications as ordered by a physician for 1 of 3 residents reviewed for physician's orders in the sample of 5. The findings include:R1's electronic face sheet dated 6/12/26 showed R1 has diagnoses including but not limited to displaced fracture of right lower leg, subluxation of right ankle joint, type 2 diabetes, asthma, morbid obesity, muscle weakness, obstructive sleep apnea, hypertension, and osteoporosis. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment. R1's care plan dated 2/24/26 showed, (R1) has the potential for pain .administer pain strategies according to MAR/TAR (Medication Administration Record/Treatment Administration Record). On 6/12/26 at 11:37AM, R1 stated, Several times I would have increased pain and wonder why and it was because I didn't have my pain medication. I didn't understand why I had to ask for it when I was always having to ask for it so it should have just been automatic. Lyrica was missed too and I didn't know why I would have to ask for it. R1's medication administration record for February 2026 showed R1's Lyrica 75mg was ordered to be administered at 9AM, 1PM, and 8PM on a daily basis. R1's Lyrica 75mg was not administered on 2/24/26 at 8PM and 2/25/26 at 1PM due to Not Available. On 6/12/26 at 11:02AM, V3 (Director of Nursing) stated, We have 2 delivery times 1AM and 1-2PM every day/7 days per week. Upon arrival to the facility, if there is a billing issue or clarification from the physician that needs to occur about medications, the resident's medications will be on the following delivery cycle. Sometimes hospitals don't send a script or something like that. Pharmacy has a cutoff so if it's too late, they won't send it until the next delivery. If we don't have a prescription, we can't get it out of the emergency supply. Sometimes family can get medications delivered if needed. It would be my expectation that medications are ordered within enough time to be delivered so that the resident does not miss any doses. I'm not sure why (R1) missed her doses of Lyrica because we were in constant communication with the hospital prior to her admission. On 6/12/26 at 12:25PM, V11 (Registered Nurse) stated, If a patient comes earlier in the day, then we would get their medications on the afternoon pharmacy rounds. No reason why they wouldn't be here by the next day. If we don't have a medication, we can check the emergency stock and we need to notify the provider if it's not in there so they can be kept up to date. The facility's policy titled, Medication Administration dated 03/2021 showed, Policy: To ensure that medications are administered safely as prescribed .6. If the physician's medication order cannot be followed, the physician should be notified, depending upon the situation .

Based on observation, interview, and record review the facility failed to ensure a resident's wheelchair was maintained for one of 32 residents (R147) reviewed for accommodations of needs in the sample of 32.The findings include:R147's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including cachexia, history of falling, unsteadiness on feet, difficulty in walking, and muscle weakness.R147's Minimum Data Set, dated [DATE] shows she was cognitively intact.On April 6, 2026 at 9:49 AM, R147 said, This wheelchair is dangerous. It won't lock. R147 demonstrated by placing her wheelchair locks on while she was sitting in it, then made a forward movement while sitting in her wheelchair and the wheels became unlocked automatically. R147 said she asked to go back to her original wheelchair. R147 said she was concerned with the brakes on her wheelchair and trying to get up since the wheelchair unlocks. R147 said she asked staff who could fix her wheelchair. R147 said she talked with maintenance. R147 said this has been going on for about one month.On April 7, 2026 at 8:52 AM, V3 (Director of Nursing )said, R147 was a busy body. R147 was always on the move, alert and oriented resident. V3 said R147 never complained about her wheelchair to V3. V3 said maintenance has not said anything to V3 about the brakes on R147's wheelchair.On April 7, 2026 at 9:28 AM, V5 (Maintenance Manager) said he received a report on April 2, 2026 that R147's brakes on her wheelchair were not functioning. V5 said he went to R147's room and he tightened her brakes. V5 said the left brake worked, but the right one needed to be tightened. V5 said he received a call on April 6, 2026 that R147's brakes needed to be looked at again. V5 said he did and saw that the brakes were loose again so he tightened them.The State of Illinois Residents' Rights for People in Long-term Care Facilities dated April 2024 shows, Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication errors in the sample of 8. This failure resulted in R1 experiencing iatrogenic hypotension which required hospitalization from 2/2/26 through 2/9/26.The surveyor confirmed by observation, interview and record review that the deficient practice occurred on 2/2/26 and was corrected on 2/2/26 prior to the start of this survey, and was therefore Past Noncompliance.The findings include:R1's face sheet showed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include cellulitis of right lower limb, cellulitis of left lower limb, sepsis, anemia in chronic kidney disease, hypertensive heart and chronic kidney disease, acute pulmonary edema, paroxysmal atrial fibrillation, chronic congestive heart failure, and venous insufficiency. R1's admission Assessment showed she was alert to person and time. R1's Initial Nursing assessment dated [DATE] showed she is alert and oriented to person and place and confused at times. R4's face sheet showed she was admitted to the facility 1/26/26 with diagnoses to include gastroparesis, chronic kidney disease, mixed hyperlipidemia, hypertensive chronic kidney disease, nonrheumatic aortic valve insufficiency, atherosclerotic heart disease, peripheral vascular disease, and acute kidney failure. On 2/10/26 at 9:44 AM, V10 (R1's daughter) said, My mom was admitted to the facility on [DATE] after she was treated at the hospital for cellulitis in her legs. She was there Saturday and Sunday and then on Monday, 2/2, I was called by [the acute care hospital] telling me that they had her there. They told me that she had been given her medicine and also another resident's medicine and she was in 'shock'. They had to give her some intravenous medications really quick to bring her blood pressure up. The hospital told me she had been given 4 different blood pressure lowering medications. [the facility] never has told me about the drugs. I asked my mom and she said she remembered sitting at the table and then they gave her some medicine. She said it was around lunchtime so 11ish. Then she said the room got black and she couldn't remember anything after that. [The acute care hospital] told me poison control was involved. She went to the emergency room on the 2/2 and then discharged yesterday (2/9/26) to [another long-term care facility]. She was in ICU (Intensive Care Unit) from 2/2/26 through 2/4/26 because they were administering a medication that they said can only be given in the ICU. On 2/4/26 she was transferred to another floor and then discharged on 2/9/26. I have her discharge paperwork from the hospital it says her diagnoses was Iatrogenic Hypotension (low blood pressure that occurs as a result of medical treatment or intervention, often due to. medication effects) . R1's 2/2/26 Nursing Note entered at 2:02 PM showed, Resident was received at the start of the shift in bed, clean, comfortable, and without signs or symptoms of distress. During morning medication pass, resident was seated in chair and presented without complaints or observable concerns. At approximately 10:00, a nursing assessment was completed. Resident assessment findings were within normal limits and consistent with documented baseline. Scheduled morning medications were administered per physician orders. No immediate adverse reactions were observed. Later in the shift, resident was observed seated in wheelchair at the nurse's station leaning to the left side, which was not consistent with baseline presentation. Immediate nursing assessment was performed. Vital signs were obtained and noted to be outside of the residents established baseline parameters. Due to a cute change in condition, emergency medical services were activated via 911 for urgent evaluation and transport. Resident was transferred by EMS (emergency medical services) without further observed decline at the time of departure. Incident referred for administrative and clinical review. R1's February 2026 eMAR (electronic Medication Administration Record) showed she received Bumetanide 1 mg (diuretic used to treat fluid retention associated with congestive heart failure).R4's February 2026 eMAR (electronic Medication Administration Record) showed the following medications scheduled to be administered at 9:00 AM: Venlafaxine 225 mg (antidepressant), Furosemide 20 mg (diuretic), Carvedilol 25 mg (blood pressure medication), Entresto 97-103 mg (blood pressure medication), Procardia 60 mg (blood pressure medication), aspirin 325 mg, Clopidogrel Bisulfate 75 mg (antiplatelet medication) . R4's 2/2/26 Nurses Note entered at 1:14 PM showed, Resident came to nurse's station questioning her am (morning) medications. Vitals were obtained, resident stated she didn't want her medications and requested to discharge today.R4's Weights and Vitals Tab showed a blood pressure obtained at 7:42 AM on 2/2/26 of 95/60. This blood pressure was then struck out as inaccurate documentation at 12:22 PM. On 2/10/26 at 1:25 PM, V9 LPN (Licensed Practical Nurse) said, First of all I apologize for whatever happened, that day I was doing morning medications, [R1] was new to the facility, I checked the picture in the system, it looked like her, I went up and asked her if her name was [R4's Name] and she nodded yes, I asked her about pain, how she was doing, and she said her day was going good. Her blood was normal, so I didn't give her two of blood pressure pills, I don't remember the name of the medications I didn't give. After that, sometime passed and the other patient [R4] came and asked about her medications. I then realized I might have given other resident (R1) the wrong medications. I called the Director of Nursing and stayed with R1] and checked her vitals. I don't know which medications I held. She was alert and talking to me before and when I checked her again, she was confused. I called the Assistant Director of Nursing right away and the other nurse was with me. I was trying to talk to her. She was responding by nodding her head, we were trying to get her blood pressure, but I don't remember what the numbers were. It was very low. I'm a new nurse. They had me do training with pharmacy and again with the staff. They said I'm safe to pass medications. my DON went through the training with me again. The statement provided by the facility from V9 LPN dated 2/2/26 showed, [V9] went to [R1] who was sitting near nurse's station in wheelchair, verified verbally by asking [R1] if her name was [R4] in which [R1] said yes and nodded yes as well. Checked vitals around 7:30-7:40 AM at this time [V9] noted BP was lower than parameter when she went back and checked the eMAR for [R4]. After preparing medications, she went back to patient and administered the medication with no issues. Around 10:15 AM [V9] realized another resident hadn't gotten her medication yet but medications were not in the cart, she alerted another nurse that she mistakenly gave patient [R1] medication that was supposed to go to patient [R4]. Both nurses immediately assessed [R1] and noted [R1] to be hypotensive, 911 was called, medical director was present during this and also assessed patient with orders to send out.On 2/10/26 at 11:54 AM, V5 RN (Registered Nurse) said, I just got done with all of my medications. [R1] was my last patient I saw. I gave [R1] her medication last. Then another resident came up and started arguing with [V9-LPN] saying that she didn't receive her medications. I noticed that my patient was the only one that had been in that area. I went to assess [R1], and her blood pressure was around 64/40 something. Her head was slumped to the side and her pulse was so faint that I couldn't get her bp with a manual blood pressure cuff. When the paramedics got there, I asked them what they got for a blood pressure, and it was 55/30 something if I remember right. I had called 911 immediately as soon as I got that blood pressure because I assumed she was the one who got the other resident's medications and [R1] didn't receive anything from me that would do that to her. she was confused and talking off the wall. In report I got that she was alert and oriented x 2. By the time I got her blood pressure, she was not alert at all. Very lethargic but she was responsive, just inappropriate responses. I was talking to the paramedics when they got there, and I told them she received some kind of medication because the other nurse said she got the two patients confused. I asked to see [R4's] medication list to see what [R1] was given, and she was given blood pressure medications. I wrote out a quick list and sent with the EMS in the case the doctors there would need to see that. Immediately after this, they did in-servicing and they continued it throughout that day. On 2/10/26 at 10:38 AM, V1 (Administrator) said, . In this situation, [V9] has been a nurse for about a year. We had a new patient admitted over the weekend. She went to the resident and asked her, using the name, and [R1] responded back appropriately. She gave her the medications and 30-45 seconds later, [R4] came and asked when she was going to get her medications. she immediately notified the DON or ADON, they stopped, assessed the patient, and sent out 911. She held some of the blood pressure medications, she gave one of the meds that was able to be given with her blood pressure being in the parameters. When [V3 DON] comes in she will bring in the info, she can tell you for sure what she was given. We know exactly the medications that were given because they were checked off in the MAR for the resident who should have received them. (R4's eMAR showed all medications as refused by R4. Nothing was documented as being given.On 2/10/26 at 10:47 AM, V3 DON (Director of Nursing) said, I was alerted by the nurses that [V9 LPN] had administered the medication to the wrong patient. They assessed the patient and because her blood pressure was lower, they sent her out . the bp was the reason why she was sent out. Immediately, we checked the MAR (medication administration record) to see what the medication she was given was. We called the doctor right away; the Medical Director was here in the facility at the time and she was made aware of the incident. We started in-servicing right away. We asked the nurse what happened, she pretty much said that she asked the resident if her name was the other resident's name and she nodded that yes, she was. She said she looked at the picture in the MAR and it looked like the resident. [R1] received [R4's] medications. R1 received venlafaxine, furosemide, aspirin, Entresto, iron, omeprazole, oxybutynin, and Procardia. She also received her own medications that day, she takes Bumex. She doesn't take blood pressure medications.On 2/10/26 at 2:06 PM, V11 (Medical Director) said, There was a medication error, It happened right in front of me actually. I was rounding at that time. The patient was kind of confused, nurse tried checking blood pressure, I tried checking her blood pressure. I was not able to get the blood pressure because it was very feeble. When the paramedics arrived, I think they were able to get one. It was a pretty low hypotensive number. I talked to them that morning regarding that this should not have happened. The facility's policy and procedure dated 03/2021 showed, Medication Administration: General Guidelines. Policy: To ensure that medications are administered safety as prescribed. All medications shall be administered as prescribed by personnel authorized to do so in accordance with standard practice and current regulations. The resident is identified prior to administration by: a. Checking the photograph of the resident and/or; b. Asking the resident to identify him/herself by name. 7. Medications prescribed for one resident shall not be administered to another resident.The facility's Medication Pass (Guidelines/Tips) dated 12/2024 showed, Competency. 7. Nurse must always identify the resident prior to administering any medications or treatments. 9. All medications must be given in the correct strength, route, dosage form, time and to the correct resident.

Based on observation, interview and record review the facility failed to ensure insulin pens were labeled and dated when opened and disposed of when expired, and failed to ensure the medication refrigerator temperature was checked twice a day for 4 of 4 residents (R11, R14, R22 and R23) reviewed for medication storage in the sample of 23. The findings include: On [DATE] at 8:55 AM the 3rd floor medication cart for residents in rooms 3117-3128 was checked with this surveyor and V10 (Licensed Practical Nurse/LPN). Inside the cart was an open Novolog insulin pen labeled as belonging to R14. There was a sticker on the outside of the insulin pen to write the open and expiration dates on but those were blank. Inside the same medication cart was a Novolog insulin pen belonging to R11 the expiration date on the pen was listed as [DATE]. On [DATE] at 8:58 AM, V10 said insulin pens should be dated when they are open and have an expiration date of 28 days. V10 said someone must have opened the insulin pen for R14 and forgot to label it. V10 also said that insulin pens should be disposed of when it is past the expiration date. R11's Medication Administration summary shows he received Novolog insulin at least daily between 7/14-[DATE]. On [DATE] at 9:09 AM, the medication room was on the 3rd floor was checked with this surveyor and V2 (Director of Nursing/DON). There was a refrigerator in the room that had a Medication Refrigerator Temperature Log hanging on the outside of it. The log shows that temperatures for the refrigerator should be checked twice daily. The log sheet shows one signature per day from [DATE]-[DATE], and nothing documented after [DATE]th. Inside the refrigerator were numerous Novolog insulin pens belonging to R11 and R14. Also inside were Humalog Lispro insulin pens belonging to R22 and Aspart insulin pens belonging to R23.On [DATE] at 9:12 AM, V2 (DON) said the refrigerator in the medication room is primarily used to store insulins and other liquid medications that require refrigeration. V2 said the refrigerator temperature should be checked by the nurses and documented 2 times a day to ensure that medications are being stored at the proper temperature. The facility provided Prefilled Insulin Multi-Dose Pen policy dated 3/2021 shows insulin pens should be dated when open and include an expiration date and staff initials and discarded when expired.

Based on observation, interview, and record review the facility failed to ensure residents oxygen equipment was changed and labeled for 4 of 5 residents (R6, R7, R12, R19) reviewed for oxygen use in the sample of 23. The findings include: On 7/21/25 at 9AM, R6 was in bed with oxygen via nasal cannula connected to an oxygen concentrator. R6's oxygen tubing was not dated. V12 (License Practical Nurse-LPN) said oxygen tubing should be labelled and dated to know when they will be changed. R6's July Physician orders shows Oxygen per nasal cannula 2-5 liters per minute continuous related to COPD (Chronic Obstructive Pulmonary Disease). Oxygen Tubing - Change monthly night shift and as needed. 2. On 7/21/25 at 8:45 AM, R7 was in bed with oxygen via nasal cannula connected to a concentrator. R7's oxygen tubing was not dated. V15 Certified Nursing Assistant-CNA who was at bedside said she does not know who changes and dates/label the oxygen tubing, maybe the nurses. R7's July Physician orders shows Oxygen per nasal cannula 2-4 liters per minute continuous. Oxygen Tubing - Change monthly night shift and as needed. 3. On 7/21/25 at 9:15 AM, R12 was in bed wearing oxygen via nasal cannula that was undated. R12's July Physician orders shows Oxygen per nasal cannula 2-5 liters per minute as needed. Oxygen Tubing - Change monthly night shift and as needed. 4. On 7/21/25 at 8:41 AM- R19 was sitting in dining room. Oxygen on via portable tank. Oxygen tubing was not dated or labeled. R19's July Physician orders shows Oxygen per nasal cannula 2-5 liters per minute as needed. Oxygen Tubing - Change monthly night shift and as needed. R19's July Physician orders shows Oxygen per nasal cannula 2-4 liters per minute as needed. Oxygen Tubing - Change monthly night shift and as needed. On 7/22/25 at 8:50 AM, V17 (Registered Nurse-RN) said oxygen tubing should be labeled and dated to show when they were changed. They are to be changed monthly. On 7/21/25 at 10:11 AM, V4 (Assistant Director of Nursing) Nurses are responsible for dating and changing oxygen tubing some are weekly some monthly depending. V4 stated I do 2nd floor and the former DON (V3) did 3rd floor. We do audit floors and tubing. V3 left last Friday 7/18/25 so 3rd floor might have got missed. Night shift should change out tubing. The facility policy on Oxygen Therapy Devices-nasal cannula documents, oxygen delivered per nasal cannula will be used to prevent or reverse hypoxia and improve tissue oxygenations. 4. A nasal cannula will be changed monthly and PRN (as needed).

Based on observation, interview and record review, the facility failed to ensure staff were wearing the right personal protective equipment to follow enhance barrier (EBP) precautions to 1 of 3 residents (R6) reviewed for EBP in the sample of 23. The findings include:R6's electronic face sheet show R6 has diagnoses of benign prostatic hyperplesia, retention of urine, and suprapubic catheter. R6's Physician Order Sheet dated 7/25 documents EBP For Device Care or Use of Urinary Catheter. On 7/21/25 at 9AM, a sign outside R6's room show EBP: wear gown and gloves for a high contact resident care activities V11 (Certified Nursing Assistant-CNA) was with R6 providing morning care, incontinence care/hygiene and changing R6's incontinent brief. V11 (CNA) was only wearing gloves and was not wearing a gown. V12 (License Practical Nurse (LPN) was with this surveyor. V12 said R6 was on EBP due to R6 having a suprapubic catheter. Staff including V11 (CNA) should be wearing gown and gloves when providing care to R6. Wearing the right PPE can prevent the spread of infection or cross contamination. The Facility Policy entitled Enhanced Barrier Precautions (EBP) dated 12/24 show, EBP are on infection control intervention designed to reduce transmission of multidrug resistant organism (MDRO) in nursing homes. As well as to prevent MDRO acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. 1. High contact resident care activities include the following: providing bathing, hygiene changing briefs. 2. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP.

Based on interview and record review the facility failed to ensure a resident was free from a significant medication error by missing doses of a blood thinner (Warfarin) which applies to 1 of 4 residents (R1) reviewed for significant medication error in a sample of 4. The findings include: R1's Admission Record showed R1 is an eighty-two-year-old male resident originally admitted to the facility with diagnoses which include: peripheral vascular disease and a history of pulmonary embolism (blood clot in lungs). R1's March 2025 Warfarin Worksheet showed on 3/24/25 V4 R1's Primary Care Physician was notified of R1's Protime results and an order to continue the order for Warfarin 3 milligrams (mg) was given. R1's March 2025 Medication Administration Record (MAR) showed no order for Warfarin 3mg was entered on 3/24/25. R1's MAR showed R1 missed 4 doses of Warfarin from 3/24/25 through 3/27/25. R1's MAR showed the next order for Warfarin was entered on 3/28/25 for the same dosage of 3mg. On 3/30/25 at 9:30 AM, V6 LPN stated Warfarin needs to have lab draws to monitor if it is therapeutic or not. Protime/INR blood tests are used to monitor the medication. We have a binder at the desk we use to verify the current order, when we contact the physician, lab results, verification of the new order, and what date the new order is entered into the computer. V6 stated if someone misses doses of their blood thinner they are at a higher risk for developing blood clots. R1's March Warfarin Worksheet showed an entry for 3/24/25 with a Protime/INR result of 21.5/2.8, V4 R1's Primary Care Provider (PCP) was notified, and a new order for Warfarin 3mg to be continued. This worksheet showed on 3/31/25 R1's Protime/INR was 16.5/1.7, and a new order was given by V4 for Warfarin 3.5mg. There was not entry for an order, physician contact, or lab result dated 3/28/25. On 4/30/25 at 10:20 AM, V4 R1's PCP (Primary Care Physician) stated he did not receive a call or text for a Warfarin order on 3/28/25. V4 stated they were reviewing their records during the phone interview. V4 stated he gave an order for 3mg of Warfarin on 3/24/25, and a new order for 3.5mg on 3/31/25 for a PT/INR of 16.5/1.7. V4 stated therapeutic levels for Warfarin should be an INR of 2.0 to 3.0. V4 stated the lab result is consistent with R1 missing several doses of blood thinners. V4 stated by not taking Warfarin regularly it can put someone at a higher risk for developing blood clots. R1 has been on Warfarin for a long time for previously having pulmonary embolisms. On 3/30/25 at 12:40 PM, V2 Director of Nursing stated R1's Warfarin order were not continued from 3/24/25 through 3/27/25. V2 stated R1 did not receive their blood thinners for those dates. If a resident misses their blood thinners it puts them at risk for developing blood clots. The facility's Medication Administration Policy dated 9/2020 stated medications will be administered in accordance with the established polices and procedures.

Based on interview and record review the facility failed to ensure a physician ordered medication was continued for a resident with a history of pulmonary embolisms. This applies to 1 of 4 residents (R1) reviewed for pharmacy services in the sample of 4. The findings include: R1's Admission Record showed R1 is an eighty-two-year-old male resident originally admitted to the facility with diagnoses which include: peripheral vascular disease and a history of pulmonary embolism (blood clot in lungs). R1's Progress notes dated 3/24/25 at 5:58 PM showed V9 Licensed Practical Nurse (LPN) related the blood thinner lab result (PT/INR) to V4 R1's Primary Care Physician (PCP), and received an order to continue R1's blood thinner (Warfarin) at 3 milligrams (mg). R1's Progress Notes dated 3/28/25 at 7:47 PM showed V9 entered an order for Warfarin 3mg. The order was entered 4 days later. R1's March 2025 Medication Administration Record (MAR) showed no order for Warfarin at 3mg was entered on 3/24/25. R1's MAR showed R1 missed 4 doses of Warfarin from 3/24/25 through 3/27/25. R1's MAR showed an order for Warfarin 3mg was entered on 3/28/25 which R1 started receiving. On 3/30/25 at 9:30 AM, V6 LPN stated if there is a problem with a medication order (dose, wrong time, allergy, etc) the physician should be contacted to verify the order. If a resident has received an wrong dose or missing doses of medications the physician should be called to verify a new order and/or if a residents medication order needs to be changed. V6 stated for Warfarin orders there is a binder at the desk we use to verify the current order, when we contact the physician, lab results, verification of the new order, and what date the new order is entered into the computer. On 4/30/25 at 10:20 AM, V4 R1's PCP (Primary Care Physician) stated he did not receive a call or text for a Warfarin order on 3/28/25. V4 stated they were reviewing their records during the interview. V4 stated he gave an order for 3mg of Warfarin on 3/24/25, and a new order for 3.5mg on 3/31/25 for a PT/INR of 1.7. On 3/30/25 at 12:40 PM, V2 Director of Nursing stated they were not sure why R1's Warfarin orders were not continued from 3/24/25 through 3/27/25. V2 stated R1 did not receive their blood thinners for those dates.

Based on interview and record review the facility failed to notify a resident and a resident's primary care physician (PCP) of missed medication doses for 1 of 4 residents (R1) reviewed for notification in the sample of 4. The findings include: R1's Admission Record showed R1 is an eighty-two-year-old male resident originally admitted to the facility with diagnoses which include: peripheral vascular disease and a history of pulmonary embolism (blood clot in lungs). R1's March 2025 Medication Administration Record (MAR) showed from March 24 through March 27,2025, R1 did not receive their Warfarin (blood thinner) doses. The MAR showed no order for Warfarin in R1's record for March 24th through March 27th. The MAR showed R1 had an order placed on 3/28/25 with a new order for Warfarin 3mg to give 1 tablet at bedtime related to personal history of pulmonary embolism. On 4/30/25 at 10:05 AM, R1 stated they knew they were on a blood thinner. R1 stated he did not remember anyone telling him he missed any of his medication doses. On 4/30/25 at 10:20 AM, V4 R1's PCP (Primary Care Physician) stated he did not receive a call or text for a Warfarin order on 3/28/25. V4 stated they were reviewing their records during the interview. V4 stated he gave an order for 3mg of Warfarin on 3/24/25, and a new order for 3.5mg on 3/31/25. V4 stated he had not been notified R1 had missed any doses of their Warfarin between 3/24/25 and 3/31/25. V4 stated if he were contacted about any missed doses, he would have ordered labs to be drawn, and a new order based on the lab results. On 4/30/25 at 11:30 AM, V8 R1's Emergency Contact (Family) stated the facility has contacted them in the past when R1 has gone to the hospital and when R1 was put on isolation. V8 stated they have not been notified R1 had any missed medication doses. R1's progress notes dated 3/28/25 at 7:47 PM showed V9 placed an order was for Warfarin 3mg. This progress note has no reference regarding notifying R1's physician at that time for not being admistered the physician ordered medication doses. On 4/30/25 at 12:40 PM, V2 Director of Nursing stated, the physician should have been notified about the missed medication doses when it was realized R1 did not receive them.

Based on observation, interview, and record review the facility failed to ensure food preparation was completed in a manner to prevent cross contamination. This applies to 15 of 15 residents (R4, R14, R79, R119, R36, R61, R5, R97, R52, R449, R3, R107, R82, R70, R240) reviewed for cross contamination in the sample of 29. The findings include: On 3/6/25 at 1:00 PM, the facility provided a list of residents on a pureed diet which included R4, R14, R79, R119, R36, R61, R5, R97, R52, R449, R3, R107, R82, R70, and R240. On 3/4/25 at 10:40 AM, V5 (Executive Chef) was preparing the pureed foods for service. V5 placed a glove on his right hand and scooped servings of meatballs into a container to take to the blender. V5 took the container of meatballs to the blender and used his gloved hand to scoop the meatballs into the blender. V5 removed the glove from his right hand. No hand hygiene was completed. V5 completed the puree process pushing the buttons on the blender, touching the containers, the lid to the blender, and the handles of the utensils. V5 then scooped the servings of pureed meatballs into separate containers for the steam table. V5 went to the other side of the counter and removed a magnetic folding thermometer off the vent hood. V5 used his bare hands to open the thermometer (touching the thermometer probe) and placed the probe directly into the pureed meatballs without wiping the probe. V5 touched his uniform to remove a marker from his pocket and label the pureed meatballs. V5 started pureeing the noodles, touching the utensils and the containers, pulling at his uniform and touching his mask. Once completed, V5 went across to the other side of the counter and took another thermometer off the vent hood. Again, V5 used his bare hands to open the folding thermometer, touching the probe and not wiping the probe with alcohol prior to checking the temperature of the pureed noodles. V5 again touched his uniform to remove a marker from his pocket and label the pureed noodles. V5 proceeded to puree the vegetables in the same manner. No hand hygiene was performed during the duration of the puree process or temping of the pureed foods. On 3/6/25 at 11:06 AM, V6 (Dietary Supervisor) said handwashing or hand hygiene should be done in between tasks, anytime they are going from one task to another and all thermometers should be wiped with alcohol prior to introducing them into food products to prevent cross contamination. The facility's policy and procedure with review date of 3/18 showed, Handwashing . To reduce the risk of food borne illness through cross contamination . The facility's policy and procedure with review date of 7/2018 showed, Taking Temperatures of Food . Purpose: To reduce the risk of food borne illness from undercooking or improper holding . After taking the temperature of any food, sanitize the probe to reduce the risk of cross contamination.

Based on observation, interview, and record review the facility failed to ensure a video posted to a staff member's personal social media account did not include identifiable resident images and the facility failed to ensure residents at a dining table were served at approximately the same time. This failure applies to five residents R77, R24, R25, R62 and R120 reviewed for resident rights on the total sample list of 29. The findings include: 1. R77's Admission Record (Face Sheet) documents an admitted [DATE] with diagnoses including senile degeneration of the brain, anxiety, and depression. R77's 2/13/25 Quarterly Minimum Data Set (MDS) showed he had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. On 3/6/25 at 11:08 AM, V15 Memory Care Executive Director confirmed that V23 Memory Care Director posted a video of a code blue drill to his personal social media account. V15 stated that while the video was intended to feature V23, it also depicted R77. V15 confirmed the facility did not authorize the posting and that such posting to a personal social media account is not an approved use under the facility's consent policy. V15 expressed concern regarding resident dignity. On 3/6/25 at 11:27 AM, V1 Administrator stated she was aware of the incident with R77. V1 stated she did not view the video, she understood it depicted a resident. V1 said she did not believe it was V23's intent to show a resident in the video and it was an accident. V1 said, I don't think anyone should be scrolling through and see a family member in a social media post. V1 said posting a video to a staff member's personal social media account, which shows resident's, would not be respecting the resident's dignity. V1 said V23 should have been more careful. On 3/6/25 at 11:42 AM, V23 said he posted the video of the code blue drill to his personal social media account. V23 said he was notified by staff that they did not want to be in the video, so the video was deleted. V23 said the R77's face was not visible; however, the side profile of his face was visible in the video. V23 said he did not believe there was a policy stating he could not post videos of residents to her personal social media page. V23 said, twice, I would have to get the resident or family's permission and if I did get that permission, I could post it [a video with residents] to my own personal [social media video] page. The facility's Social Media Policy (undated) showed, Employees may not use or disclose any resident identifiable information of any kind on any social media site. This includes photographs of residents. Even if an individual is not identified by name within the information you wish to use or disclose, if there is a reasonable basis to believe that the person could still be identified from that information, then its use or disclosure could constitute a violation of the Health Insurance Portability and Accountability Act. On 3/6/25 at 12:18 PM, stated the facility uses the Ombudsman program resident right pamphlet as their dignity policy. The State of Illinois Residents' Rights for People in Long-term Care Facilities showed, Your facility may not give information about you or your care to any unauthorized person(s) without your permission. R77's [The Facility's] Photo Consent, signed 3/10/2020, showed I give [the facility] consent to use my loved one's likeness to be used for Activity Photo Purposes and to be sent out via Family Newsletter. The consent does not show staff's personal social media pages as an accepted posting site. 20042 2. On 3/5/25 at 10:30 AM during the Resident Council Group Meeting they stated when sitting at their table for meals one person maybe served and then 45 minutes later another person at the table will get served. They stated they were all at the table at the same time when this happens. They stated their food should be served at the same time so they can eat together. On 3/6/25 at 11:19 AM, R24 was sitting in her wheelchair at the dining room table and was served her lunch. At 11:22 AM, R62 arrived at the dining room in her wheelchair and sat at the table with R24. At 11:26 AM, R25 came into the dining room in her wheelchair and sat at the table with R24 and R62. At 11:29 AM, R120 walked into the dining room and sat in a chair at the dining room table with R24 and R62. At 11:39 AM, R62 was served her drinks and lunch. At 11:41 AM, R25 was served her lunch and drinks. At 11:47 AM, R120 was served her drinks, her main meal of spaghetti and vegetables. R120 did not receive her mashed potatoes or dessert. R120 did not have any silverware. On 3/6/25 at 11:48 AM, V21 (Activity Aide) stated the first people into dining room get served first. Then it gets busy and sometimes it takes longer. It also takes longer if we don't have enough of the dishes for someone that orders something else. Today some dishes needed to go down to be cleaned. They didn't get cleaned from this morning; so there aren't enough dishes. R120 is waiting for her mashed potatoes and fruit because there aren't enough plates/bowls to serve it. This happens frequently. Sometimes one person at a table will get food and then 30 minutes later someone else will get their food. I have had people complain about it so I told V6 (Dietary Supervisor). It tends to happen more at dinner. On 3/6/25 at 11:51 AM, R24, R25, R62 and R120 stated they should get served at the same time and did not like being served at different times. They stated they wanted to be able to eat their meals together. R120 continued to wait for silverware. R24 stated they did not have enough clean dishes to give R120 her food (mashed potatoes and dessert). At 11:53 AM, R120 stood up and walked to the middle of the dining room. V22 (Activity Aide) asked R120 if she was okay and if she needed anything. R120 replied that she needed silverware. At 12:03 PM, R24 called V22 over to the dining room table to remind V22 that R120 still had not received her mashed potatoes. At 12:05 PM, V22 brought R120 her mashed potatoes. R120 still did not receive her dessert. R120's meal ticket dated 3/6/25 for the lunch meal showed she was supposed to receive cookies as a dessert. At 12:11 PM, V22 was asked if R120 could get her dessert. V22 looked at R120's meal ticket and stated she is supposed to receive cookies for dessert. At 12:12 PM, V22 brought R120 her cookies. The meal ticket dated 3/6/25 for R120 showed she was supposed to receive spaghetti, vegetable, mashed potato, desert, water, gingerale and fruit. R120 never received any fruit. On 3/6/25 at 12:17 PM, V6 (Dietary Supervisor) stated meals times are 7:00 AM for breakfast, 11:00 AM for lunch, and 4:30 PM for dinner. V6 stated anyone that comes into the dining room first is served first V6 stated they start doing the room trays. They try to get through as quickly and accurately as possible. V6 stated there are standing orders on residents meal tickets. V6 stated they can flip the meal ticket over to the other side and circle what they want for meals. V6 stated staff will read the ticket and they serve the food according to what is on the ticket as long as it follows the residents dietary recommendations. V6 stated he was not aware of residents waiting for food unless they were residents that needed to be fed. V6 stated he was not aware of not having enough clean dishes to serve food to residents. V6 stated he was aware that residents seated at a table together wanted to be served together at the same time. The MDS (Minimum Data Set) dated 1/13/25 for R120 showed no cognitive impairment. The MDS dated [DATE] for R25 showed no cognitive impairment. The MDS dated [DATE] for R62 showed no cognitive impairment. The MDS dated [DATE] for R24 showed no cognitive impairment. The facility's Dining Room Meal Service policy (3/18) showed food will be served in a manner that is appealing to the senses. meals are delivered to the resident by the assigned staff for the dining room. The policy did not show all residents at a table would be served together. The Residents' Right for People in Long-term Care Facilities brochure by the Illinois Long Term Care Ombudsman Program ( 4/24) showed, you have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Your facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for the administration of oxygen for 1 of 5 residents (R38) reviewed for respiratory care in the sample of 29. The findings include: R38's electronic face sheet printed on 3/6/25 showed R38 has diagnoses including but not limited to acute respiratory failure with hypoxia, sepsis, chronic diastolic congestive heart failure, and dysphagia. R38's physician's orders dated 2/20/25 showed, Oxygen per nasal cannula at 2-4 liters per minute continuous. R38's care plan dated 12/30/24 showed, (R38) requires oxygen therapy .administer oxygen per physician's orders. On 3/4/25 at 9:53AM, V9 and V10 (Certified Nursing Assistants-CNA's) provided personal cares to R38. Upon completion of personal cares, V10 applied oxygen via nasal cannula at 4L to R38. V9 and V10 stated the CNAs are allowed to administer oxygen and it is not a physician's order. V10 stated the CNAs are able to look in their task list to see what liter flow the residents are supposed to be on. On 3/6/25 at 10:15AM, V7 (Registered Nurse) stated, (R38) is on continuous oxygen due to her congestive heart failure. The nurse's usually set and apply oxygen for the residents, but I think the CNA's can do it as well. Usually, they come and ask the nurses to verify the liter flow, but I don't see any reason why they can't do it. It's a simple procedure. On 3/6/25 at 11:41AM, V2 (Director of Nursing) stated, Oxygen is to be applied by the nurse's only because it's out of the CNA's scope of practice. The nurse is the only one who can ensure the oxygen is set at the correct liter flow according to physician's orders. The facility's policy titled, Oxygen therapy devices-nasal cannula dated 02/11 showed, 1. Verify physicians order .these guidelines are not meant to be excusive or exhaustive. Guidelines are meant to leave room for the exercise of professional judgement based on individual circumstances.

Based on observation, interview and record review, the facility failed to perform a dressing change for a resident with a surgical incision in a manner to prevent cross-contamination, and failed to ensure enhanced barrier precaution (EBP) signage was on or near the doorway to a resident's room for a resident with an IV (intravenous) midline for to two of two residents (R242 and R130) reviewed for infection control in the sample of 29. The findings include: 1. R242's Admission Record, printed by the facility on 3/6/25, showed she had diagnoses including, but not limited to, displaced intertrochanteric fracture of right femur with subsequent encounter for closed fracture with routine healing (right hip fracture and surgical procedure to repair), anxiety disorder, muscle weakness, presence of left artificial knee joint, primary osteoarthritis, and glaucoma. The Admission Record showed no diagnosis of dementia, Alzheimer's disease, or other cognitive dysfunction. R242's initial Nursing assessment dated [DATE] showed she was alert and oriented to person, place and time with no confusion. On 3/6/25 at 9:08 AM, V8 (Registered Nurse-RN) performed a dressing change to the surgical wound on R242's right hip. V8 applied saline to all 3 wounds and then used the same gauze, and the same section of gauze to dab the lower incision, then the middle incision, then the upper incision. V8 used the same gauze, same section of gauze to go back and dab the middle and lower incisions, and then back up to dab the middle and upper incisions again. V8 did not use a different gauze for each site, and did not change gloves, or perform hand hygiene between incisions. On 3/6/25 at 9:59 AM, V11 (Wound Nurse) said whenever you do a dressing change, the wound should be cleaned with normal saline or soap and water. You clean one incision site then discard the gauze. V11 said a clean gauze should be used for each incision to prevent infection and cross-contamination. R242's March 2025 Treatment Administration Record, showed an order dated 2/27/25 to change the dressing on R130's right hip three days after surgery, daily on day shift. The facility's 3/4/2021 policy and procedure titled Wound Care (Surgical) showed sterile dressing and sterile technique should be used for fresh post op-patients. Often the original dressing applied in the operating room is left in place for the first 48 hours .Thereafter 1. Utilize clean/aseptic technique .3. Undress and expose only one area at a time. 4. Change dressings in order from clean to dirty. 5. After performing hand hygiene, with clean gloves, remove dressings one layer at a time, observing appearance and drainage on dressing. 6. Inspect wound for appearance, drainage, and integrity. Any sutures or staples and how many were used . 9. Perform hand hygiene. 10. Cleanse area following doctor's orders. 11. Perform hand hygiene. 12. Follow doctor's orders and apply new dressing. 13. Perform hand hygiene. 2. R130's Admission Record, printed by the facility on 3/6/25, showed she had diagnoses including, but not limited to, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypercapnia (occurs when the body cannot remove excess carbon dioxide from the bloodstream, causing it to build up), and hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), bronchiectasis (a disease in which there is permanent enlargement of parts of the airways of the lung-symptoms can include a chronic cough with mucus production, shortness of breath, coughing up blood, and chest pain), severe protein-calorie malnutrition, essential (primary) hypertension, atherosclerotic heart disease, atrial fibrillation, atrial flutter, emphysema, and dependence on supplemental oxygen. R130's Order Summary Report, printed by the facility on 3/6/25, showed she had an IV (intravenous) midline. The report showed an active order dated 2/27/25 for EBP for device care or use of midline. The report also showed an order for Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM. Use 4.5 gram intravenously every 6 hours for pneumonia for 4 Days start 3/5/25. end date 3/9/25. R130's 2/15/25 facility assessment showed she was cognitively intact. On 3/4/25 at 9:19 AM, R130 was in her room sitting up in bed receiving a nebulizer treatment. An IV pole was positioned next to R130's bed. No signage showing R130 was on enhanced barrier precautions was posted on or near R130's doorway. At 10:40 AM, when surveyor left the second floor, there was still no EBP signage on R130's doorway. At 12:17 PM, when surveyor went back up to the second floor to watch V12 (Licensed Practical Nurse-LPN) remove the completed antibiotic medication that had been administered through R130's IV midline, signage was now posted on R130's doorway showing she was on EBP precautions. At 12:27 PM, V12 performed hand hygiene and put on the appropriate PPE (personal protective equipment). V12 removed the tubing for the empty antibiotic bag. Prior to exiting R130's room, V12 removed the gown and gloves and was looking around R130's room and bathroom for an isolation bin to dispose of the PPE. After V12 exited the room, R130 said the nurse's usually do not wear a gown when they are doing anything with her IV. R130 said they wear a face mask and gloves. On 3/5/25 at 8:43 AM, there was no sign showing R130 was on EBP on or near her doorway again. At 9:15 AM, the signage was back up on R130's doorway. V1 (Administrator) was asked what would qualify a resident to be on enhanced barrier precautions. V1 said a resident is placed on EBP precautions if they have a catheter, an IV, a draining wound that cannot be contained. V3 (Infection Preventionist/Assistant Director of Nursing) walked up and added if a resident has recurrent ESBL and cannot be contained, or a chronic wound they would also be placed on EBP precautions. V3 was informed that there was no signage on R130's doorway in the morning the previous day, then around noon signage was observed on R130's doorway, and again that morning (3/5/25) there was no signage on R130's doorway when this surveyor arrived on the second floor. V3 said R130 changed rooms yesterday and the census had not been updated. V3 said she removed the sign, then did an audit that morning (3/5/25) and put the signage back up. On 3/5/25 at 9:25 AM, V13 (Registered Nurse-RN) confirmed that the EBP signage was not on R130's door when she started her shift at 7:00 AM that morning (3/5/25). V13 said V3 put the sign on R130's door around 9:00 AM. On 3/6/25 at 8:55 AM, V3 (Infection Preventionist/ADON) said R130 was on EBP precautions due to having a midline IV. The facility's 12/2024 policy and procedure titled Enhanced Barrier Precautions showed Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. As well as to prevent multidrug-resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device .1. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. The policy showed Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP.

Based on observation, interview, and record review the facility failed to ensure R74's indwelling urinary drainage bag was maintained in a manner to prevent contamination and kept below the level of the bladder for 1 of 2 residents (R74) reviewed for catheters in the sample of 29. The findings include: On 3/4/25 at 10:10 AM, R74 was sitting in a motorized wheelchair in her room. R74's catheter tubing was visible an had cloudy, yellow urine present with sediment. R74 had a dignity cover on her drainage bag that covered the top half of the drainage bag. The lower half of the drainage bag was visible and laying on her [NAME] rest behind her feet. R74 stated the drainage bag slips out the bottom all of the time. Discussed the drainage bag laying on her foot rests and R74 stated no one ever told her that it should not be there or explained anything related to infection control. R74 stated she wished there was a way to keep the drainage bag completely covered. R74 stated the drainage bag was on her foot rest because she doesn't like to keep it attached to the arm of her wheelchair because her catheter doesn't drain like it should. R74 stated the drainage bag is attached to the armrest of her wheelchair when she goes to meals. On 3/4/25 at 11:38 AM, R74 was sitting in her motorized wheelchair in the dining room. The catheter drainage bag was attached to the armrest of her wheelchair and was not below the level of the bladder. The Progress Notes for the Month of February 2025 through 3/5/25 did not show any education given to the resident related to her indwelling urinary catheter and infection control such as keeping the bag off the foot rests and floor or to keep the bag below the level of the bladder. The Face Sheet dated 3/5/35 for R74 showed diagnoses including acute kidney failure, methicillin resistant staphylococcus aureus, cellulitis of right lower limb, type 2 diabetes mellitus, muscle weakness, abnormalities of extremities and gait, chronic venous hypertension, anemia, chronic kidney disease, peripheral vascular disease, hypertension, and congestive heart failure. The Physician Orders dated 3/5/25 for R74 showed, may use indwelling urinary catheter size 16, size 10 balloon due to urine retention per urologist; indwelling urinary catheter care daily and as needed; may change catheter bag as required due to sediment, staining, or contamination. The MDS (Minimum Data Set) dated 1/13/25 for R74 showed no cognitive impairment; dependence for toileting hygiene and lower body dressing; and substantial/maximal assistance needed for upper body dressing. The Care Plan dated 1/19/25 for R74 showed, R74 requires the use of an indwelling catheter. Catheter care per orders. Keep drainage bag covered to promote privacy. The care plan did not show any intervention related to keeping the drainage bag below the level of the bladder and to keep the drainage bag off the floor/foot rests. The facility's Indwelling Catheter Policy (9/2020) showed, Place drainage bag below the level of the resident's bladder to facilitate drainage and minimize stasis of urine. A sterile, continuously closed drainage system will be maintained for indwelling and suprapubic catheter systems.

Based on observation, interview, and record review, the facility failed to obtain daily weights for a resident (R38) with congestive heart failure, failed to assess and perform dressing changes for a resident with a surgical wound (R242), failed to provide skin care for a resident with reddened skin (R86). These failures apply to 3 of 4 residents reviewed for quality of care in the sample of 29. The findings include: 1. R38's electronic face sheet printed on 3/6/25 showed R38 has diagnoses including but not limited to acute respiratory failure with hypoxia, sepsis, chronic diastolic congestive heart failure, and dysphagia. R38's physician's orders dated 2/21/25 showed, Daily weight notify physician if patient gains more than 5lbs (pounds) in a week. R38's care plan dated 2/21/25 showed, (R38) has a diagnosis of CHF (Congestive heart failure), has potential for impaired gas exchange, edema, and respiratory distress .(R38) utilizes diuretic to manage edema and is therefore with a potential for dehydration .monitor for fluid excess (weight gain, elevated blood pressure .monitor weight as ordered . R38's progress notes dated 12/28/24 showed, admitted to facility from local hospital due to CHF exacerbation, BLE (bilateral lower extremity) swelling .on fluid restriction . R38's weight log showed R38's weight was not obtained on 2/27/25. R38's weight on 2/28/25 was 164.2lbs which was a 5.4lb weight gain within 48 hours. Additionally, R38's weight was not obtained on 2/23/25 or 3/2/25 as ordered by R38's physician. On 3/6/25 at 10:15AM, V7 (Registered Nurse) stated, (R38) has congestive heart failure and she has orders for daily weights to be performed and we should notify her physician if she gains more than 5lbs in a week. If daily weights are not done, she could go into fluid overload and experience CHF exacerbation. The weights are a starting point for us so if there is an increase in weight, we would do further assessments on her to ensure she is not in exacerbation. On 3/6/25 at 11:41AM, V2 (Director of Nursing) stated, The CNA's (Certified Nursing Assistants) and nurse's work together to obtain the weights. Either staff member can enter the weights but for a CHF resident, the nurse will have to enter it on the medication administration record because it is a physician's order. As managers we make sure the weights are getting done. It is important to obtain weights on a resident with CHF to ensure they are not going into fluid overload or becoming dehydrated. On 3/6/25 at 12:13PM, V4 (R38's physician) stated, If a resident has an acute decompensation, then we would need the daily weights to determine their fluid status and to ensure they do not become dehydrated or overloaded with fluid. I would prefer they would do it as ordered but it's not a huge jump for her when they missed a day. I would like them to obtain consistent weights to determine their trend. If you lose the consistency, then you can't see the trend. The facility's policy titled, Weights dated 09/2020 showed, Residents will be weighed to establish baseline weights and identify trends of weight loss or weigh gain. 34491 2. R242's Admission Record, printed by the facility on 3/6/25, showed she had diagnoses including, but not limited to, displaced intertrochanteric fracture of right femur with subsequent encounter for closed fracture with routine healing (right hip fracture and surgical procedure to repair), anxiety disorder, muscle weakness, presence of left artificial knee joint, primary osteoarthritis, and glaucoma. The Admission Record showed no diagnosis of dementia, Alzheimer's disease, or other cognitive dysfunction. On 3/4/25 at 9:40 AM, R242 was sitting up in bed. R242 was alert and oriented. R242 said she had been at the facility for five days. R242 said the dressing to her right hip has not been changed since she was admitted to the facility. R242 said the dressing should have been changed. At 12:14 PM V14 (Certified Nursing Assistant/CNA) assisted R242 with rolling onto her left side and pulling down her pants so an observation of her right hip dressings could be observed. R242's right hip had two areas with white dressings. A large (transparent) dressing covered the entire surgical area. R242 said that is the bandage that was put on in the hospital. V14 agreed and said that is the same dressing R242 was admitted with. R242's March 2025 TAR (Treatment Administration Record) showed an order to change R242's right hip dressing 3 days after surgery, daily, on day shift. V8 signed off as having done the dressing change to R242's right hip on 3/1/25 and 3/2/25 on the day shift. On 3/5/25 at 8:49 AM, R242 said one of the nurses changed the dressing to her right hip yesterday and did an assessment. R242 said it was the first time it was done since her admission. On 3/5/25 at 4:27 PM, V8 (Registered Nurse-RN) said she was R242's nurse on 3/1/25 and 3/2/25. V8 said she changed the dressing to R242's right hip on 3/1/25 and 3/2/25. V8 was asked what the treatment was to R242's right hip. V8 said she thinks it was a large island dressing. V8 described the dressing as a large white dressing with softer material in the middle and adhesive around the edges. V8 was asked if she did an assessment of R242's surgical wound and documented the assessment. V8 said she assessed R242's surgical wound but did not document an assessment of the wound site. V8 was asked what the surgical site looked like. V8 said she charts by exception and did not see anything concerning that she would need to notify R242's doctor for. V8 said she did not know if she was the first one to remove the dressing from the hospital, and did not know if there was a documented full assessment of the wound site prior to her changing the dressing on 3/1/25. V8 said she did not measure the surgical site. V8 was asked if sutures or staples were used to hold the surgical incision together. V8 said she did not recall, but thinks it was staples. On 3/5/25 at 1:29 PM, V11 (Wound Nurse/RN) said initially the admitting nurse does the initial assessment. They go through the resident's AVS (after visit summary from the hospital) and do a reconciliation with the resident's physician. At 1:33 PM, V11 said if any changes were made to the wound treatments, it would either be documented in the initial assessment, or in the resident's progress notes. On 3/6/25 at 9:08 AM, V8 entered R242's room carrying supplies for her right hip dressing change. V8 had a large white bordered dressing with adhesive edges. R242 had three incisions to her right hip/upper-thigh area from the hip surgery. Staples were used to hold the surgical incisions together. V8 cleaned the areas, then went to apply the dressing. V8 was asked if that was the same type of dressings she used when she did the dressing changes on 3/1/25 and 3/2/25. V8 replied yes. The large white dressing did not cover all three incisions. V8 had to fold over the end of the dressing and go out of the room to get another dressing. V8 returned to R242's room and placed another partial dressing that she had cut over the bottom incision. On 3/6/25 at 9:59 AM, V11 (Wound Nurse) said treatment supplies are kept in the treatment carts. V11 said she was not sure if the facility had any large tegaderm or large transparent dressings. V11 said the facility usually does not get them for stock supplies. V11 identified V24 (Unit Manager/CNA) as the staff responsible for ordering house-stock supplies. V11 said wound assessments are initially done when the patient first arrives. Skin checks are part of the initial assessment. V11 said We do not normally document surgical wounds. V11 said she did an assessment of R242's surgical wound on 3/4/25 (the day the annual survey was initiated). V11 said the information from R242's after visit summary from the local hospital showed her dressing was to remain in place for three days after surgery. V11 said typically there should be an assessment completed and documented the first time the dressing is removed. V11 was asked what day R242's surgery was done. V11 said she would have to look to see when her surgery was done. V11 said if R242's surgery was done on 2/25/25, then the first dressing change should have probably been done on 2/28/25. On 3/6/25 between 10:12 AM-10:30 AM, this surveyor reviewed the treatment carts and medication rooms on the second and third floors with V11. No large tegaderm or transparent dressing were found. V11 said the only large transparent dressings she is aware of are in sealed wound vac kits. V11 said none of the nurses have requested a large transparent dressing from her. V11 said R242's treatment order does not call for a large transparent dressing. During that same period (at 10:16 AM) a review of the facility's central supply room was conducted with V24 (Unit Manager/CNA). V24 said she orders supplies such as bandages, tape, syringes, etc. V24 said the only supplies she cannot order are for IVs (intravenous lines). V24 said the only bandages they have for surgical hip wounds are bordered gauze w/adhesive border. V24 showed this surveyor the dressings. they were the same dressings that V8 placed on R242's right hip during the previously observed dressing change. V24 said she keeps track of the supplies in the central supply room and the facility had not had any large transparent dressings recently. At 10:30 AM, V11 (Wound Nurse) said it is important to assess wounds as soon as possible, so we can monitor progression, or identify any issues such as dehiscence (a surgical complication where a wound partially or completely separates along the incision line) or signs of infection. On 3/6/25 at 1:05 PM, V2 (Director of Nursing/DON) said the dressing changes should be completed as ordered. R242's 2/27/25 after visit summary from a local hospital showed Keep dressing in place for 3 days after surgery, after which you may remove and subsequently cover with clean, dry dressings and change as needed. R242's hospital documents, provided by the facility on 3/6/25, showed her hip surgery was performed on 2/25/25. The operative report from R242's surgical procedure was filed by the surgeon at 10:31 AM on 2/25/25. R242's March 2025 Treatment Administration Record (TAR) showed an order dated 2/27/25 to change R242's dressing on her right hip 3 days after surgery, every day shift. The TAR showed V8 signed off as having done the dressing change on 3/1/25 and 3/2/25. The TAR showed no dressing change was signed off as being completed on 3/3/25. R242's February 2025 TAR showed no dressing change was signed off as being completed on 2/28/25. R242's progress notes were reviewed from 2/27/25-present. The only full assessment of R242's surgical wound was done on 3/4/25 at 1:04 PM (after the start of the annual survey) by V11 (Wound Nurse). The progress note showed Resident's surgical dressing changed. Site is well-approximated. Three incision sites, staples present. Nine staples to proximal incision approximately 5 x 0 x 0. Three staples to next incision approximately 3 x 0 x 0, and three staples to distal incision approximately 3 x 0 x 0. Site is free of signs of infection. No drainage, bleeding, redness, or warmth noted. R242's notes showed no new order to change the date of the dressing change to 3/1/25. R242's Initial Nursing assessment dated [DATE] showed Wound/Skin Condition: Unable to see due to dressing covered. The facility's 3/4/2021 policy and procedure titled Wound Care (Surgical) showed 6. Inspect wound for appearance, drainage, and integrity. Any sutures, staples and how many used .12. Follow MD (Doctor's) orders and apply new dressing .13. Daily evaluate resident for complaints of increasing pain, site for redness, changes in drainage amount, increase in temperature, swelling or induration (an inflammatory process that can make the skin feel firmer or thicker than normal), Report to Surgeon or Physician for further management if applicable. 20042 3. On 3/4/25 at 9:15 AM, V16 CNA (Certified Nursing Assistant) and V17 CNA were at R86's bedside to provide incontinence care. R86 had a wet incontinence brief. V16 opened R86's incontinence brief and his scrotum was reddened. V16 used disposable wipes to clean R86's groin, penis and scrotum. When V16 was wiping R86's scrotum he complained of pain and hissed. R86 stated it was cold and painful. At 9:25 AM, V18 RN (Registered Nurse) came into R86's room, applied a zinc ointment to R86's buttocks but not to his reddened scrotum and then left the room. V17 asked V16 if the nurse was going to apply the ointment to R86's scrotum. V16 did not reply. V16 and V17 put a clean incontinence brief on R86, changes his bed, changes his gown, repositioned him to a sitting position, and covered him. The Progress Notes for R86 dated 3/4/25 did not show any documentation of redness to his scrotum or any treatments applied. The Physician Orders dated 3/5/25 for R86 showed Zinc Oxide Ointment 20%; Apply to buttocks topically every shift for skin condition (use house stock) and apply to buttocks topically as needed for skin condition (use house stock) with an order date of 3/14/24. Nystatin powder 100000 unit/GM, apply to groin topically as needed for skin conditions. Cleanse area with normal saline prior to application. On 3/5/25 at 1:58 PM, V19 CNA (Certified Nursing Assistant/Unit Manager) stated if a resident has redness to their skin it is to be reported to the nurse immediately. The nurse will come in and depending on what the nurse think needs to be done they will put a cream on maybe zinc or whatever the wound nurse thinks is best to apply on resident. On 3/5/25 at 2:06 PM, V2 DON (Director of Nursing) stated if a CNA saw that the resident had a reddened scrotum they would notify the nurse to make sure she is aware. The nurse assess what's going on and would see if there are any orders for that. V2 stated he was not sure what happened or why the nurse did not apply cream or anything for R86's reddened scrotum. V2 stated he would go and check R86's scrotum. On 3/5/25 at 2:14 PM, V2 stated he went and looked at R86's scrotum and it was red but not that red. R86 stated he was fine and it only hurts with cleaning. V2 stated he would do some education on it. The Face Sheet dated 3/5/25 for R86 showed diagnoses including type 2 diabetes mellitus, chronic kidney disease, malignant neoplasm of the prostate, and unspecified protein-calorie malnutrition. The MDS (Minimum Data Set) dated 2/21/25 for R86 showed he is dependent for toileting hygiene and shower/bathing. The Care Plan dated 2/27/25 showed, R86 has the potential for alteration in skin integrity related to need for assistance with care, impaired mobility, and contributing medical diagnosis of type 2 diabetes mellitus, chronic kidney disease, asthma, and long term use of aspirin. R86 is noncompliant with turning and repositioning and poor nutritional intake. R86 prefers to stay in bed. Barrier cream to areas exposed to moisture/incontinence. Inspect skin daily with care. The facility's Prevention and Treatment of Pressure Injury and other Skin Alterations policy (3/2/21) showed non-pressure skin alterations i.e.: skin tears, abrasions, surgical wounds, moisture associated skin dermatitis, lesions and rashes, will be documented weekly on a skin progress note: if you are using electronic health record or on TAR (Treatment Administration Records) if using paper chart. Develop a care plan for either actual or potential alteration in skin integrity and change as needed. At least daily, staff should remain alert for potential changes in the skin condition during resident care. Moisture barrier may be applied as needed. Revise care plan approaches as needed based on resident's response and outcomes.

Based on interview and record review, facility staff failed to implement physician's orders for a resident's (R2's) downgraded diet to mechanical soft, resulting in R2 experiencing a second choking episode. R2 expired in the local hospital on [DATE] from complications of aspiration pneumonia and choking on food. This applies to 1 of 3 residents reviewed for specialized diets in the sample of 8. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R2 experienced a choking episode and R2's nurse practitioner ordered for R2 to receive a mechanical soft diet until he was evaluated by speech therapy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:30PM. While the immediacy was removed on [DATE], noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's electronic face sheet printed on [DATE] showed R2 has diagnoses including but not limited to Parkinson's disease, dementia without behaviors, dysphagia, congestive heart failure, and muscle weakness. R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment and does not receive a mechanically altered diet. R2's physician's orders audit report for [DATE] showed, Mechanical soft texture, thin liquids. (This order was entered on [DATE] at 3:55PM after R2 was sent to the hospital following a choking episode). R2's nursing progress notes dated [DATE] showed, Resident was choking at dinnertime, and he was able to remove all the food. (V7-Nurse Practitioner) here and saw resident at the time after he was done with episode of choking. (V7) referred resident to re-evaluate for swallow study. R2's nurse practitioner visit note dated [DATE] showed, Patient seen and examined RN (Registered Nurse) requested he be seen due to choking during mealtime this PM. Seen sitting upright in wheelchair. He is currently being fed 1:1 with nursing staff. He remains aspiration risk. Patient on a modified diet .assessment: dysphagia discussed with nursing staff repeat speech therapy evaluation. Continue 1:1 feeding. Slow feeding. On [DATE] at 2:09PM, V7 (Nurse Practitioner) stated, I saw (R2) after his initial choking incident and staff were told to feed (R2) a mechanical soft diet until speech therapy could evaluate him the next day. I was very specific with the nurse on what I ordered so I'm not sure why none of my orders made it into his chart until after (R2) was hospitalized . On [DATE] at 9:00AM, V8 (Licensed Practical Nurse-LPN) stated, I worked on [DATE] and was present during (R2's) choking incident. I was sitting at the nurse's station charting and (V5-LPN) was passing medications outside of the dining room when she began yelling Help! Help! I looked in and (R2) was blue and looked lifeless .I didn't know there had been a choking incident the night before or that he needed a downgraded diet or 1:1 supervision. This is the first I'm hearing about this as it was never provided to me in nursing report. That is a significant event that should have been reported to me so that I could monitor him closely and make sure the correct interventions were implemented. From what I remember, (R2) had regular food on his plate and had been choking on sausage that was not ground up. On [DATE] at 9:51AM, V14 (LPN) stated, On [DATE] one of the aides notified me that (R2) was coughing while he was eating and looked like he was choking. I had (V7) assess him and she wanted me to downgrade his diet to a mechanical soft diet, but I never entered the order because I got busy. I was going to enter it in the morning when I came back so I thought it wasn't a big deal. I told (V8) about (R2) coughing, but I did not report any of (V7's) orders to him so he would have no way of knowing what (R2) needed. Looking back, I should have called the kitchen right away and notified them to downgrade (R2's) diet to mechanical soft .The orders should have also been entered into the medical record, so all staff were aware. R2's death certificate dated [DATE] showed, Cause of death: complications from aspiration pneumonia, choking on food. On [DATE] at 2:42PM, V24 (Corporate Registered Nurse) stated, We didn't know (V7) gave orders to the nurse until you told us. It never came out in our investigation. It is absolutely unacceptable that the nurse didn't enter the orders or tell the oncoming nurse of the changes with (R2). If a resident is supposed to have a mechanically altered diet or receive 1:1 supervision at meals, then that is what we must provide for them. The facility's policy titled, Physician's Orders dated ,d+[DATE] showed, 1. Verbal telephone orders may be accepted form each resident's attending physician/Nurse Practitioner/Physician's Assistant by licensed nurses or pharmacists. Verbal orders must always be based on actual conversations with the prescribing practitioner or on approved written protocols .Verbal orders are documented in the resident's medical record with the date, time, and signature of the person receiving the order. The facility's policy titled, Diet Consistency/Texture Change Protocol dated ,d+[DATE] showed, Licensed nursing staff, after thorough assessment, may use their discretion in ordering the following diets for residents, without initial physician order. 2. Modification in texture (puree, mechanical soft) .A diet modified in texture may be provided on a short-term basis as requested by speech therapy or a licensed nurse. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: (Facility) respectfully submits this Removal Plan which also represents the facility's allegation of compliance for F808 on this date [DATE]. The facility requests the immediacy be removed as of [DATE]. Submitted on [DATE]. Residents who have suffered, or are likely to suffer, a serious adverse outcome because of the non-compliance: F808. o A verbal order to downgrade diet for R2 was not carried out by the nurse. o The nurse failed to relay new orders at shift-to-shift report. o This failure had potential to impact all residents with a change in diet orders. Action the facility will take: F808. On [DATE] education listed below was started by (V2-Director of Nursing), with all nursing staff that were working and those that were scheduled to work upcoming shifts on [DATE]. Education will continue to be conducted prior to the start of the next shift for each nursing staff and on an ongoing basis until all nurses scheduled to work have been educated and demonstrate understanding of the education through written quizzes and/or return demonstration of competency. Education will focus on all nursing staff with the potential to be impacted by the non-compliance and not limited to staff involved in the actual incident. On [DATE], a review of all residents who are at risk for aspiration, choking and/or noted with swallowing difficulty was conducted. All nursing staff were educated by (V2) or designee on the facility's Diet Consistency/Texture Change Protocol policy. Initiated ,d+[DATE]-ongoing. All nursing staff were educated by (V2) or designee on facility's policy physician orders. Initiated ,d+[DATE]- ongoing. -Physician orders audited by (V2) or (V3-Assistant Director of Nursing) or designee. Initiated ,d+[DATE]-ongoing. -Shift to shift will be audited by (V2) and (V3) daily to ensure completion. Audit tool will be utilized to ensure compliance. Initiated [DATE]. Systems, Policies and Procedure: F808 On [DATE] the facility DON, and Administrator reviewed policies and procedures on shift-to-shift report and physician orders with the medical director. This review included but is not limited to staffing, addressing risk factors, assessing changes in conditions related to swallowing ability. The following policies were reviewed with no changes made. Diet Consistency/Texture Change Protocol policy Physician Orders -Shift to shift report Monitoring, Audits, QAPI, and Facility Assessment. (V2) and (V3) conducted a review of compliance using Quality Assurance Audit tool for monitoring of implementing physician orders. The audits will be done for 5 residents three times a week for four weeks, then weekly for four weeks by (V2) or (V3) until compliance is maintained. An audit of shift-to-shift report will be completed by (V2) or (V3) for 10 residents 5 days per week for 4 weeks. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. The QA meeting is held at least quarterly and PRN. An emergency QA meeting was held on [DATE] by the Administrator with the Interdisciplinary Care Team and Medical Director. Topics included residents at risk for choking, diet downgrades, and in services for physician orders and shift to shift report. The Medical Director and IDT approved this removal plan. This will be monitored by the Administrator, DON, ADON.

Based on interview and record review, the facility failed to provide 1:1 supervision for a resident (R2) during mealtimes after R2 experienced a choking episode. This failure resulted in R2 experiencing a second choking episode with cyanosis, low oxygen levels, and hospitalization . R2 expired in the local hospital on [DATE] from complications of aspiration pneumonia and choking on food. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 8. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R2 experienced a choking episode and R2's nurse practitioner ordered for R2 to have 1:1 supervision until he was evaluated by speech therapy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:30PM. While the immediacy was removed on [DATE], noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's electronic face sheet printed on [DATE] showed R2 has diagnoses including but not limited to Parkinson's disease, dementia without behaviors, dysphagia, congestive heart failure, and muscle weakness. R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment. R2's nursing care plan dated [DATE] showed, (R2) requires nutritional support .feed slowly. Give resident time to chew and swallow, meal monitoring and recording as indicated. R2's speech therapy discharge summary dated [DATE] showed, Supervision for oral intake= distant supervision (resident able to feed self, supervision in dining room). R2's nursing progress notes dated [DATE] showed, Resident was choking at dinnertime, and he was able to remove all the food. (V7-Nurse Practitioner) here and saw resident at the time after he was done with episode of choking. (V7) referred resident to re-evaluate for swallow study. R2's nurse practitioner visit note dated [DATE] showed, Dysphagia-discussed with nursing to repeat speech evaluation, continue 1:1 feeding. Slow feeding. On [DATE] at 3:08PM, V6 (Speech Therapist) stated, When a resident has a supervision level of distant supervision that means the resident needs to eat in the dining room with staff present. (R2) was still a risk for choking as he has a diagnosis of dysphagia and just recently had his diet upgraded from a mechanical soft diet to a regular diet. On [DATE] at 11:53AM, V15 (Certified Nursing Assistant) stated, I was working the day (R2) had his first choking incident. A resident yelled he's choking! so I ran into the dining room and began patting (R2's) back and at first, he wasn't breathing. I kind of froze and didn't know what else to do other than pat his back so I yelled for the nurse. One of the nurse's looked into the dining room and stated, 'That's not my resident, I'll go get his nurse.' I couldn't believe she just left me there alone in the dining room with a resident that was choking. There was nobody else in the dining room and I was the only one that responded. I was shocked nobody was in there supervising any of the residents. By the time (R2's) nurse came to the dining room, he had already coughed up what he was choking on and then the nurse took over. On [DATE] at 2:09PM, V7 (Nurse Practitioner) stated, I saw (R2) after his initial choking incident. I recommended for a speech evaluation and ordered 1:1 feeding at a slow rate. 1:1 feeding means staff are sitting with the resident and providing constant, close supervision and cues for safe swallowing. (R2) has a history of swallowing difficulties and had dysphagia so he is at a higher risk for choking. If staff were not supervising (R2), it put him at increased risk for choking which led to his pulmonary complications. On [DATE] at 9:51AM, V14 (Licensed Practical Nurse-LPN) stated, On [DATE] one of the aides notified me that (R2) was coughing while he was eating and looked like he was choking. I had (V7) assess him and she wanted me to have staff sit with (R2) while he ate but I didn't realize nobody knew that. I told (V8 - LPN) about (R2) coughing, but I did not report any of (V7's) orders to him so he would have no way of knowing what (R2) needed. There is always 1 person in the dining room, but we can't spare a staff member to provide 1:1 assistance for feeding, we don't have the staff for that during mealtimes because it's a busy time of day. Looking back, I should have called the kitchen right away and notified them to downgrade (R2's) diet to mechanical soft and I should have entered the orders and notified the CNAs (Certified Nursing Assistants) to provide 1:1 supervision. The orders should have also been entered into the medical record so all staff were aware, but I was just busy and thought it would be okay to do it the next day. R2's nursing progress notes dated [DATE] showed, Resident noted in dining room eating breakfast, nurse on duty noted to be observing residents in the dining room. Resident noted to be coughing while eating, nurse went to assess resident and decided to start the Heimlich maneuver. Resident noted to expectorate chewed up food from his mouth. Oxygen was administered to resident via non-rebreather mask at 10 liters, oxygen saturation noted at 68% with rapid breaths. 911 was called .resident transported to hospital for further evaluation . On [DATE] at 9:00AM, V8 (LPN) stated, I worked the overnight shift on [DATE] and was still on the unit on [DATE] during (R2's) choking incident. I was sitting at the nurse's station charting and (V5-LPN) was passing medications outside of the dining room when she began yelling Help! Help! I looked in and (R2) was blue and looked lifeless. I ran over and started the Heimlich while (V5) went and got oxygen. (R2) looked like he was recovering so I went to call 911 and then (V5) called out for help again so I put the phone down and ran back over and helped her get (R2) to his room. We took him to his room and then I went to the nurse's station to call 911. His oxygen was in the 60's and he looked bad. There were no staff members near him when we ran into the dining room so there couldn't have been anyone providing 1:1 assistance. I didn't know there had been a choking incident the night before or that he needed a downgraded diet or 1:1 supervision. This is the first I'm hearing about this as it was never provided to me in nursing report. That is a significant event that should have been reported to me so that I could monitor him closely and make sure the correct interventions were implemented. From what I remember, (R2) had regular food on his plate and had been choking on sausage that was not ground up. On [DATE] at 11:07AM, V5 (LPN) stated, If a physician or nurse practitioner orders a resident to have 1:1 supervision, then that means staff are to be sitting next to the resident during mealtimes supervising them. If staff are not sitting with the resident and providing them cues or assistance, they could choke. I was working the day that (R2) had his choking incident. I was outside of the dining room passing medications and when I looked in, (R2) was blue. I called for help and (V8) ran in to help me and performed the Heimlich. We got (R2) to his room as fast as we could to finish caring for him while 911 was on their way. From what I remember, there were no staff members feeding (R2) otherwise they would have yelled for help when he started choking. On [DATE] at 1:30PM, V6 (Speech Therapist) stated, 1:1 supervision is provided to residents that are at high risk for swallowing difficulties that could result in choking. I would consider a resident that has had a recent choking incident at high risk for another episode. (R2) should have been provided 1:1 supervision as ordered until we could evaluate him and clear him. I remember walking in on [DATE] and (R2) was being wheeled out to the ambulance so we never even had a chance to evaluate him. On [DATE] at 2:54PM, V11 (CNA) stated, (R2) was on my assignment for [DATE] but I did not take him to the dining room. Night shift gets him up and takes him to the dining room, but nobody told me that he needed 1:1 supervision at meals. That wasn't normal for him, and I wasn't aware there had been an incident the day before with his swallowing. R2's death certificate dated [DATE] showed, Cause of death: complications from aspiration pneumonia, choking on food. On [DATE] at 2:42PM, V24 (Corporate Registered Nurse) stated, We didn't know (V7) gave orders to the nurse until you told us. It never came out in our investigation. It is absolutely unacceptable that the nurse didn't enter the orders or tell the oncoming nurse of the changes with (R2). If a resident is supposed to have a mechanically altered diet or receive 1:1 supervision at meals, then that is what we must provide for them. The facility's policy titled, Physician's Orders dated ,d+[DATE] showed, 1. Verbal telephone orders may be accepted form each resident's attending physician/Nurse Practitioner/Physician's Assistant by licensed nurses or pharmacists. Verbal orders must always be based on actual conversations with the prescribing practitioner or on approved written protocols .Verbal orders are documented in the resident's medical record with the date, time, and signature of the person receiving the order. As of [DATE], the facility was unable to provide a policy regarding supervision of residents at mealtimes. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: (Facility) respectfully submits this Removal Plan which also represents the facility's allegation of compliance for F689 and on this date [DATE]. The facility requests the immediacy be removed as of [DATE]. Submitted on [DATE]. Residents who have suffered, or are likely to suffer, a serious adverse outcome because of the non-compliance: F689. o The facility failed to provide 1:1 supervision for R2 during mealtimes. o The facility failed to ensure that order for 1:1 supervision was input and carried out. o This failure had the potential to impact all residents who require 1:1 supervision during mealtimes. Action the facility will take: F689. On [DATE] education listed below was started by (V2-Director of Nursing), with all nursing staff that were working and those that were scheduled to work upcoming shifts on [DATE]. Education will continue to be conducted prior to the start of the next shift for each nursing staff and on an ongoing basis until all nurses scheduled to work have been educated and demonstrate understanding of the education through written quizzes and/or return demonstration of competency. Education will focus on all nursing staff with the potential to be impacted by the non-compliance and not limited to staff involved in the actual incident. On [DATE], a review of all residents who are at risk for aspiration, choking and/or noted with swallowing difficulty was conducted. All nursing staff were educated by (V2), or designee on the facility's Diet Consistency/Texture Change Protocol policy. Completed [DATE]- ongoing for incoming staff. All nursing staff were educated by (V2), or designee on 1:1 supervision for meals. Completed ,d+[DATE]-ongoing for incoming staff. All nursing staff were educated by (V2), or designee on ensuring interventions were established to prevent further choking episodes based on root cause analysis/assessment. Initiated ,d+[DATE]- completed ,d+[DATE]. -All residents who are high risk for aspiration/choking will be monitored at all meals by managers, nurses, CNAs. Initiated [DATE]-ongoing. Systems, Policies and Procedure: F689 On [DATE], (V2) and (V1-Administrator) reviewed policies and procedures on choking, diets, change in condition, and physician orders with the medical director. This review included but is not limited to staffing, addressing risk factors, assessing changes in conditions related to swallowing ability. The following policies were reviewed with no changes made. -Diet Consistency/Texture Change Protocol policy -Choking -Meal monitoring policy Monitoring, Audits, QAPI, and Facility Assessment. (V1) and (V2) conducted a review of compliance using Quality Assurance Audit tool for monitoring resident change in ability to swallow and/or requiring 1:1 supervision. An audit of residents at high risk for aspiration/choking was started on [DATE]. The audit will be done for 5 residents three times a week for four weeks, then weekly for four weeks. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. The QA meeting is held at least quarterly and PRN. An emergency QA meeting was held on [DATE] by (V1) with the Interdisciplinary Care Team and Medical Director. Topics included residents at risk for choking, diet downgrades, and in services for physician orders and shift to shift report. The Medical Director and IDT approved this removal plan. This will be monitored by V1, V2, V3 (Assistant Director of Nursing).

Based on observation, interview, and record review the facility failed to ensure hot liquids were safely served; failed to ensure a process was in place for service of hot liquids; and failed to identify safe hot liquid temperature. These failures resulted in R1 sustaining a first degree burn to his left forearm and a second degree burn to his left inner thigh. These failures have the potential to affect all residents residing in the facility. The Immediate Jeopardy started on 9/20/24 at 8:36 PM when R1 sustained burns to his left forearm and left inner thigh from spilled coffee. V1 (Administrator) was notified of the Immediate Jeopardy on 10/2/24 at 3:54 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/2/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-services and the process changes. The findings include: The facility Data Sheet dated 10/1/24 showed there were 148 residents residing in the facility. On 10/1/24 at 11:33 AM, R1 was sitting on the toilet. R1 was wearing a long-sleeved shirt, but was exposed from the waist down. V8 (Wound Care Nurse) and V17 (CNA) assisted him to a standing position. R1's left inner thigh had a dark red area, the size of an irregularly shaped baseball. The skin was peeling and there were open areas. V8 said R1 had a change to his wound today and she had ordered a Wound Care Consult. V8 said coffee was spilled on R1 and he had redness to his left forearm and left inner thigh. V8 said R1's forearm had healed, but his thigh wound was worsening. R1 said the server guy spilled coffee on the table and it went on me and burned me. R1 said it wasn't my fault, I can't move that fast any more and boy did it hurt. R1 said his arm doesn't hurt anymore, but his leg does. R1's dressing came off during the transfer and V8 (Wound Care Nurse) obtained more supplies. When V8 applied the Medi-honey treatment, R1 complained of pain. V8 administered Tylenol. R1's Face sheet showed he had diagnoses to include, but not limited to: right sided weakness following a stroke; congestive heart failure; pulmonary hypertension; chronic atrial fibrillation; other epilepsy; other epilepsy; and Brown-Sequard Syndrome (a rare spinal disorder from injury to one side of the spinal cord). R1's facility assessment dated [DATE] showed R1 needed partial to moderate assistance for eating. R1's BIMS (Brief Interview for Mental Status) assessment dated [DATE] showed he was cognitively intact. R1's Risk Management Report dated 9/20/24 at 8:36 PM showed, staff reported a cup of coffee spilled on the dining room table while being served to resident and the coffee went from the tabletop to the resident's lap. This document showed R1 had redness to his left forearm and left thigh. R1's Progress Notes dated 9/20/24 at 8:48 PM showed, Staff reported he slipped the coffee cup and opened the lid of hot coffee on the table and (the coffee was) dripping down onto the resident. Resident stated, It wasn't my fault, I could not get up fast enough. Removed the resident from the table and assessed the area. (There was) redness noted to left forearm ad left inner thigh at that time . This note doesn't include the size or measurements of the wound. R1's Post Occurrence Documentation dated 9/21/24 at 3:50 AM showed R1 had redness and blisters. (This note contains no further details). R1's Order Note for MAR dated 9/21/24 at 6:53 PM showed, Redness and blister noted to left inner thigh, skin intact. No open wound. R1's Skin/Wound Progress Note dated 10/1/24 at 9:54 AM, showed R1 had an open area to the left inner thigh. R1's Physician Order Sheet dated 10/1/24 showed an order for Silver Sulfadiazine cream 1%. Apply to inner left thigh topically every day and night for skin condition, burn area. This record also showed a new order for a Medihoney Wound/Burn Dressing Paste to be applied to R1's left inner thigh and cover with a dressing daily. R1's EMR (Electronic Medical Records) did not show that R1 had been seen by the facility's Wound Care NP (Nurse Practitioner) between 9/20/24 and 10/1/24. On 10/1/24 at 10:23 AM, V15 (RN) said she was familiar with R1. V15 said he is alert to person, place, and time, but will be forgetful from time to time. V15 said R1 is able to make his needs known and communicate effectively. V15 said R1 had a stroke and had weakness to one side of his body. The surveyor asked what the nurse could tell her about R1's wound. V15 replied, Are you talking about the burn? V15 said she was not present the day of the incident, but her understanding was that a cup of coffee was spilled and landed on R1. On 10/1/24 at 10:42 AM, V17 (CNA) said the CNAs ensure the residents are in the dining room for meals, but the dietary staff handles the meal service. V17 said if a resident asks for a cup of coffee and dietary is not available, then the nursing staff can obtain a cup of coffee from the automatic coffee machines in the kitchenettes. On 10/1/24 at 11:01 AM, V19 (Server) said he serves the residents coffee. V19 said he checks the temperature of the coffee from the machine before each meal service. V19 said the temperature is written on the log. V19 said he didn't know if there was a temperature that they were supposed to report. V19 said he did not know if there was too high of a temperature. V19 said he usually serves it in a styrofoam cup with a lid. On 10/1/24 at 11:12 AM, V6 (Dietary Supervisor) used the facility's digital thermometer to check the temperature of the coffee from the automatic machine, on the 2nd floor. The temperature was 158 degrees. The Coffee Temperature Log was posted on the corkboard. This document showed on 10/1/24 at Breakfast the temperature was 172 degrees (Fahrenheit) and the Lunch Temp was 167 degrees. V6 said the automatic coffee machine temperatures are checked before each meal service (three times a day). V6 said the coffee machine does not display the temperature. V6 said only the service technician can see the temperature. V6 said that's why we check the temperatures. V6 said the coffee/hot liquids are not served to the resident right away. V6 said he doesn't re-check the temperature of the hot liquids before serving them to the residents. V6 said the coffee shouldn't be served above 155 degrees. At 11:12 AM, V6 used the facility's digital thermometer to check the automatic coffee machine, on the 3rd floor. The temperature was 173 degrees. There were no trays of prepared coffee or hot liquids that were sitting to cool, before service. A hot liquid temperature was not checked before coffee was served to the residents. V25 (Server) obtained coffee directly from the coffee machine, into white coffee cups and delivered to the resident table. The hot liquid was not set aside to cool. On 10/1/24 at 11:21 AM, V21 (Dietary Aide) said he puts the food on the plates and the servers usually handle the tray delivery and beverage service. V21 said he wasn't sure if coffee temperatures were checked. V21 said the coffee is made to order, so it stays hot. V21 said he is unsure if there is temperature that is too high. On 10/1/24 at 2:32 PM, V6 (Dietary Supervisor) calibrated the digital thermometer in an ice bath. The coffee temperatures were obtained. The 2nd floor coffee temperature was 158 degrees. The 3rd floor coffee temperature was 172 degrees. V6 said he calibrates the thermometers every day in an ice bath. V6 said the thermometers used today were calibrated before checking the temperatures. V6 said he was not in the building the evening of 9/20/24, but he was notified coffee was spilled on R1 by V12 (Server). V6 said he was not sure if the temperatures were adjusted after R1 was burned. V6 said he did not call the service company for temperatures to be adjusted, maybe V7 (Building Manager) did. V6 said the hot liquid temperatures are taken to ensure they won't cause burns or scalding. On 10/2/24 at 7:47 AM, V6 was preparing room trays for R2, R5, R7, R8, and R9. R2's tray had a styrofoam cup of coffee with a plastic lid on top. The surveyor asked V6 to obtain a coffee temperature from the machine. The temperature was 158. V6 continued assembling R5, R7, R8 and R9's trays. V6 obtained hot liquid from the automatic dispenser, into a styrofoam cup, placed a lid on top, and placed the beverages on the trays. At 8:04 AM, V6 left the kitchenette to deliver the trays. There were no cooling or pre-prepared hot liquids in the kitchenette. At 8:02 AM, R10 was seated in a high back wheelchair. R10 was positioned in a slightly reclined position. R10 had a steaming cup of coffee on the upper right corner of her tray. There was no lid on the coffee. There was no staff present in the dining room. V27 (Server) left the kitchenette to deliver room trays. R10 rocked her body and reached toward the cup of coffee, but was unable to reach it. R10 repeated this rocking motion a couple times, but was unsuccessful in reaching her coffee. At 8:09 AM, R11 was seated at a table, drinking from a steaming cup of coffee from a Styrofoam cup. On 10/2/24 at 8:12 AM, V28 (Server) obtained a coffee temperature from the automatic machine. The temperature was 168. There were no pre-prepared or cooling hot beverages in the kitchenette. V25 (Server) was preparing room trays, obtaining hot liquids from the automatic machine and placing them on the trays. On 10/1/24 at 12:46 PM, V9 (LPN - Licensed Practical Nurse) said she was R1's nurse on 9/20/24. V9 said she was on break when the coffee was spilled on R1. V9 said V10 (LPN) was in the dining room and provided immediate care. V9 said R1 is able to make his needs known and so nice. V9 said she feels bad about what happened to R1. V9 said R1 told her the server guy' spilled coffee on the table and it dripped onto him. V9 said R1 said, It's not my fault. He said it really hurt. V9 said she did a skin assessment. V9 said R1's left arm was slightly reddened. V9 said R1's left inner thigh was angry red and raised a little bit. V9 said she did not measure R1's burns. V9 said she notified V4 (R1's PCP), V8 (Wound Care Nurse) and R1's POA. On 10/2/24 at 9:42 AM, V10 (LPN) said she was in the dining room the evening of 9/20/24, assisting another resident with eating. V10 said she heard R1 yell, OUCH! V10 said when she looked up V12 (Server) was standing next to R1. V10 said V12 told her coffee spilled on the table and dripped into R1's lap. V10 said she removed R1 from the dining room and immediately removed his clothing and assessed his skin. V10 said R1 had pain and redness to his left forearm and left inner thigh. On 10/2/24 at 10:45 15 AM, V12 (Server) said the resident food order is taken and they go get it. V12 said he doesn't take coffee temperatures. V12 said the machine has a preset temperature. V12 said he puts the coffee in the cup and takes it directly to the resident. V12 stated, It's pretty quick delivery. V12 said R1 was in the dining room on 9/20/24. V12 said he was delivering R1's dinner tray and coffee. V12 said as he was sitting the coffee down on the table, he must have squeezed the Styrofoam cup too hard and the lid popped off. V12 said the coffee dripped on his hand and then spilled on the table. V12 said the coffee ran off the table onto R1. V12 said the nurse was in the dining room and responded right away. On 10/1/24 at 12:08 PM, V8 (Wound Care Nurse) said she was on call 9/20/24 (when R1 was burned). V8 said V9 (LPN) notified her via telephone. The nurse told me that the dietary staff had spilled coffee and it had landed on R1. She said he had redness to his left forearm and left inner thigh. V8 said R1 told her that the Server spilled coffee on the table and it fell in R1's lap. V8 said R1's left forearm redness had already resolved, but he still had the wound to his left inner thigh. V8 said R1 had not seen the Wound Care Provider, but she had ordered a consult today because R1's wound was open and had slough. V8 said she's not sure what degree of burns R1's would be considered. V8 said the Wound Care Provider will see him the next time they round and they will make that determination. V8 said she did not measure R1's wounds because they weren't open. On 10/1/24 at 2:54 PM, V4 (R1's PCP) said R1 is a nice gentlemen. He is decisional, his mood fluctuates, and he is considered stable at this time. V4 said if a hot liquid spills on the skin and redness or pain occurs this would be considered a first degree burn. V4 said if the underlying flesh is exposed, the area blisters or opens then it would be considered a second degree burn. V4 said the facility notified her on 9/20/24 that coffee was spilled on R1. V4 said R1's burns to his left forearm and left inner thigh were caused by the coffee being spilled on him. V4 said she would expect the facility to serve hot liquids at a temperature that is safe for the residents. On at 10/1/24 1:42 PM, V23 (Coffee Machines Customer Service) said the facility had just called in a service ticket today 10/1/24. V23 said the facility requested the temperature be turned down to 135 degrees for two automatic coffee dispensing systems. V23 said the facility did not make a request for service between 9/20/24 (when R1 was burned) and today. V23 said she can see the service history and the last time the technician was at the facility for repairs was 3/21/24. On 10/1/24 at 3:31 PM, V26 (Dietician) said the corporation does not have a set maximum hot liquid temperature. V26 said she was reviewing the corporation policy's and does not see a maximum temperature for hot liquids. V26 said that she knows the food service temperature should be around 120 degrees and the hot liquids should be similar. V26 said she would expect the hot liquids to be served at a safe temperature to avoid burns. V26 said coffee temperatures of 160-170 definitely sounds too high. On 10/1/24 at 3:20 PM, V1 (Administrator) said the facility does not own the coffee machines. V1 said the coffee company loans them to us for using their coffee. V1 said the coffee company services the machines. V1 said she did not call the service company. V1 said she was aware V12 (Server) had spilled coffee over, it ran off the table, and came into contact with R1. V1 said she would expect V6 (Dietary Supervisor) to report any high temperature concerns to her, but he had not. V1 said the hot water temperatures should be kept below 165. V1 said the facility's hot liquid policy says it is the resident's preference. There is no exact temperature identified as safe. On 10/2/24 at 9:13 AM, V32, Coffee Machine's Regional Field Service Manager, said there is a contract with the facility. V32 said the facility is responsible for checking hot liquid temperatures and calling for service if there is an issue. V32 said the machines do not have a visible temperature reading. They would have to check the temperature of the hot liquid. V32 said the facility protocols determine the safe hot water temperatures and if they have a concern or need adjustments made, then they should call in a service request. V32 said the facility is responsible for ensuring the hot beverages is safely served to the residents. V32 said there is a low temperature kit, available for the coffee machines to keep the temperature below 145 degrees. V32 said this kit is used primarily by the healthcare industry for resident safety concerns. V32 said the low temperature kits are an available option for purchase. V32 said there are no routine services provided by his company, but they treat service as on demand. V32 stated, When they call us, we come. On 10/2/24 at 10:45 AM, V7 (Building Manager) said he had worked at the facility three months and had not called the service company for the coffee machines. The facility's Coffee Temperature Logs for September and October 2024 showed results of 152 to 172 degrees. This form does not show a safe hot temperature parameter or how the staff should respond. The facility's At Risk Hot Food & Beverage Temperature Policy dated 3/24 showed, Policy: Food and Beverages will be served at a temperature that is safe and palatable. Purpose: To reduce the risk of injury . 4. Coffee held at lower temperature will be placed in a carafe with a label reading, low temp coffee/liquid. Coffee temperatures are all based on resident preference and can change from day to day and resident need . The Coffee Machine service reports were requested, but not received. The Immediate Jeopardy that began on 9/20/24 was removed on 10/2/24 when the facility took the following actions to remove the immediacy. On 10/2/24 education listed below was reinforced by the Administrator and Assistant Administrator, with all staff that were working and those that were scheduled to work upcoming shifts thereafter. Education will continue to be conducted prior to the start of the next shift for each nursing and dietary staff member and on an ongoing basis until all employees scheduled to work have been educated and demonstrate an understanding of the education through pop quizzes and/or return demonstration of competency. Education will focus primarily on dietary staff with the potential to be impacted by the non-compliance and not limited to staff involved in the actual incident. 1. All residents were reviewed for conditions that may make them more at risk for the unsafe handling and distribution of hot beverages. Completed 10/2/24. Care Plans and assessments updated as needed. Completed 10/2/24. 2. All dietary and nursing staff were educated on safe handling of hot beverages, safe vessels to hold hot beverages, temperature checking of coffee prior to serving, and notification to appropriate vendors of equipment malfunction. Completed 10/2/24 and ongoing for all oncoming staff not on duty today. 3. The coffee vendor was called on 10/1/24 to verify that all coffee makers are functioning properly and are producing coffee at the lowest safe temperature that the machine can brew. Completed 10/2/24. On 10/2/24, the facility Administrator and IDT reviewed policies and procedures on serving hot beverages and food to residents. The review included but is not limited to resident BIMS scores, beverage service, environment, addressing risk factors. The following policies were reviewed: At Risk Food Temperature Policy; Hot Water Temperature Policy; Incidents & Accidents; Coffee Machines Owner's Manual; A Cool Liquid Program was developed. All were completed 10/2/24. The Administrator and Assistant Administrator completed a QA audit tool for the Dietary Department to ensure that taking temperatures of hot beverages is occurring prior to the serving of coffee each meal. Coffee shall be served for the general population between 120-140 degrees and below 120 degrees for the at risk population. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Completed 10/2/24 and ongoing for QA monitoring. An Emergency QA meeting was held by the Administrator with the IDT and Medical Director on 10/2/24 to review the removal plan. The QA Committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and IDT approved this Removal Plan. This will be monitored by the Administrator and Assistant Administrator. Completed 10/2/24 and ongoing for QA monitoring.

Based on observation, interview, and record review the facility failed to stop providing ADL-Activity of Daily Living care to prevent a fall when a resident exhibited known dementia related behaviors on a memory care unit for 1 of 5 residents (R1) reviewed for falls in the sample of 5. This resulted in R1 fracturing her left hip and losing the ability to ambulate independently. The findings include: On 07/22/2024 at 11:50AM, R1 was lying in bed. R1 was calling out and complaining of pain. R1's current Care Plan on 07/22/2024 shows, multiple diagnosis including Wandering Diseases, Dementia, Behavioral Disturbance, Parkinson's, Anxiety Disorder, and Alzheimer's. On 07/22/24 at 11:58AM, V7 RN-Registered Nurse said, R1 was in the wheelchair with family this morning. R1 started crying, complaining of left hip pain, she then requested to go back to bed. R1 transfers with extensive one person assists. R1 is using a wheelchair that the staff must propel. Prior to R1's fall she was able to ambulate with a walker. R1 only needed verbal cues to remember to use her walker. On 07/22/24 at 12:14PM, V5 CNA-Certified Nursing Assistant said, I provided R1 with a shower on the day the resident fell . I put R1's shoes on. R1 became anxious and wanted to get out. R1 stood up as I was trying to finish. The back part of R1's shoe was folded over. I tried to get R1 to sit down so I could fix it, she wanted to leave. As I fixed the back of her shoe she stepped away and fell on to the floor. R1 did not have her walker when she fell . After R1 fell , I pulled the call light for help. The other CNA and the Nurse helped me. On 07/22/2024 at 12:38PM, V4 R1's POA said, I do not know why they did not have her sit down before messing with her shoe. That contributed to her fall. R1 was able to walk before the fall; she is not able to walk now. Therapy says she has too much pain for rehabilitation. On 07/22/24 at 2:46PM, V4 Restorative Nurse said, R1 is currently a two persons assist. R1 no longer initiates movement on her own. R1 will not get out of bed independently which is what she did prior to her falling. The new intervention to reduce the risk of falls for R1 is to ensure her shoes are on properly. On 07/22/24 at 3:25PM, V6 R1's Primary Physician said, after the fall R1 was sent to the hospital. Imaging shows a femur fracture post fall. R1 received surgical intervention to repair the fracture. On 07/23/24 at 11:30AM, V2 DON-Director of Nursing said, it is an expectation the CNA's know the resident's fall risk and precautions. R1 has a history of impulsive behavior. The CNA was adjusting R1's footwear and R1 fell . R1 is a Memory Care Dementia resident. The CNA was familiar with resident. R1 was independent. We have had conversations with V5 CNA and explained the need to have the resident sit down to adjust shoes. R1's Fall Risk assessment dated [DATE] shows, At Risk for falls. R1's Care Plan shows, At risk for falls initiated 03/21/23. Encourage appropriate use of walker. Monitor for changes in ability to navigate the environment. Provide proper, well-maintained footwear. R1's Fall Investigation Report dated 06/11/2024 at 2:20PM, shows, Notes: dated 06/19/2024 shows, R1 has a history of Parkinson's disease, Alzheimer's disease, Anxiety, and Wandering disease. Resident is impulsive. On 06/11/2024 at 2:20PM, nurse noted resident with clothes on, One Shoe Off, lying on her left lateral side. New Intervention-CNA to ensure shoes on properly prior to resident walking.

Based on interview and record review, the facility failed to ensure a resident was safely positioned in a wheeled recliner for one of 28 residents (R82) reviewed for safety in the sample of 28. This failure contributed to R82 falling out of the wheeled recliner and obtaining a subdural hematoma. The findings include: R82's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, dementia, major depressive disorder, and generalized anxiety disorder. R82's Fall Risk assessment dated [DATE] shows R82 is at risk for falling. R82's Care Plan initiated November 29, 2023 shows she is at risk for falls. Interventions include audio monitoring to prevent unassisted transfers, provide an environment clear of clutter. R82's Psychiatry Note dated April 16, 2024 at 9:16 AM, shows staff reporting increased agitation and behaviors. R82 was seen in her wheelchair after eating lunch and is unfocused and very restless. The facility's Occurrence Report dated April 16, 2024 shows R82 was observed on the floor next to the nurses station. R82 stated she did not know what happened and upon assessment swelling was noted to the back of R82's head. R82 complained of pain. 911 was called and R82 was taken to the local hospital. R82's Progress Notes dated April 16, 2024 at 5:55 PM written by V20 LPN (Licensed Practical Nurse) shows, R82 was place in a (high back reclining) wheeled chair. R82 tipped backwards out of the chair and hit her head. R82 had a lump on the back of her head and a hematoma was forming. R82 was sent out to the local hospital via 911. R82's Progress Note dated April 16, 2024 at 9:28 PM shows R82 was admitted to the local hospital with a subdural hematoma. R82's Hospital Records dated April 17, 2024 shows R82 presented to the emergency department with a chief complaint of a fall. It shows R82 to be leaning too far back in her recliner causing her to fall. R82 struck the back of her head. R82's CT Scan results show that R82 had a right sided subdural hematoma and a moderate soft tissue hematoma to the back right of R82's head. R82's Assessment shows neurosurgery was consulted and recommended intensive care unit admission for neuro checks every hour and aggressive blood pressure control. R82 was a do not resuscitate code status and after talking with R82's power of attorney, and R82's daughter, the family decided they were not going to pursue any aggressive interventions including operative plans. On April 24, 2024 at 10:59 AM, V20 LPN said R82's fall was a frustrating one for me. It has bothered me since it happened. V20 said it was around dinner time and V20 was in the dining room helping residents. V20 said that V21 CNA (Certified Nursing Assistant) was assisting R82 and another resident to eat. V20 said she did not realize that V21 placed R82 in the high back wheeled recliner and near the nurses' station. V20 said next thing she knew, R82 was flipped backwards. V20 said R82's high back wheeled recliner was flipped backwards, and the back rest was laying on the floor. V20 said she did not see it happen. V20 said that V21 must have walked away. V20 said that she ran to R82 and R82's head was on the ground. V20 said she asked R82 if anything hurt and R82 pointed to her head. V20 said she could see a bump on the back of R82's head. V20 said she asked V21 what she did and V21 told V20 that V21 reclined R82 in her high back wheeled recliner and placed a wheelchair under R82's feet rest. V20 said she told V21 that she couldn't do that because it was a restraint. V20 said that she always tries to keep a close eye on R82 because R82 constantly tries to get up. R82 is restless and anxious. Someone has to be around R82 to watch her. On April 24, 2024 at 11:39 AM, V5 said that she performed the investigation in regards to R82's fall. V5 said V21 was with R82 at the nurses' station and then walked away to assist another resident. V5 said based on her investigation, they believe R82 was moving around in the chair, and it was tipped. V5 said she did not know if the chair was tipped backwards or sideways. V5 said that V21 no longer works at the facility. V5 said that V21 has had issues with tardiness. V5 said she did not get reports that a wheelchair was used as well, but V5 said there was a wheelchair nearby R82. On April 24, 2024 at 12:00 PM, V2 DON (Director of Nursing) said he was not sure if her recliner got tipped. V2 said that R82 must have gotten herself out of the recliner. V2 said he did not get any reports of a wheelchair being used as well. V2 said that V21 no longer works at the facility due to attendance issues. V2 said that V21's late date of employment with the facility was April 16, 2024 which was also the same date of R82's fall. On April 24, 2024 at 12:30 PM, V21 said R82 was trying to climb out of her chair. V21 said she did not witness R82's fall. I think she just climbed. The facility's Fall Management Program dated August 2020 shows, The facility is committed to minimizing resident falls and/or injury. While preventing all resident fall is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies and facilitate a safe environment.

Based on observation, interview, and record review the facility failed to ensure a person under investigation for possible covid remained in transmission based precautions, failed to ensure a visitor was in a designated visiting area, failed to ensure staff removed an N95 and disinfected a face shield after leaving an isolation room.These failures have the potential to affect all residents in the facility and has the potential to infect high risk residents with Covid 19 and spread Covid 19 to other residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on August 16, 2021 at 10:30 AM when the facility failed to implement transmission based precautions for R349 who was a person under investigation for Covid 19. The Immediate Jeopardy was identified on August 16, 2021 at 10:30 AM When R349 was observed outside of their room, less than 6 feet apart from other residents residing on the unit. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on August 18, 2021 at 3:32 PM; however noncompliance remains at a lever two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R349's Face sheet printed on August 16, 2021 showed R349 was admitted to the facility on [DATE]. R349's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's COVID vaccination list dated August 15, 2021 showed R349 is not vaccinated for COVID-19. On August 16, 2021 at 10:15 AM, R349's room has an isolation cart and isolation signage on their door. R349 was not observed in their room at this time. At 10:30 AM, R349 was sitting on the patio with eight other residents during the patio music activity not being social distanced (at least 6 feet apart ) from other residents in the activity. On August 16, 2021 at 11:25 AM, V8 Memory Care Unit Manager moved R349 into the unit from the patio by wheelchair. R349 was moved into the dining room and positioned at a table with 3 other residents (R42, R68, and R49). The residents were not at least 6 feet apart at the table. R349 completed her meal while at the table. On August 16, 2021 at 2:30 PM, V8 stated R349 was not socially distancing during lunch, she is out of her room because she was a fall risk, but should be socially distanced. R349 was observed multiple times outside of her room with V8, V16, and V17 (CNAs), V18 Licensed Practical Nurse (LPN), and V19 and V20 Activity Aides had engaged R349 at various times without attempting to redirect R349 to wear a mask, or socially distance R349 from other residents. On August 16, 2021 at 3:00 PM, V13 Nurse Consultant/Interim Infection Control Preventionist (ICP) stated memory care staff should attempt to redirect residents on quarantine (droplet/contact) isolation to go back to their rooms, attempt to wear a mask, and attempt to socially distance (6 feet) from other residents to try to reduce potential spread of Covid. CDC guidance updated May 12, 2020 for Memory Care Units states .Try to keep their environment and routines as consistent as possible while still reminding and assisting with frequent hand hygiene, social distancing, and use of cloth face coverings (if tolerated) .Limit number of residents or space residents at least 6 feet apart as much as feasible when in common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel. The facility's Positive COVID-19 tracking for August 2021 showed the facility entered outbreak status on August 3, 2021 due to R82 having a positive COVID-19 result. Consecutive positive results are: R64 on August 8, 2021, V21 Certified Nursing Assistant (CNA) on August 11, 2021, V22 Social Services Director on August 15, 2021, and V23 Assistant Administrator on August 16, 2021. The facility resident vaccination rate printed on August 16, 2021 showed 83% of residents are vaccinated. The facility staff vaccination rate printed on August 16, 2021 showed 56.37% of staff are vaccinated. On August 16, 2021 the [NAME] county positivity rate for [NAME] County was 6.1% per the www.dph.illinois.gov website. The facility's Census list printed on August 16, 2021 showed R8, R9, R13, R14, R15, R31, R36, R42, R43, R44, R45, R47, R49, R50, R56, R58, R68, R84, R87, R94, R199, and R349 are residents on the 200 wing (Building A) of the memory care unit. On August 18, 2021 at 11:00 AM, V3 (Assistant Director of Nursing) stated the facility has 2 buildings, but we do share staff between buildings to cover the schedule. The Residents Census and Conditions of Residents Form (form CMS-672) completed on August 17, 2021 showed the facility census was 101 residents. 2. R249's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Census list printed on August 16, 2021 showed R249 resides on the second floor of Building B. The facility's list of PUI (Person Under Investigation-for COVID illness) shows that R249 is quarantine for COVID precautions. On 8/16/21 at 10:06 AM, there was a contact/droplet sign on R249's door. There was a container of disinfectant wipes on top of the isolation cart outside of R249's room. The isolation cart included disposable gowns, gloves, and N95 masks. At 10:08 AM, V5 CNA (Certified Nursing Assistant) entered R249's room and shut the door. V5 exited R249's room and did not disinfect his face shield or dispose of his N95 mask. V5 then went into another resident's room that was not on isolation. At 10:15 AM, V5 said R249 is on isolation because R249 went out to the hospital. V5 said, We are supposed to change our N95 mask and disinfect our face shields when we leave [R249's] isolation room. I forgot to change my mask and disinfect my shield. The facility's list of COVID vaccinated residents dated 8/15/21 shows R249 is not vaccinated for COVID. On 8/16/21 at 2:20 PM, V6 RN (Registered Nurse) and V7 LPN said that staff change their N95 masks when exiting rooms that are on droplet and contact precautions for COVID illness. At 3:00 PM, V13 Infection Control Preventionist said staff should be changing their N95 masks when they leave contact/droplet isolation rooms for COVID. The CDC guidance updated 2/23/21 shows, Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [CONDITION(S)] CoV-2 infection: Disposable respirators should be removed and discarded after exiting the patient's room or care area and closing the door. Reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. The facility's Universal Eye Protection policy updated 3/12/21 shows, Eye protection and/or face shields should be cleaned/disinfected; after each encounter with patients on quarantine (new admissions or readmissions). The facility's Use of N95 Respirations policy updated 2/12/21 shows, An N95 respirator should be used instead of a facemask when performing or present for aerosol-generating procedures for residents with known or suspected COVID-19 or who are on droplet precautions for other illness or reason. To reduce the amount of contamination, staff may wear either a surgical mask or face shield over the N95. In such cases, the surgical mask must be discarded, or face shield cleaned after providing care. To reduce the amount of contamination when providing care to a resident with confirmed or suspected respiratory infection, staff may wear either a surgical mask or face shield over the N95. In such cases, the surgical mask must be discarded, or face shield cleaned after providing care. 3. R8's Face sheet printed on August 17, 2021 showed R8 was originally admitted to the facility on [DATE]. On August 16, 2021 at 11:35 AM, V11 (R8's family) was sitting at a dining room table with R8, R9, R50, R199. V11 was not social distanced (6 feet apart) from the other residents. V8, V16, V17, and V18 made no attempts to redirect V11 or R8 away from other residents to R8's room or to a designated visiting area. On August 16, 2021 at 3:00 PM, V13 stated compassionate care visitors should be visiting residents in their rooms and/or in designated visiting areas. Visitors should not be sitting in the dining room with other residents. Visitors still need to socially distance from other residents. The facility's Visitation Guidance revised August 10, 2021 showed .Visitors should physically distance from other residents, staff and visitors in the facility .Visits may occur: a. outdoors, b. in dedicated indoor visitation spaces, and c. in private rooms . The Immediate Jeopardy began on August 16, 2021 and was removed on August 18, 2021 when the facility took the following actions to remove the immediacy: 1. All staff have been in-serviced by Administrator, Executive Director, DON, and IP on the following infection control items: -Resident quarantine precautions -Appropriate doffing and disinfection of PPE upon exiting a quarantine room -Visitation restrictions -Social distancing Corrected 8/18/21 for staff on duty. All other staff will be in-serviced before next shift worked. 2. QA audits on maintaining resident quarantine precautions have begun immediately and are conducted on all shifts by Administrator, DON, ADONs, or designee. These will continue daily x one week and then weekly x 2 months. Started 8/18/21. Will be completed on an ongoing basis. 3. QA audits on appropriate doffing and disinfection of PPE upon exiting a quarantine room have begun immediately and are conducted on all shifts by Administrator, DON, ADONs, or designee. These will continue daily x one week and then weekly x 2 months. Started 8/18/21. Will be completed on an ongoing basis. 4. QA audits on resident visitation have been begun immediately and are conducted by Administrator, DON, ADONs, or designees. These will continue daily x one week and then weekly x 2 months. Started 8/18/21. Will be completed on an ongoing basis. 5. A process has been created to ensure all COVID-19 regulations from all entities are reviewed, incorporated into the facility's policies, and implemented. This plan will include routine in-servicing, upon guidance change, to all appropriate staff, and audits to ensure this in-servicing occurs. This will be completed and monitored by the Administrator and updated upon receipt of new guidance. Started 8/18/21. Will be fully implemented by 8/20/21 with continued in-servicing and audits done, as guidance changes, on an ongoing basis. 6. In-servicing and QA audit tools developed during this plan have been implemented to ensure ongoing compliance and will be monitored by the Administrator and/or designee. The results of the monitoring completed under this plan are submitted to the QA Committee for review weekly x 2 weeks, then monthly x 2 months. New interventions will be developed as needed. Started 8/18/21. Will be completed on an ongoing basis.

Based on interview and record review the facility failed to ensure a resident (R97) received a physician prescribed anticoagulant which resulted in R97 missing 383 doses of the anticoagulant. This failure resulted in R97 being hospitalized with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 21 (R97) residents reviewed for medications in the sample of 21. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on December 21, 2020 when the facility failed to initiate/transcribe a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was identified on August 16, 2021. V1 (Administrator) was informed on the Immediate Jeopardy on August 18, 2021. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on August 18, 2021 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R97's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R97 missed a total of 383 doses. R97's Nurse's note dated July 1, 2021 showed R97 was sent to the hospital in respiratory distress. R97's oxygen saturations were 84% on 3L (liters) of oxygen, respirations of 22 PM (per minute), and was weak and had a decline from her baseline. R97's hospital records dated July 1, 2021 showed she is a [AGE] year old female with significant history to include CVA (cerebrovascular disease), dysphagia, congestive heart failure, and chronic heart failure. R97 presented to the hospital on 7/1/21 with [CONDITION(S)] and shortness of breath. R97's report showed an acute and subacute pulmonary embolism and [CONDITION(S)] in the left popliteal vein. R97 was on anticoagulant medication prior to admission. R97's anticoagulation therapy was changed from anticoagulant medication to [MEDICATION(S)] and [MEDICATION(S)] (anticoagulent). R97 remains on a [MEDICATION(S)] drip for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's CT of chest showed acute segmental pulmonary emboli are seen in the upper lobes. (R97 did not indeed receive the prescribed anticoagulant medication as the hospital presumed.) The same hospital records showed R97 whom reportedly had been on an anticoagulant medication as an outpatient due to a history of a stroke. She now presents with [CONDITION(S)] and what appeared to be acute pulmonary emboli in the upper lung fields as well as a subacute or chronic thromboemboli in other lung fields . R97 on anticoagulant medication for history of CVA. (R97 did not indeed receive the prescribed anticoagulant medication as the hospital presumed.) R97's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R97 was also diagnosed with acute and subacute Pulmonary Embolism (blood clot in the lungs), and DVT ([CONDITION(S)]) of the left popliteal vein. She was switched to [MEDICATION(S)]. On August 16, 2021 at 11:04 AM, V14 (R97's POA) said her mom was hospitalized in July for pneumonia and blood clots in her leg and lungs. V14 said (R97) was supposed to be on anticoagulant medication and she's not sure if she was getting her medication. On August 18, 2021 at 9:00 AM, V24 (Nurse Practitioner) said residents with a history of stroke should receive an anticoagulant medication. If they don't receive the medication they are at risk for having another stroke, blood clots or pulmonary embolism. V24 said she was not aware of R97 not receiving her anticoagulant medication as prescribed. On August 17, 2021 at 9:04 AM, V15 LPN (Licensed Practical Nurse) said when a resident is admitted to the facility the medications are reviewed with another nurse and verifies all the medications are ordered. V15 said anticoagulant medication is a blood thinner and if a resident does not get the medication they could be at risk for developing blood clots. On August 17, 2021 at 8:49 AM, V9 (RN) said when a resident is admitted the facility the nurse calls and verifies the orders with the physician. All admit orders and medications should be reviewed by the ADON(Assistant Director of Nursing)/DON (Director of Nursing). V9 said anticoagulant medication is a blood thinner used to prevent blood clots. On August 17, 2021 at 10:50 AM, V3 (Interim DON) said in July 2021 we implemented a new process for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 said anticoagulant medication is used to prevent blood clots and should not be discontinued unless ordered by a physician. On August 18, 2021 at 8:40 AM, V3 (Interim DON) said nursing enters the orders into the electronic medical records and they must have missed that order. V3 said she was not aware of R97 not receiving her anticoagulant medication. The facility's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Medication Administration General Guidelines Policy dated March 2018 states, All medications should be administrated as prescribed by licensed personnel The Immediate Jeopardy that began on December 21, 2020 was removed on August 18, 2021 when the facility took the following actions to remove the immediacy: 1. Nurses have been in-serviced by clinical leadership on facility admission process related to medication reconciliation and verification. Started 8/18/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 2. A whole house medication reconciliation and verification audit has begun immediately on current residents, by clinical leadership, to ensure all medications have been carried out as ordered. Started 8/17/21. Will be completed by 8/20/21. 3. Medication reconciliation and verification audits have begun immediately on new admissions/re-admissions, by clinical leadership. These will continue daily x 2 weeks and then weekly x 2 months for all residents admitting/re-admitting. Started 8/18/21. Will be completed on an ongoing basis. 4. MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Started 8/18/21. Will be completed on an ongoing basis. 5. A verification process, conducted by two nurses at the time of admission, has been immediately developed to ensure consistency in verifying resident medication lists upon admission, physician review of medication orders, and pharmacy receipt of medication orders. This will continue daily x 2 months. Started 8/18/21. Will be completed on an ongoing basis. 6. Facility changes made to the resident admission process to ensure all medication orders are verified and ordered have been added to facility medication administration policy as an addendum. Completed 8/18/21. 7. Nurses have been in-serviced by clinical leadership on updated facility medication administration policy related to verification of medication orders during admission process. Started 8/18/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 8. In-servicing and QA audit tools developed during this plan have been implemented to ensure ongoing compliance and will be monitored by the Administrator and/or designee. The results of the monitoring completed under this plan are submitted to the QA Committee for review weekly x 2 weeks, then monthly x 2 months. New interventions will be developed as needed. Started 8/18/21. Will be completed on an ongoing basis.

Based on interview and record review the facility neglected to follow their policy and procedure for physician's orders for medications and failed to follow their policy regarding medical care services by the physician. These failures resulted in R97 not being seen by a physician for 181 days and R97 missed her (anticoagulant) medication for 192 days to a resident with a history of strokes. These failures contributed to R97 being hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 21 residents (R97) reviewed for neglect in the sample of 21. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on December 21, 2020 when the facility failed to initiate/transcribe a physician's order for (anticoagulant) 2.5 mg twice a day for R97 upon her admission to the facility. The Immediate Jeopardy was identified on August 16, 2021. V1 (Administrator) was informed on the Immediate Jeopardy on August 18, 2021. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on August 18, 2021, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R97's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's Physician Orders dated December 21, 2020 showed orders including anticoagulant medication 2.5 mg twice a day (anti-coagulation) therapy. R97's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R97 missed a total of 383 doses. R97's hospital records dated July 1, 2021 showed she is a [AGE] year old female with significant history to include CVA (cerebrovascular disease), dysphagia, congestive heart failure, and chronic heart failure. R97 presented to the hospital on 7/1/21 with [CONDITION(S)] and shortness of breath. R97's report showed an acute and subacute pulmonary embolism and [CONDITION(S)] in the left popliteal vein. R97 was on anticoagulant medication prior to admission. R97's anticoagulation therapy was changed from anticoagulant medication ordered at facility to [MEDICATION(S)] and [MEDICATION(S)]. R97 remains on a [MEDICATION(S)] drip for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's CT of the chest showed acute segmental pulmonary emboli are seen in the upper lobes. (R97 did not indeed receive the prescribed anticoagulant medication as the hospital presumed.) The same hospital records showed R97 whom reportedly had been on anticoagulant medication as an outpatient due to a history of a stroke. She now presents with [CONDITION(S)] and what appeared to be acute pulmonary emboli in the upper lung fields as well as a subacute or chronic thromboemboli in other lung fields . R97 on [MEDICATION(S)] for history of CVA. (R97 did not indeed receive prescribed anticoagulant medication as the hospital presumed.) On August 17, 2021 at 10:50 AM, V3 (Interim DON) said it's considered neglect for not entering in a resident's prescribed medication as ordered. On August 18, 2021 at 8:40 AM, V3 said nursing enters the physician orders into the electronic medical records. V3 said nursing must have missed entering R97's anticoagulant medication order and no one caught the error. R97's inital Nurse Practitioner Progress note dated December 24, 2020 showed R97 is oriented to person, time and place, well developed and well nourished. She had a fall resulting in acute C2 fracture and will continue skilled therapy services (physical therpay/occupational therpay). R97's next Nurse Practitioner Progress note dated June 23, 2021 (181 days later) showed R97 had a recent decline in functional mobility. A chest x-ray showed right lung base density consistent with an infiltrate and/or effusion. R97 is now on oxygen and complains of fatigue and has noted a decline in ambulation and transfers. (The facility did not provide evidence of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 17, 2021 at 2:08 PM, V3 (Interim DON) said physician visits should be once upon admission and once a month for skilled care residents. V3 said she could not find any evidence of physician visits for R97 after December 24, 2020 to June 23, 2021. On August 18, 2021 at 9:00 AM, V24 (Nurse Practitioner) said her medical group starting seeing R97 in July 2021. The facility's Physician's Orders for Medications or Treatments policy dated March 2018, states The nurse will transcribe any telephone or transfer sheet orders to the POS .fax a signed hard copy of the physician's orders to the pharmacy for facilities using e-MARs that interface with pharmacy, the pharmacy will enter orders based on the faxed POS and orders will be electronically transmitted immediately after pharmacist verification The facility's Abuse Policy dated September 2020 states, Neglect is the failure of the facility, it's employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facilities Medical Care Services policy dated September 2020 states, Residents will receive medical care and services which met their individual needs and ensures adequate health care 4. Residents will be seen by a physician, or delegated physician's assistant or nurse practioner at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required . The Immediate Jeopardy that began on December 21, 2020 was removed on August 18, 2021 when the facility took the following actions to remove the immediacy. 1. Nurses have been in-serviced by clinical leadership on facility policies related to physician orders for medications, focusing on admission medication orders. Started 8/18/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 2. Medication reconciliation and verification audits have begun immediately on new admissions/re-admissions, by clinical leadership, to ensure physician orders are entered correctly. These will continue daily x 2 weeks and then weekly x 2 months for all residents admitting/re-admitting. Started 8/18/21. 3. Facility changes made to the resident admission process, as it relates to physician orders, have been added to facility physician's order and medications policy as an addendum. Started 8/18/21. 4. Nurses have been in-serviced by clinical leadership on updated facility physician's order and medications policy. Started 8/18/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 5. In-servicing and QA audit tools developed during this plan have been implemented to ensure ongoing compliance and will be monitored by the Administrator and/or designee. The results of the monitoring completed under this plan are submitted to the QA Committee for review weekly x 2 weeks, then monthly x 2 months. New interventions will be developed as needed. Started 8/18/21.

Based on interview and record review the facility failed to ensure a resident (R1) received a physician prescribed antibiotic which resulted in R1 missing fifty-two (52) doses of the antibiotic. This failure contributed to R1 being hospitalized , in an intensive care unit, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 4 residents (R1) reviewed for medications in the sample of 7. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 5, 2021, when the facility failed to initiate/transcribe a physician's order for [MEDICATION(S)] (antibiotic) for R1 upon her readmission to the facility from the hospital. The Immediate Jeopardy was identified on July 14, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on July 20, 2021. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on July 20, 2021, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Infectious Disease Note dated May 27, 2021 showed R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Note showed, Plan: To continue [MEDICATION(S)] 100 mg by mouth twice a day indefinitely (history of the above MSSA bacteremia and discitis/colonized with MRSA .). A fax sheet dated May 27, 2021 showed R1's Infectious Disease Note (dated 5/27/21) was faxed successfully to V8 (R1's Physician). R1's Nurses Note dated June 5, 2021 showed R1 was admitted to the facility from the hospital. R1's hospital After Visit Summary instructions dated June 5, 2021 showed R1 was to continue taking [MEDICATION(S)], 100 mg, twice a day, in the facility. R1's Nurses Notes dated June 18, 2021 showed R1 was sent to the hospital for the complaint of chest pain. R1 was hospitalized from June 18-25, 2021. R1's Nursing Admission assessment dated [DATE] showed R1 was readmitted to the facility. R1's hospital After Visit Summary instruction dated June 25, 2021 showed, Take these medications [MEDICATION(S)] 100 mg capsule by mouth two times daily . R1's hospital record dated July 9, 2021 showed R1 presented to the emergency room with fever and lethargy after being sent from the facility by ambulance. R1 was found to be markedly hypotensive. R1's hospital record showed R1 was subsequently admitted to the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's hospital blood culture results dated July 10, 2021 showed R1 was positive for MSSA bacteria growth in her blood. R1's hospital Orthopedic Surgery Consult note dated July 11, 2021 showed R1 underwent surgical revision of her left knee replacement due to an acute left total knee arthroplasty infection from chronic MSSA discitis/bacteremia. R1's June 1-30, 2021 Physician Order Summary and July 1-9, 2021 Physician Order Summary were each reviewed and showed no physician orders for [MEDICATION(S)] for R1. R1's June 2021 and July 2021 Medication Administration Records were reviewed and showed R1 was not administered any doses of [MEDICATION(S)] while residing in the facility from June 5, 2021 through July 9, 2021. . On July 14, 2021 at 12:05 PM, R1's hospital After Visit Summaries (dated 6/5/21 and 6/25/21), physician orders, and June/July 2021 medication administration records were reviewed with V1 Administrator and V2 Interim Director of Nursing (DON). V2 stated, When a resident returns to the facility from the hospital, we use the medication list sent from the hospital as a resource for what meds to order/continue for our resident. The admission nurse reviews the resident's medication list with the physician and then sends the orders to our pharmacy. (R1) should have been on [MEDICATION(S)] the whole time she was here. R1's physician orders for [MEDICATION(S)] never got sent to the pharmacy. I don't know what happened. I don't know how it was missed. On July 14, 2021 at 2:00 PM, V8 (R1's Physician) stated, When a resident is admitted from the hospital, we usually follow the medication orders from the hospital and continue the medications the resident received in the hospital. (R1) has a history of recurrent effusions to her left knee and [CONDITION(S)]. She takes [MEDICATION(S)] prophylactically to help prevent a recurrent episode of [CONDITION(S)] and to prevent an infection from developing around her prosthetic in her left knee. I have never discontinued her [MEDICATION(S)]. It is primarily prescribed by her infectious disease doctor. If (R1) didn't get her [MEDICATION(S)], it could increase her risk of becoming septic again from staph (staphylococcus aureus bacteria) which could also lead to an infection of her left knee prosthetic. [CONDITION(S)] could cause [CONDITION(S)], bacteremia, and could lead to death. On July 14, 2021 at 11:20 AM, V6 Infectious Disease Physician stated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated, The goal of the [MEDICATION(S)] was to try to prevent (R1) from becoming septic again or risk getting an infection in her left knee prosthetic. If (R1) was not getting the [MEDICATION(S)], she is at risk for becoming septic again related to an overgrowth of staphylococcus bacteria. [CONDITION(S)] can lead to a fatal end result. The facility's Medication Administration policy dated September 2020 showed, 1. Drugs must be administered in accordance with the written orders of the attending physician. The facility's Admission Notes policy dated September 2020 showed, When the resident is admitted to the nursing unit, the Nurse must record the following data (as each may apply) to the Nurses Notes or other appropriate place .h. The date the Physician Orders were received and verified . The Immediate Jeopardy that began on June 5, 2021 was removed on July 20, 2021 when the facility took the following actions to remove the immediacy: 1. Facility has completed a medication reconciliation audit on R1, upon her re-admission from recent hospitalization , to ensure all medications were verified and carried out as appropriate. Corrected 7/15/21. 2. Nurses have been in-serviced by ADON on facility admission process related to medication reconciliation and verification. Started 7/14/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 3. A whole house medication reconciliation and verification audit has begun immediately on current residents, by clinical leadership, to ensure all medications have been carried out as ordered. Started 7/14/21. 4. Medication reconciliation and verification audits have begun immediately on new admissions/re-admissions, by clinical leadership. These will continue daily for the next 2 weeks and then weekly for 2 months for all residents admitting/re-admitting. Started 7/14/21. 5. A verification process, conducted by 2 nurses at the time of admission, has been immediately developed to ensure consistency in verifying resident medications lists upon admission, physician review of medication orders, and pharmacy receipt of medication orders. This will continue daily for 2 months. Started 7/20/21. 6. A resident admission medication reconciliation and verification audit schedule has been immediately developed, and is being conducted by clinical leadership, to ensure orders are not missed and are correct. This audit schedule will continue daily for 2 months. Started 7/14/21. 7. Facility changes made to the resident admission process to ensure all medication orders are verified and ordered have been added to the facility medication administration policy as an addendum. Corrected 7/20/21. 8. Nurses have been in-serviced by ADON on updated facility medication administration policy related to verification of medications orders during admission process. Started 7/20/21 for all nurses on duty. All other nurses to be in-serviced before next shift worked. 9. Additional education related to facility medication reconciliation and verification process has been added to new nurse training binders and will be discussed during new hire orientation, by clinical leadership, for every new nurse going forward. Corrected 7/20/21. 10. In-servicing and QA audit tools developed during this plan have been implemented to ensure ongoing compliance and will be monitored by the Administrator and/or designee daily for 2 weeks, then monthly for 2 months. The results of the monitoring completed under this plan are submitted to the QA Committee for review weekly for 3 weeks, then monthly for 3 months. New interventions will be developed as needed. Started 7/14/21.

Based on interview and record review the facility neglected to administer a physician prescribed medication (antibiotic) for twenty-nine days (29) to a resident (R1) which resulted in R1 missing fifty-two (52) doses of the medication. This failure contributed to R1 being hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] This applies to 1 of 4 residents (R1) reviewed for neglect in the sample of 7. The findings include: R1's Infectious Disease Note dated May 27, 2021 showed R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Note showed, Plan: To continue [MEDICATION(S)] 100 mg by mouth twice a day indefinitely (history of the above MSSA bacteremia and discitis/colonized with MRSA .). A fax sheet dated May 27, 2021 showed R1's Infectious Disease Note (dated 5/27/21) was faxed successfully to V8 (R1's Physician). R1's Nurses Note dated June 5, 2021 showed R1 was admitted to the facility from the hospital. R1's hospital After Visit Summary instructions dated June 5, 2021 showed R1 was to continue taking [MEDICATION(S)], 100 mg, twice a day, in the facility. R1's Nurses Notes dated June 18, 2021 showed R1 was sent to the hospital for the complaint of chest pain. R1 was hospitalized from June 18-25, 2021. R1's Nursing Admission assessment dated [DATE] showed R1 was readmitted to the facility. R1's hospital After Visit Summary instruction dated June 25, 2021 showed, Take these medications [MEDICATION(S)] 100 mg capsule by mouth two times daily . R1's hospital record dated July 9, 2021 showed R1 presented to the emergency room with fever and lethargy after being sent from the facility by ambulance. R1's hospital record showed R1 was subsequently admitted to the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's hospital Orthopedic Surgery Consult note dated July 11, 2021 showed R1 underwent a surgical revision of her left knee replacement due to an acute left total knee arthroplasty infection from chronic MSSA discitis/bacteremia. R1's June 1-30, 2021 Physician Order Summary and July 1-9, 2021 Physician Order Summary were each reviewed and showed no physician orders for [MEDICATION(S)] for R1. R1's June 2021 and July 2021 Medication Administration Records were reviewed and showed R1 was not administered any doses of [MEDICATION(S)] while residing in the facility from June 5, 2021 through July 9, 2021. On July 14, 2021 at 12:05 PM, R1's hospital After Visit Summaries (dated 6/5/21 and 6/25/21), physician orders, and June/July 2021 medication administration records were reviewed with V1 Administrator and V2 Interim Director of Nursing (DON). V2 stated, When a resident returns to the facility from the hospital, we use the medication list sent from the hospital as a resource for what meds to order/continue for our resident. The admission nurse reviews the resident's medication list with the physician and then sends the orders to our pharmacy. (R1) should have been on [MEDICATION(S)] the whole time she was here. R1's physician orders for [MEDICATION(S)] never got sent to the pharmacy. I don't know what happened. I don't know how it was missed. On July 14, 2021 at 2:00 PM, V8 (R1's Physician) stated R1 was to be on [MEDICATION(S)] prophylactically indefinitely, twice a day, due to her history of [CONDITION(S)] and also to prevent an infection to the prosthetic in her left knee. V8 stated she never discontinued R1's [MEDICATION(S)] order. V8 stated R1 should have been receiving the [MEDICATION(S)] twice a day while residing in the facility. On July 14, 2021 at 11:20 AM, V6 Infectious Disease Physician stated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated, The goal of the [MEDICATION(S)] was to try to prevent (R1) from becoming septic again or risk getting an infection in her left knee prosthetic. The facility's Abuse Policy dated September 2020 showed, Neglect is the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional stress.

Based on interview and record review the facility failed to assess and monitor a resident after a fall and the facility failed to ensure necessary care for a resident with abnormal chest x-ray findings. This failure resulted in a delay in treatment for [REDACTED]. This applies to 2 of 6 residents (R1, R2) reviewed for necessary care and services in the sample of 6. The findings include: 1. The Physician order [REDACTED]. The Minimum Data Set assessment dated (MONTH) 12, 2019 shows R1's cognition is impaired and requires extensive assist with activities of daily living. The nurse's notes dated (MONTH) 8, 2019 show V4 (Registered Nurse) documents at approximately 5:25 AM, R1 was on the floor beside her bed lying on her left side .V4 administered pain medication for complaints of pain to her left arm 5/10. V4 documents R1 has no swelling or bruising observed on the affected side. V12 (Physician) was notified at 5:40 AM, with orders for a STAT (immediately/rush) x-ray of R1's left arm. V4 documents she called the x-ray provider at 5:56 AM. The P.O.S. sheets dated through (MONTH) 2019 shows R1's x-ray order was entered in at 9:55 AM (fours after receiving the order). The nurse's note dated (MONTH) 8, 2019 with a late entry on (MONTH) 11, 2019 (three days after the fall), show V5 (RN) documented she called the x-ray company, they state will be there later in the evening as they are very busy today. The nurse's notes from (MONTH) 8, 2019 documents R1 complains of pain to her left arm at 6:02 AM, 12:25 PM, and 1:15 PM. The nursing notes did not show any documentation of assessments of R1's left arm after her fall at 5:25 AM. R1's nurse's note do not show what time R1 left the facility. On (MONTH) 24, 2019 at 8:00 AM V4 (RN) said she was R1's nurse when she fell on (MONTH) 8, 2019. V4 said R1 was complaining of left arm pain after she fell . V4 said she received orders from the physician for a STAT x-ray for R1's left arm. V4 said I was too busy to put the STAT order in right away. On (MONTH) 24, 2019 at 9:00 AM, V5 (RN) said she was R1's day shift nurse on (MONTH) 8, 2019. V5 said she received report from (V4) about R1's fall. V5 said she called the x-ray company sometime in the late afternoon to follow up to see what time they were coming to do R1's x-ray. V5 said the x-ray company stated they were very busy today. V5 said R1 had complaints of left arm pain and had limited movement to her left arm. V5 said when she left her shift at 7:00 PM (13 hours after the order was received) R1 did not have her left arm x-rayed. V5 said she did not notify the physician or family. On (MONTH) 24, 2019 at 8:35 AM, V6 (RN) said she was R1's nurse on (MONTH) 8, 2019 from 7:00 PM-7:00 AM. V6 said V5 reported to her R1 had a fall in the early morning and was waiting for x-ray for her left wrist. V6 said she went to R1's room and V11 (R1's daughter) was there and upset her mother did not receive her x-ray yet(approximately 13 hours after it was ordered). V6 said R1 was complaining of pain, her left arm was swollen, and she didn't want me to touch her left arm. V6 said V11 took R1 to the emergency room herself and returned back around 10:00 PM. V6 said R1's x-ray showed a left wrist fracture. On (MONTH) 24, 2019 at 3:05 PM, V2 (DON) said nursing staff should assess a resident every shift after a fall and monitor for any changes of condition. The Resident and Family Risk Notification: Falls document dated (MONTH) 24, 2019 documents a statement from V11 stating she was notified of R1's fall and was told an x-ray was ordered because R1 was complaining of left arm pain. Around 6:00 PM my sister arrived to the facility on (June 8, 2019) to find R1's left wrist blue and swollen again no x-ray had been taken. On (MONTH) 23, 2019 at 12:38 PM, V2 said when staff receive an order for [REDACTED]. R1's x-ray report dated (MONTH) 8, 2019 showed she has a left wrist fracture. The x-ray was performed at 8:00 PM (14 hours after R1's fall). The facility's Management of Falls policy dated (MONTH) 2019 states, Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. The facility's Change of Condition (Resident) Policy dated (MONTH) 2019, states, The attending physician or physician on call NP and responsible part will be notified with changes in condition .will be notified of all changes in condition. 2. On (MONTH) 23, 2019 at 9:05 AM, R2 was laying in bed still in a hospital gown. R2 stated I'm ok, was short of breath for a bit before. R2's Progress Note dated (MONTH) 18, 2019 at 11:30 AM, shows Dr notified of dry cough early this AM, with O2 saturation of 91% on room air , with audible wheezing. Ordered chest X-ray, PRN [MEDICATION NAME] every 6 hours, and [MEDICATION NAME] PRN every 4 hours for cough. R2's Progress Noted dated (MONTH) 18, 2019 at 1:00 PM, shows R2 complains of shortness of breath. Audible wheezing and non-productive cough noted. MD paged and he is aware. Chest X-ray to be performed today. R2's chest X-ray dated (MONTH) 18, 2019 shows Impression. Large left-sided pleural effusion. Chronic perihilar congestion Clinical correlation and follow up is advised. This same X-ray is time stamped (MONTH) 18, 2019 10:05 PM and has a faxed stamped time 07/18/2019 10:11 PM. R2's Progress Notes dated (MONTH) 18, 2019 does not contain any assessment of R2 from 8:11 PM until 8:43 AM on (MONTH) 19, 2019. R2's Progress Notes dated (MONTH) 19, 2019 at 8:43 AM (10 hours after the X-ray results were faxed to facility) shows Chest X-ray results relayed to MD. Ordered [MEDICATION NAME] 20 mg daily for 7 days . On (MONTH) 23, 2019 at 10:25 AM, V8 Registered Nurse stated the X-ray company calls us with results and then they follow up with a fax. We call the doctor right away whether significant findings or not. On (MONTH) 23, 2019 at 12:38 PM, V2 Director of Nursing stated the X-ray company calls us with abnormal results and we inform the doctor right away, as soon as we get the results.