Every finding on record at Alden Poplar Creek Rehab & HCC

Based on observation, interview, and record review, the facility failed to ensure no delay in care and treatment to a resident with unwitnessed fall that was later diagnosed with fractured left elbow. The facility also failed to revise resident comprehensive care plan in a timely manner for cast management and ADLs (Activity of daily living) limitation affected by cast on left elbow due to fracture. This deficiency affects one (R1) of three residents reviewed for Fall management.Findings include: On 3/11/26 at 10:05AM, V5, Family member, said R1 reported she fell backward in her room on 2/21/26 sometime between 1:30PM to 8:30PM. R1 complained of left elbow pain with limited mobility and swelling. X-ray of elbow was not done until the following evening, 2/22/26. V5 said V6, RN (Registered Nurse), called him around 9:00PM to inform him the x-ray result indicated a fracture of the left elbow. R1 was sent to the hospital emergency room (ER) for further evaluation as ordered by physician. V6 informed him there will be a 2 hour delay in ambulance pick due to it being a non-emergency. He went to the facility around 10:00PM and he brought R1 to the hospital ER. Cast was applied to R1's left elbow and returned to the facility on 2/23/26 at 1:00AM. R1 had surgery on the left elbow on 3/6/26. V5 is concerned about the delay in x-ray and transport of R1 to the hospital. On 3/11/26 at 9:28AM, R1 was sitting in bed with a left arm cast; arm sling hanging at bedside corner. The wheelchair was in the corner away from her. R1 has difficulty dressing by herself. V2, DON (Director of Nursing), offered to call CNA (Certified Nursing Assistant) to assist R1. R1 was alert and oriented with periods of confusion but she can verbalize her needs to staff. She said she fell and hurt her elbow.On 3/11/26 at 9:39AM, V7, RN, said she was the nurse on duty when R1 returned from out on pass with family on 2/21/26 at around 1:00PM. V5, Family member, brought her to the dining room for lunch and stayed there until end of her shift. V5 did not report a fall incident occurring at home and R1 did not complain of pain. V7 said the following day, it was reported R1 complained of pain to her left elbow on the evening shift and had order for x ray. She medicated R1 for left elbow pain during her shift. X-ray service did not arrive on her shift. V7 said she did not follow up because it usually arrived around 3 PM by the time she leaves.Review of R1's active physician order sheet and comprehensive care plan with V4, Restorative Nurse, showed the hospital discharged instruction on 2/21/26 and 3/6/26 were not carried over on the order sheet and care plan. R1 had a cast after returning to hospital due fractured left elbow from unwitnessed fall on 2/21/26. R1's discharged instructions from the hospital indicated: Keep your arm raised (elevated) to reduce pain and swelling. Ice pack on the injured area. Keep the cast completely dry at all times. May use acetaminophen or ibuprofen to control pain unless another pain medicine was prescribed. Don't put creams or objects under the cast if you have itching. R1 had ORIF (Open Reduction Internal Fixation) on 3/6/26, with discharged orders from the hospital including: Keep the limbs on a pillow when resting. Keep dressing on until seen by MD. Call 911 when you have chest pain and or trouble breathing. Call MD when pain is not relieved with prescribed pain medication, fever of100.4 and above, drainage from the wound. Ice pack on the operated area 30 minutes on /30 minutes off while awake for 7-10 days. No care plan revision for her cast management and ADLs care plan was made due to limited mobility from left arm cast. V4 said she is only responsible for updating the fall care plan. V4 said the floor nurses should update R1's ADLs and cast management.On 3/11/26 at 10:54AM, V9, Nurse Practitioner, said she received a text message on 2/21/2/6 from V6, RN, that R1 fell and bumped her left elbow. It was an unwitnessed fall. R1 complained of left elbow pain and confusion. V9 ordered X-ray of left elbow, CBC (complete blood count), CMP (Complete metabolic profile) and UA (urinalysis). On 2/22/26 at 9PM, she received a text message from V6, RN, that R1's X-ray result indicated fractured left elbow. She ordered R1 to be sent out to the hospital for further evaluation. She was not informed by V6, RN, that there was a delay in transporting R1 to the hospital and she was not notified that V5, Family member, intervened to transport R1 to hospital. V9 said it was expected R1 should immediately be transported to the hospital for evaluation since report of fall and pain over 24 hours to prevent complications.R1's fall incident report was submitted to IDPH (Illinois Department of Public Health) on 2/22/26. Informed V2 there is a discrepancy in the incident report that he completed and submitted to IDPH. He documented R1 reported left elbow pain upon arrival back to the facility on 2/21/26 and stated, I fell at home in the living room and hurt my elbow. R1's progress note, dated 2/21/26 at 1:19PM, documented by V7, RN, indicated, Returned from out on pass. (R1) in the dining room having lunch. V6, RN, documented on 2/21/26 at 8:24PM, (R1) appeared to be confused tonight, observed taking a plastic gown and put it on like a diaper. Assisted with dressing. (R1) claimed that she slipped and bumped into her elbow. (R1) talking nonsense when asked to describe her fall. She said that the girls picked her up off the floor but none of the staff were aware of it. (R1) complained of left elbow pain with limited movement. In addition, it was not indicated V5, family member, was the one who transported R1 to the hospital. V2, DON, said he was not aware at that time R1 was transported to the hospital ER by V5, Family member. He was not aware V5 intervened to transport R1 to hospital using his private car due to delayed in ambulance transportation. V2 said R1's discharge orders from the hospital should be written in physician order and ADLs care including cast management should be updated by V4, Restorative Nurse, in the care plan.On 3/11/26 at 11:59AM, V6, RN, said she works on 3-11 shift on 2/21/26. V13, Certified Nursing Assistant/CNA, reported to her around 8 PM when providing evening care to R1 that she complained of pain in her left elbow when lifting her arms to remove her clothes. She said she appeared to be confused that night. She said she slipped and bumped her left elbow. She is talking nonsense when asked to describe her fall. She said the girls picked her up off the floor but none of the staff were aware of it. She complained of left elbow pain with limited movement and slight swelling. She called V9, NP, and ordered X-ray of left elbow. V6 notified V5, Family member. V6 medicated R1 for pain in her left elbow. She worked with her on the following day, 2/22/26. X-day was done in the evening with abnormal result- fractured of left elbow. She relayed to V9, NP, and ordered to send R1 to hospital ER for evaluation. She called V5 around 9pm to inform him the ambulance transportation will be delayed for 2 hours. V5 said he cannot wait and will provide transportation for R1. V5 came around 10PM and took R1 to hospital ER. V6 said she did not inform V9, NP, of the delay in ambulance transportation and the V5, family, intervened to transport R1 to the hospital.On 3/11/26 at 12:31PM, V13, CNA, said she worked with R1 on 2/21/26. She saw R1 in the dining room when coming to work. She did not complain of pain. Around 8PM, when making rounds for evening care, R1 complained of left elbow when lifting her arms to remove her clothes. She reported to V6, RN.On 3/11/26 at 1:19PM, V3, Care Plan Coordinator, said the care plan should be updated with resident change of condition or treatment/management. V3 said R1's ADLs care plan should be updated by V4, Restorative Nurse.R1 was admitted on [DATE], with diagnoses listed in part but not limited to Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for closed fracture with routine healing, Dementia, Type 2 Diabetes Mellitus, Long term use of antithrombotic/antiplatelets. Hyperlipidemia. Active physician order sheet did not indicate hospital discharge instruction post cast application for fractured left elbow following fall on 2/21/26 and post ORIF surgery on left elbow on 3/6/26. Comprehensive care plan was not updated for cast management and ADLs (Activity of daily living) limitation affected by cast on left elbow.Facility's policy on Management of falls 8/2020 indicated: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards risks, implement appropriate resident interventions and revise the resident's plan of care to minimize the risks for fall incidents or injuries.Facility's policy on Comprehensive care plans 11/2017 indicated: Policy: An individualized, person-centered comprehensive care plan including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident.Facility's policy on Change of condition (Resident) 7/2025 indicated: Purpose: To ensure that the resident's physician/physician on call/NP and responsible party is kept informed regarding the resident's change of condition.

Based on observation, interview, and record review, the facility failed properly store food in a manner to prevent cross-contamination and failed to label prepared foods stored in the refrigerator. This applies to all residents residing in the facility.The findings include:The CMS 671 form, dated 12/2/25, showed there were 164 residents residing in the facility.On 12/2/25 at 9:40 AM, there was a cardboard box of cornflakes on the floor of the dry storage room. The surveyor showed V10 (Hostess/Assistant Supervisor) the box and asked if food should be stored on the floor. V10 replied, No that shouldn't be on the floor because the floor may be dirty and there is a risk of cross contamination. At 9:43 AM, there were two boxes of food (1 with elote and another with baguettes) on the floor of the left side of the freezer. The boxes were frozen to the floor of the freezer. On the right side there was a box of unknown food and a black plastic bag on the floor of the freezer. The surveyor asked V10 what was in the box. V10 attempted to pull the box out from under the shelving but was unable to remove the box from the floor. V10 moved items on the shelf above and stated the box contained waffles, but it was stuck pretty good. The surveyor asked what was in the black, plastic bag. V10 opened the bag and said it was a frozen turkey. There were boxes of beef bulgogi and pork loins on the shelves above the waffles and turkey. V10 said there should be any boxes or food items stored on the floor of the freezer. At 9:48 AM, there was a tomato and tomatillo on the floor of the walk-in refrigerator. There were stainless steel contains of prepared lettuce, tomato, and onion. The lettuce was discolored to a yellow/brown and red color. The diced tomatoes and onions were very watery. The bins were covered with clear, plastic wrap, but they were not labeled. The surveyor asked V10 about the bins. V10 stated, That's prep for salad. The night shift cook must have put them in here. It shouldn't look like that and will need to be thrown out. V10 said she didn't see any labels on the containers. The surveyor asked if the tomato and tomatillo should be on the floor of the refrigerator. V10 replied, No, they should be thrown out.On 12/2/25 at 10:09 AM, V9 (Dietary Manager) said there shouldn't be any food items stored within 6 inches of the floor and 12 inches from the ceiling due to the risk of cross-contamination. V9 accompanied the surveyor to the walk-in freezer, the boxes were still on the floor. V9 stated, There shouldn't be any food stored on the floor. V9 was able to remove the box of elote and baguettes from the left floor but had to tug on the box of waffles to remove them from the floor. V9 said the freezer shouldn't have any food stored on the floor, especially under meat to avoid the potential for drippings and cross-contamination. At 10:15 AM, the surveyor entered the walk-in refrigerator with V9 and asked about the food in the steel containers. V9 stated, That's salad from yesterday, but it is no good and it will need to be disposed of. V9 said there was no label on the containers and there should be. V9 said the purpose of the labels communicate when the food was prepared and when it should be disposed of. The facility's Food Storage Policy, revised 7/17, showed, Food storage areas will be maintained in a clean, safe and sanitary manner. Purpose: To reduce the risk of food borne illness. Procedure: .2. All food items will be stored 6 inches above the floor and 18 inches below the ceiling. Food will be stored on shelves, racks, dollies, or other surfaces which are easily cleanable.The facility's Labeling and Dating Policy, revised 7/24, showed, Ready-to-eat time/temperature control for safety foods may be stored in the refrigerator held at 41 degrees Fahrenheit for 7 days. Purpose: To reduce the risk of food borne illness. Procedure: .1. Ready-to-eat/temperature for safety (TCS) food that is held for less than 24 hours may be labeled with the common name and date it is placed in the refrigerator. 2. On premise preparation of ready-to eat TCS that is to be held for longer than 24 hours in the refrigerator will be marked to indicate which date or day the food must be consumed or discarded. The day or date marked by the food service establishment may not exceed the manufacturer's use by date.

Based on interview and record review, the facility failed to notify a resident's provider of elevated blood glucose levels. This applies to 1 of 1 residents (R34) reviewed for notification in the sample of 45. The findings include:R34's admission Record (Face Sheet) showed a current admission date of 11/9/24, with diagnoses to include but not limited to, diabetes type2, heart failure, and atrial fibrillation (rapid, irregular heartbeat). R34's Order Summary Report (physician orders) showed an order for rapid acting insulin before meals. The order shows the amount of insulin to be given is dependent upon R34's blood sugar value. The order shows if R34's blood sugar is greater than 350, then the nurse should give 10 units of rapid acting insulin and call the provider. (All blood sugar values are in milligrams per deciliter.) R34's October 2025 Medication Administration Record (MAR) showed on 10/1/25 a blood sugar of 378 prior to his evening meal. The MAR showed a value of 351 on 10/3/25 prior to his noon meal. The MAR showed a value of 359 on 10/12/25 prior to his evening meal. R34's MAR showed a blood sugar value of 365 on 10/14/25 prior to his evening meal. R34's care plan showed blood sugar results that are outside of ordered parameters should be reported to the provider (8/29/25). R34's October 2025 Nurses' Notes showed no physician communication documentation for the blood sugar values equal to or greater than 351. R34's November 2025 MAR showed on 11/16/25 a blood sugar value of 379 prior to his noon meal, a value of 353 on 11/17/25 prior to his noon meal, and a value of 388 on 11/23 prior to his noon meal. R34's November 2025 Nurses' Notes showed no documented physician communication for the above blood sugar values greater than 351. On 12/04/2025 at 9:51 AM, V5, Registered Nurse (RN), stated she has had to call providers for elevated blood sugar values. V5 stated the provider will typically say continue to monitor the resident or the provider will give an order for additional insulin and continue to monitor. V5 said the provider communication would be documented in the nurses' notes. On 12/04/2025 at 10:21 AM, V2, Director of Nursing (DON), stated, Typically when providers are notified for high blood sugar values, they will either order more insulin or say, 'thanks for notifying me.' The MAR links to the nurses' notes if the nurse checks a box that the provider was notified. While reviewing R34's progress notes, V2 stated he could not locate any nurses' notes in November 2025 indicating R34's provider had been notified of the high blood sugar values. V2 stated the purpose of notifying the provider is to make them aware of the elevated value and to evaluate if additional insulin is required. On 12/04/2025 at 12:33 PM, V4, Nurse Practitioner, stated she has been notified of R34's elevated blood sugars in the past, however, she does not know when or how often. V4 stated it is the facility's responsibility to document provider notifications and to document any orders she may give. V4 stated if she was notified of an elevated blood sugar, as high as 379 on 11/16/25, she would have ordered additional insulin. V4 said notification of elevated blood sugars are important because medication needs to be given.

Based on observation, interview, and record review, the facility failed to ensure wound care was provided in a manner to prevent contamination of the wound bed for 1 of 8 residents (R144) reviewed for pressure injuries in the sample of 45.The findings include:R144's admission Record showed diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting his left non-dominant side, a stage IV pressure ulcer of left heel, muscle spasms, and pain in his left foot. R144's care plan initiated on 5/2/2025 showed he has an actual alteration in skin integrity as evidenced by an abrasion to his left anterior ankle and a pressure injury to his left heel. R144's Order Summary Report showed an active order to clean the abrasion to his left anterior ankle, apply (a dressing designed to maintain moisture to the wound bed), and cover with a foam dressing. The report also showed an active order to cleanse R144's left heel with saline, paint with betadine, apply (dressing designed to maintain moisture to the wound bed), and cover with a foam dressing. R144's facility assessment, dated 10/29/2025, showed he was dependent on staff for transfers, lower body dressing, and putting on/taking off footwear. The assessment showed R144 required substantial/maximal assistance from staff for bathing and personal hygiene. On 12/3/2025 at 12/3/2025 11:03 AM, V12 (Wound Care Nurse/Licensed Practical Nurse) was doing dressing changes for R144's wounds. R144 had an abrasion on his left anterior ankle. V12 poured a small amount of saline over the wound bed and surrounding tissue, then placed dry gauze over the wound, picked up the gauze, and used the same gauze to wipe in one motion across the surrounding (peri-wound) skin, across the wound bed and then the surrounding skin on the other side of the wound. V12 repeated this action a second time with the same gauze before applying the dressing designed to keep the wound bed moist, and then the foam dressing. When providing wound care to R144's stage IV pressure injury on his left heel, V12 used the same technique: Poured a small amount of saline over the wound bed and surrounding tissues (peri-wound), put dry gauze over the wound bed, picked up the gauze and used the same gauze to wipe in one motion across the peri-wound skin, across the wound bed, and across the peri-wound skin on the other side of the wound. V12 repeated this action a second time, then applied betadine to the wound bed. While applying the betadine, V12 was swabbing the wound bed and surrounding skin, going back over the wound bed after the peri-wound skin several times before applying the foam dressing. On 12/4/2025 at 9:27 AM, V12 (Wound Care Nurse-LPN) said she should not have touched the wound bed with the same gauze that she touched the peri-wound skin with, for infection control. The facility's 3/2021 policy and procedure titled Non-Sterile Dressing Change showed 1. Non-sterile dressings protect open wounds from contamination and absorb drainage. 2. Designated staff member will use non-sterile dressing technique for all dressing changes unless otherwise indicated by Physician/NP (Nurse Practitioner) or manufacturer guidelines. Clean aseptic technique should be used (a practice that minimizes the transfer of microorganisms to prevent infection).

Based on observation, interview, and record review, the facility failed to provide an ordered treatment for contractures. This applies to 1 of 1 residents (R89) reviewed for range of motion in the sample of 45. The findings include:R89's admission Record (Face Sheet) showed he was admitted to the facility on [DATE], with diagnoses to include but not limited to, paralysis to his right side due to a stroke, dementia, and nerve pain. R89's 10/30/25 Quarterly Minimum Data Set (MDS) showed he had severe cognitive impairment. R89's Order Summary Report (Physician Order Sheet, POS; as of 12/4/25) showed an order started on 9/10/24 for [cotton gauze wrap] to right hand during the day and off at night, can remove for skin checks. On 12/04/2025 at 9:49 AM, R89's right hand appeared contracted. R89 did not have a (cotton gauze) wrap in or around his right hand. On 12/04/2025 at 9:57 AM, V6, Licensed Practical Nurse (LPN), stated she has provided care for R89. V6 stated she believed the order was not a wound dressing, but a cotton roll to be placed in R89's hand due to his contracture. V6 stated she was aware of the order, and she believed the nurses would provide the roll. V6 stated she follows physician orders, but she also follows what is indicated in the Medication Administration Record (MAR) and the Treatment Administration Record (TAR). R89's November 2025 and December 2025 MAR/TAR, as of 12/4/25, showed no orders or entries for R89's cotton roll. On 12/04/2025 at 10:14 AM, V2, Director of Nursing, stated the restorative nurse was on vacation and she was not available. V2 stated he does not know what the cotton roll was for; however, it was most likely for R89's contracture. V2 stated the cotton roll should be documented as being done or refused on the TAR (Treatment Administration Record). V2 stated the purpose of cotton rolls for residents with contractures is to prevent their fingernails from digging into their hand and to minimize the progression of the contracture. On 12/4/25 at 10:53 AM, V2 stated the cotton roll was for R89's contracture and it was the CNAs (Certified Nursing Assistants) responsibility to both document the treatment and to provide the treatment. On 12/04/2025 at 11:17 AM, V2 stated the facility does not have any documentation regarding application or refusal of R89's cotton roll. V2 stated when the order was initiated 15 months prior, the person who entered the CNA task did not check the box in the electronic charting, which would have required the CNAs to chart on the cotton roll. V2 stated this error should have been identified when the restorative nurse reviewed this charting. V2 stated he believed R89 would refuse the cotton roll; however, these refusals should be documented and if he continued to refuse an alternative should be attempted. R89's Care Plan showed, Apply [cotton roll] to right hand per MD (medical doctor) order to affected area. (initiated 9/10/24) The care plan does not show he has a behavior of refusing the cotton roll. The facility's Restorative Nursing Program Policy (Dated 3/10/22) showed, It is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently as possible. The policy continued, Activities provided by restorative nursing staff include.splint or brace assistance. The policy showed, A physicians order will be obtained for therapy to evaluate and treat, as necessary.The restorative nurse will review the functional assessment and care plan with involved nursing staff and therapy to assure specific needs are identified, plan implemented, and resident placed in the appropriate restorative program(s).The restorative nurse will complete a periodic evaluation at least quarterly that will reflect the resident's tolerance and progress toward their goals.

Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner. This applies to one two (R136) reviewed for safety in the sample of 45.The findings include: The facility face sheet for R136 shows she has diagnoses to include vascular dementia, congestive heart failure, morbid obesity and history of falls. The facility assessment for R136, dated 10/30/2025, shows she has moderate cognitive impairment and requires touching assistance from staff with toilet transfers. The care plan for R136, dated 8/19/2024, shows she has poor safety awareness and poor endurance and an intervention to use a gait belt for transfers and ambulation was in place.On 12/2/2025 at 10:21 AM, R136 was being assisted to the toilet by V7, CNA (Certified Nursing Assistant). V7 pushed R136 up to the toilet and told her to stand up. V7 was using the back of R136's pants to help stabilize R136 as she stood and pivoted to the toilet. When R136 was finished using the toilet, V7 told R136 to stand up and she would clean her up. As R136 was standing and V7 was cleaning R136 skin, R136 began to yell she couldn't stand up anymore and her knees were observed beginning to give out. V7 was observed pulling up R136 pants and using the pants to help guide R136 to her wheelchair. V7 was never observed applying a gait belt to R136 to assist with the transfer to and from the toilet.On 12/4/2025 at 10:47 AM, V8, CNA, said a gait belt should always be used for the resident's safety during a pivot transfer.On 12/4/2025 at 11:00 AM, V2, DON (Director of Nursing), said a gait belt is to be used for every pivot, 1-2 person transfer for the safety of the resident.The facility policy, dated 9/2020, for gait belts shows to assist with a transfer or ambulation a gait belt will be used with weight-bearing residents who require hands on assistance.

Based on observation, interview, and record review, the facility failed to address a recommendation by the Registered Dietitian to increase a resident's enteral feeding for 1 of 4 residents (R5) reviewed for tube feedings in the sample of 45. The findings include: R5's admission Record, provided by the facility on 12/4/2025, showed diagnoses including, but not limited to adult failure to thrive, severe protein-calorie malnutrition, encounter for attention to gastrostomy (feeding tube), memory deficit following cerebrovascular disease, adjustment disorder, epilepsy, depression, and aphasia following cerebral infarction (a language disorder caused by brain damage-often from a stroke, injury, or tumor-that impairs speaking, understanding speech, reading, and writing). On 12/2/2025 at 11:32 AM, R5 was lying in bed. The head of R5's bed was up 45 degrees. No signs of distress were noted. A feeding delivery system was next to R5's bed, not running. Supplies for R5's tube feedings were in her room. A review of R5's electronic medical record showed current orders for enteral feedings of 960 ml (milliliters) daily, to be run at 80 ml an hour. R5's electronic medical records showed a nutritional assessment for R5 was completed on 11/14/2025 by V14 (Registered Dietitian). V14 had recommended increasing R5's enteral feeding to 1200 ml daily on 11/14/2025. R5's progress notes and care plans were reviewed and did not show any increase was attempted or initiated. On 12/3/2025 at 10:20 AM, V15 (Licensed Practical Nurse-LPN) said R5's enteral feeding starts at 6:00 PM nightly, infusing at 80 ml an hour for a total of 960 ml. V15 said R5 was eating before, and then she stopped eating. R5 was sent out to the hospital and came back with g-tube. V15 said she believes R5 has had that same amount since returning from the hospital. V15 looked through R5's electronic charting and said, It has always been 960 ml daily. It has never increased. On 12/3/2025 at 10:34 AM, V11 (Assistant Director of Nursing/Infection Control Nurse) said, (V14/Registered Dietitian) sends me a copy of her recommendation, and I notify the doctor to get the order. I let the nurses know of any changes. V2 (Director of Nursing-DON) was present during the conversation and said they have skin/weights meeting every week and go over any concerns. V2 said, (V14 /RD), The head of the Dietary Department, (V11 / ADON), and (V12, Wound Care Nurse) attend the weekly skin/weights meetings. Sometimes (V1, Administrator) will attend the meeting. V11 (ADON) looked on her computer and said she missed V14's recommendation to increase R5's enteral feeding. V11 and V2 said the recommendation was not followed up on. V11 said R5's doctor was not notified of the recommendation, and it was not followed up on. R5's Order Summary Report, provided by the facility on 12/4/2025 showed R5's enteral feeding order was not increased to 1200 ml a day until 12/3/2025. R5's November 2025 and December 2025 Medication Administration Records (MARS) showed R5 received 960 ml of enteral feeding daily from 11/14/2025-12/2/2025. The December 2025 MAR showed the enteral feeding order for 1200 ml daily to infuse at 80 ml hour was started on 12/3/2025 at 11:59 AM. R5's care plan, initiated on 10/28/2025, showed she requires tube feedings related to dysphagia, malnutrition, and adult failure to thrive. Interventions in place were to provide tube feeding per MD order, and monitor /record weight. Notify MD of significant weight changes. On 12/3/2025 at 11:09 AM, V2 (DON) said V11 (ADON) should have followed up with the Registered Dietitian's recommendations and updated R5's doctor. V2 said recommendations are made for the benefit of the resident. On 12/4/25 10:09 AM, V14 (Registered Dietitian) said she recommended increasing R5's tube feedings because she (R5) was a new g-tube patient. And she had a slight weight loss over the previous month. V14 said she increased R5's feeding to prevent further weight loss. R5's weight history showed she weighed 113 pounds in September 2025, 116 pounds on 10/25/2025, and 113 pounds on 11/25/2025. R5's weight on 12/4/2025 (observed by this surveyor) was 113.2 pounds. The facility's policy and procedure titled Nutrition Recommendations, with a revision date of 1/2018, showed Nutrition recommendations will be ordered or declined by the physician.1. All nutrition recommendations will be communicated by way of the Dietitian's Recommendation form. 2. All recommendations are copied. The facility will maintain a copy of the Licensed Dietitian's Nutrition Recommendations. 3. The originals are given to the director of Nursing or designee. 3. The DON designates someone to contact the physician for acceptance or refusal of the Licensed dietitian's recommendations.5. When the physician declines a Licensed Dietitian's (LD's) recommendation, nursing will document the refusal and rationale in the resident's medical record under nursing notes. Nursing will advise the Food and Nutrition Services Manager of the refusal. The Food and Nutrition Services Manager will advise the LD of the doctor's refusal.

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for the administration of oxygen for 1 of 1 resident (R122) reviewed for oxygen services in the sample of 45.The findings include:R122's face sheet showed she was admitted to the facility 10/8/25, with diagnoses to include chronic kidney disease, chronic respiratory failure, chronic congestive heart failure, hypertensive heart disease, muscle weakness, depression, and dependence on supplemental oxygen. R122's facility assessment, dated 10/15/25, showed she has mild cognitive deficit and requires assistance with transfers. R122's December 2025 Physician Order Sheet showed, Respiratory: Oxygen per nasal cannula at 2 liters per minute continuous. R122's care plan, initiated 10/21/25, showed, [R122] requires oxygen therapy; Continuous in Dx of Chronic Respiratory Failure, unspecified whether with hypoxia or hypercapnia. Interventions/Tasks. Adjust oxygen to maintain saturation within adequate parameters. R1's vital signs record for the morning of 12/4/25 showed R1's oxygen saturation was completed by V3, RN (Registered Nurse), and documented as 95%. On 12/2/25 at 12:19 PM, R122 was lying in bed with her oxygen on. R122's oxygen was set between 3.5 and 4 liters. On 12/4/25 at 11:07 AM, R122 was resting in bed with her oxygen on between 3.5 and 4 liters. On 12/4/25 at 11:36 AM, V3, RN (Registered Nurse), said, [R122's] oxygen is set at about 3 liters. This morning, she was on room air and her oxygen was good. She has it as needed as well and can be increased if it needs to be, but it depends on how her oxygen is. We usually start at 2 liters. I don't remember what her oxygen level was this morning. On 12/4/25 at 12:30 PM, V2, DON (Director of Nursing), said if the resident's order is for 2 liters, he doesn't know why it would be set higher. V2 said if the oxygen order is for a range they would be able to adjust the level, otherwise, the oxygen should be set to what the physician order it was an order that was put into a range they would be able to adjust it otherwise it should be set at the order. The facility's policy and procedure, dated 9/2020, showed, Oxygen Therapy Devices - Nasal Cannula. Policy: Oxygen delivered per nasal cannula, will be used to prevent and reverse hypoxia and improve tissue oxygenation. Procedure: 1. Verify physicians order.

Based on observation, interview, and record review, the facility failed to remove soiled gloves before touching any other clean surfaces. This applies to one of Six residents (R136) reviewed for infection control in the sample of 45.The findings include:On 12/2/2025 at 10:21 AM, R136 was being assisted to the toilet by V7, CNA (Certified Nursing Assistant). R136 had been incontinent of stool and V7 was cleaning her up standing in the bathroom. V7 wiped R136 and cleaned her skin of stool. V7 never removed her soiled gloves and then pulled up R136's pants and rubbed R136's back to comfort her. The facility face sheet for R136 shows she has diagnoses to include vascular dementia, congestive heart failure, morbid obesity and history of falls. The facility assessment for R136, dated 10/30/2025, shows she has moderate cognitive impairment and requires touching assistance from staff with toilet transfers and toileting hygiene.On 12/4/2025 at 10:47 AM, V8, CNA, said gloves should be changed when they become soiled and the hands should be cleaned before putting on clean gloves.On 12/4/2025 at 11:00 AM, V2, DON (Director of Nursing), said gloves should be removed and hands sanitized when they become soiled before touching any other surfaces. This is to help spread infections.The facility policy, dated 4/2024, for glove use shows gloves will be used to prevent the spread of infection and disease to other residents, personnel and visitors.

Based on observation, interview, and record review, the facility failed to ensure a resident with severe cognitive impairment and a history of wandering was supervised to prevent elopement. This failure resulted in R1 eloping from a secured memory care unit, exiting the building without staff identifying and preventing R1 from eloping. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. This applies to 1 of 6 residents (R1) reviewed for safety in the sample of 6. The Immediate Jeopardy began on 7/1/25, when R1 got on the elevators with another resident's family on the secured memory unit. R1 exited the first-floor elevators and ambulated out the front entrance without staff identifying R1 was eloping the facility. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. V1 (Administrator) was notified of the Immediate Jeopardy on 7/10/25 at 8:22 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 7/02/25, prior to the start of the survey on 7/08/25, and was therefore Past Noncompliance. This past non-compliance occurred from 7/1/25-7/2/25. The findings include: R1's face sheet shows she is an [AGE] year-old female, with diagnoses including vascular dementia, moderate without behavioral disturbance, hypertension, history of falling, ataxia, primary osteoarthritis, and hyperlipidemia. R1's Exit Seeking/Wandering/Elopement Risk Assessment, dated 6/9/25, shows she is at risk for elopement. R1's Fall Risk Assessment, dated 4/8/25, shows her mobility is unsteady and or/use of ambulatory aide, impaired memory and incontinent. R1's current care plan shows she has short term and memory impairment.she needs supervision and support throughout the day to maintain independence with activities of daily functioning (ADL). R1 has an ADL self-care deficit due to poor safety awareness, poor judgment, impaired balance, unsteadiness on feet and history of falling. R1 has a history of being at risk for elopement related to cognitive impairment. History of exit seeking behavior and physical ability to ambulate with walker. She continues to have compromised safety awareness. Interventions include frequent checks and supervision, monitor behaviors, staff/family escort when off secured unit. R1's facility EHR does not show documentation of R1 eloping from the facility in the medical record. R1's Final Incident Report, dated 7/7/25, shows on 7/1/25, R1 eloped from the facility, facility responded appropriately. R1 was taken to the local hospital for evaluation and returned. R1's Hospital Records, dated 7/1/25 at 8:31 PM, shows, (R1) arrives via EMS (Emergency Medical Services). EMS states someone called police, (R1) wandering around the streets to the grocery store with known baseline of dementia.brought in for evaluation for possible elopement. Family at bedside and they are upset that (R1) was not guarded appropriately and left the facility and found wandering.family and staff confirm (R1) has chronic cognitive impairment with occasional wandering behavior.On 7/8/25 at 11:38 AM, V1 (Administrator) and V2 (Director of Nursing) confirmed R1 eloped from the secured memory unit on 7/1/25. After the dinner meal around 6:30 PM, staff could not locate R1. V9 (Receptionist) said he saw someone who looked like R1 walk out of the building with family. V9 did not recognize R1 was leaving the building without her family. Both said family members had the access code to get on the elevators leaving the secured unit, and there is no alarm that alerts the staff a resident is attempting to exit the secured unit. On 7/8/25 at 9:41 AM, R1 was on the secured memory care unit, sitting in the dining room with her walker next to her. R1 was alert to self only. R1 could not recall the date, time, or where she was. This surveyor asked about the incident on 7/1/25. R1 could not recall the incident and stated, I did that, Oh my God. Did I get hurt? Oh my God, I must be losing my mind. I did not know I did that. On 7/8/25 at 11:52 AM, V7 (Certified Nursing Assistant) said on 7/1/25, she was R1's CNA. R1 was in the dining room at 5:00 PM for the dinner meal. At 5:40 PM, she left the dining room to assist other residents back to their rooms. At 6:30 PM, she could not locate R1. She asked V11 (Activity Aide), who was in the dining room supervising the residents, about R1. V11 said she did not know where R1 was. V7 said she notified V3 (R1's nurse) R1 was missing. (R1) is alert to self; she had a history of wandering when she first came to the facility. (R1) likes to lay down after meals and requires staff assistance to get back to her room. She uses a walker, and she is definitely not safe to leave the facility on her own. (R1) probably got on the elevator with someone else's family. (R1) should have been supervised to prevent her from leaving the unit attended.On 7/8/25 at 1:09 PM, V11 (Activity Aide) said on 7/1/25, she was supervising the dining room. She saw R1 leave the dining room about 5:40 PM. About 6:40 -7:00 PM, staff asked me if (R1) was in the dining room; she told them (R1) left the dining room by herself when she was done eating. V11 said R1 was not on the wandering list, and she did not report to staff when R1 left the dining room. On 7/8/25 at 12:09 PM, V3 (Registered Nurse/RN) said on 7/1/25, she was R1's nurse. R1 was in the dining room during dinner at 5:00 PM, she gave R1 medications after dinner. At about 6:30 PM, she was finished passing her evening medications, and V11 (CNA) reported they could not locate R1. We called a code a green to search for (R1), but we could not locate her. She called V9 (Receptionist) and asked if he had seen R1. V9 said there was someone who fits the description of R1 who left the facility with family. V9 said he was not 100 percent sure if that was R1 because he was not familiar who R1 was. V3 said R1 got on the elevator, and she was busy passing medications. She was not paying attention who was getting on the elevator. R1 looks like a resident, and she is not safe leaving the building unsupervised. Increased supervision should have happened, those are the busiest times of the night, after the dinner meal. On 7/8/25 at 12:30 PM, V9 (Receptionist) said on 7/1/25, he was working at the front desk, he heard a code green overhead, and he received a call from V3 (RN) asking if he saw R1. V9 said he did recognize R1 by name, then looked her up in electronic health records and said he saw R1 leave the building with family. I assumed they were family because they were walking together. V9 said, (R1) looked normal to me. V9 said he could not recall about what time this occurred. He said there is an elopement binder at the front desk, with each resident's name and picture, but he had not seen R1 before and did not review the binder every shift. On 7/8/25 at 12:09 PM, V8 (CNA) said R1 was in the dining room during the dinner meal at 5:00 PM. About 5:45 PM, she left the dining room to assist other residents, R1 was still in the dining room sitting at her table. At 6:00 PM, she was in another resident room assisting with cares. About 6:30 PM, staff were looking for R1 and could not locate her. (R1) usually needs direction to get back to her room when leaving the dining room. There is usually someone supervising her to her to room. The activity aide should report to staff when a resident is leaving the dining room, so we are aware. I'm guessing she got on the elevator with another resident's family because you need a code to get on the elevator and visitors are given the code.On 7/10/25 at 8:34 AM, V12 (RN) said on 7/2/25, he was R1's nurse after she returned back to the hospital. There was a concern she had fallen when she was found outside of the facility. They did x-rays and scans with no injury. (R1) is alert to self, she has a history of wandering into other resident rooms, and she needs to be directed and supervised. There is a reason why she is on a secured memory care unit, because she is ambulatory, she is at risk of eloping. You never know what's on her mind or what she is thinking.On 7/8/26 at 2:13 PM, V13 (R1's Power Of Attorney/POA) said she was out of the country when all this happened, but she received a call from the facility at 7:18 PM. They said they saw her last after dinner and thought she was with me. (R1) got on the elevator with another resident's family member. She called her other sisters to inform them of the incident. Her sister arrived in the facility about 7:45 PM, and the police had not been notified yet. Someone called the police and reported R1 was found wandering at the outside of the grocery store without her walker. They reported she fell because there was grass found in her hair. When R1 was living with her, she had an episode of eloping from her home, and that's when she was sent to the facility. She was no longer safe to be home because she needed more supervision. On 7/9/25 at 9:04 AM, V14 (R1's daughter) said, On 7/1/25 about 8:00 PM, I received a call from the facility asking me if my mom (R1) was with me. They said my mom (R1) had been missing since 7:30 PM. I was going to call my siblings to ask if they were with mom. My other sister arrived at the facility and asked if they had called the police yet. The facility had not notified law enforcement, which is a big problem, because my mom (R1) has dementia. My sister called the police and reported her missing, and they told her someone reported a wandering person at the local grocery store. My mom was sent to the local hospital for evaluation. When she arrived to the hospital, (R1) had grass clippings in her hair, and I was told (R1) was found on the floor by the paramedics. This was scary and nerve wracking. She got on the elevator and out the front door without anything alarming or anybody noticing she was a resident. They don't have a monitoring device to alert them someone is leaving their building; that should not be. I was concerned about her safety. She is not safe to be crossing that busy intersection. That's crazy she made it to the local grocery store in one piece she had to cross a busy intersection. The facility's Elopement and Management of Missing Resident Policy, dated 2023, states, Elopement is defined as a dependent (cognitively impaired, non-decisional) resident leaving a facility without staff awareness and under circumstances that place the resident's health, safety, or welfare at risk. Suspected Missing Resident. if a resident are unaccounted for, notify the Administrator and Director of Nursing. Direct all staff to make a thorough search of the building and external premises. In unable to locate the resident, call 911 to report the resident missing. Notify resident's legal representative/responsible party.complete incident report. Document accordingly in the medical record. The Immediate Jeopardy began on 7/1/25, and the deficient practice was corrected on 7/2/25, when the facility took the immediate actions to remove the immediacy. Abatement Plan was provided on 7/10/25. The facility implemented the following correction action/abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) committee. A head count was completed on all units to ensure no other Residents were affected. Everybody was accounted for. Completed 7/1/25.All facility door alarms were checked for proper functionality. All doors in working order. Completed 7/1/25 ongoing.All residents, including the resident in question, were assessed for exit-seeking behaviors. Completed 7/1/25.A body check and NP (Nurse Practitioner) evaluation completed upon return to facility. Completed 7/2/25.Resident care plan was updated pertaining to incident, and interventions added on 7/2/25.The Administrator, Nurse Consultant, and Medical Director reviewed the facility policies related to the occurrence: Door Alarms, Routine Resident Checks, Incidents/Accidents and Wandering. No changes were made. Completed 7/1/25.The DON (Director of Nursing, ADON (Assistant Director of Nursing), and Social Services/Designee reviewed and updated as needed related to patient safety care plans. Completed 7/2/25.The elopement binder was reviewed and updated on 7/1/25 and available at designated areas.All residents determined to have exit seeking behaviors have been evaluated for possible room change to the alarmed unit of the facility. Completed 7/2/25.All staff were in-service on the following topics: How to redirect residents that are wandering residents away from exits, how to promote safer outcomes for residents through supervision, answering door alarms promptly and reporting any changes in cognition or exit seeking behaviors to the nurse. Everyone that has worked has been in serviced. Inservice is ongoing until all employees have been educated.All staff and managers are being reeducated on routine resident checks, incident/accidents, wandering policy, and where to locate the at-risk elopement binders. Everyone that has worked has been in serviced. Inservice is ongoing until all employees have been educated.Pop quizzes are being completed by the staff to test competency on elopement, answering door alarms, change in cognition/exit seeking behaviors. Completion 7/2/25Elevator access code has been changed and only staff members have code. Staff will assist all visitors with elevator use. Visitors must sign in and receive a visitor badge to wear while in the building.A review of compliance using QA (Quality Assurance) tool for response to elopement and change in cognition and exit seeking behaviors completed on 7/2/25. Audits will be done daily for 1 month or until compliance is maintained.The QA meeting is held quarterly and as needed. An emergency QA meeting was held on 7/2/25 at 9am by the Administrator with the Interdisciplinary Care Team and Medical Director regarding the incident and to discuss the plan. QA Committee agrees with the plan above.

Based on interview and record review, the facility failed to honor the decisions of a hospice resident's health care Power of Attorney for 1 of 3 residents reviewed for rights exercised by a resident's representative in the sample of 3. The findings include: R1's facility care plan, dated [DATE], showed R1 was under hospice care due to her diagnoses of senile degeneration of the brain, cerebral atherosclerosis, and dementia. R1 was severely cognitively impaired and dependent on staff for cares. The plan showed, Coordinate care and services between facility caregivers and hospice company to ensure all resident needs are met . Obtain advanced care planning wishes of patient and family and incorporate them into the plan of care . R1's Power of Attorney for Health Care form, dated [DATE], showed V10 (Family of R1) was R1's healthcare Power of Attorney (POA). The form showed R1 authorized V10 to make decisions for R1 when R1 could no longer make decisions for herself. The form showed R1 did not want any treatment to prolong her life, but wanted treatment to ensure comfort and no pain. R1's POLST form (Practitioners Orders for Life-Sustaining Treatment), dated [DATE], showed R1 was a DNR (do not resuscitate). R1's facility progress note, dated [DATE], showed R1 began having difficulty swallowing her medications and food. R1's facility progress note, dated [DATE], showed V10 (POA/Family of R1) requested R1 become NPO (nothing by mouth) due to R1's declining condition and continued inability to swallow food or medications. The note showed R1's hospice provider and V3 (Assistant Director of Nursing/ADON) agreed with V10's request to make R1 NPO. R1's physician order, from V5 (R1's Hospice Physician), dated [DATE], showed an order for R1 to be NPO. A physician order for R1, dated [DATE], showed R1's NPO order was discontinued. An order for R1 to receive pleasure feedings, was noted on [DATE]. R1's progress notes, dated [DATE]-[DATE], showed R1's condition continued to decline. R1 expired in the facility, under hospice care, on [DATE] On [DATE] at 12:57 PM, V10 (R1's POA) stated, (R1) started having trouble swallowing on [DATE]. I knew what was coming. She has been on hospice a long time and suffered enough. By Monday ([DATE]), I requested for her to be NPO. She couldn't swallow at all. She was gurgling at that point. She wasn't responding at all. Initially, (V3, ADON) told me she was ok with my request for NPO. On Tuesday ([DATE]), (V3, ADON) tells me (R1) can't be NPO because there is some regulation saying she can't be. (V1, Administrator) tells me she can't be NPO because it's some corporate rule. I told them absolutely not. (R1) is actively dying. I was concerned she would choke if they fed her. I just wanted her to die comfortably. On [DATE] at 12:29 PM, V8 (Registered Nurse/RN) stated, By that Monday ([DATE]), (R1) couldn't swallow at all. We weren't feeding her anyway. (V10, R1's POA) told me she wanted (R1) to be NPO. (V7, Hospice Nurse) told me there was an order to be NPO. The next day, (V3, ADON) said she couldn't be NPO. I don't know why. From Tuesday on, we didn't feed her because she couldn't swallow. On [DATE] at 12:09 PM, V3 (ADON) stated R1's NPO order was discontinued because it was unethical to not feed R1 if R1 wanted to eat. V3 denied she told the NPO order was discontinued because of a regulation. V3 stated she had never reviewed R1's hospice care plan, hospice progress notes, or R1's health care Power of Attorney form. V3 stated she never spoke with V5 (R1's Hospice Physician) about discontinuing R1's NPO order. On [DATE] at 10:15 AM, V7 (Hospice Nurse) stated, Yes, we have written orders for our residents to be NPO if they can no longer swallow and the family requests it. By Monday ([DATE]), (R1) could not swallow at all. Her mouth remained open the entire time and she didn't move her tongue at all. She was actively dying. (V10, R1's POA) wanted an order for her to be NPO, so I got an order from (V5, R1's Hospice Physician) to make her NPO. On Tuesday, I got a message from (V3, ADON) saying (R1) couldn't be NPO, and she must be a pleasure feed. I had no idea why (V3) was saying (R1) couldn't be NPO. We did not discontinue the NPO order; the facility did. On [DATE] at 1:24 PM, V1 (Administrator) stated she had never reviewed R1's hospice care plan, hospice progress notes, or R1's health care Power of Attorney form. V1 stated, I spoke with (V10, R1's POA) one time because she was upset the NPO order was changed. I tried to explain why we wanted pleasure feeds for (R1). We looked at it if as we were starving (R1). She still wanted (R1) to be NPO.

Based on interview and record review, the facility failed to designate a staff member, or implement a process, to ensure effective, ongoing communication and collaboration between the facility, a hospice resident's Power of Attorney for health care (POA), and the hospice provider. The facility failed to ensure facility staff had access to and reviewed a resident's hospice plan of care and hospice progress notes. These failures apply to 1 of 3 residents (R1) reviewed for care and services of a hospice resident in the sample of 3. The findings include: R1's facility care plan, dated [DATE], showed R1 was under hospice care due to her diagnoses of senile degeneration of the brain, cerebral atherosclerosis, and dementia. R1 was severely cognitively impaired and dependent on staff for cares. The plan showed, Coordinate care and services between facility caregivers and hospice company to ensure all resident needs are met . Obtain advanced care planning wishes of patient and family and incorporate them into the plan of care . R1's Power of Attorney for Health Care form, dated [DATE], showed V10 (Family of R1) was R1's healthcare Power of Attorney (POA). The form showed R1 authorized V10 to make decisions for R1 when R1 could no longer make decisions for herself. The form showed R1 did not want any treatment to prolong her life, but wanted treatment to ensure comfort and no pain. R1's facility progress note, dated [DATE], showed R1 began having difficulty swallowing her medications and food. R1's facility progress note, dated [DATE], showed V10 (POA/Family of R1) requested R1 become NPO (nothing by mouth) due to R1's declining condition and continued inability to swallow food or medications. The note showed R1's hospice provider and V3 (Assistant Director of Nursing/ADON) agreed with V10's request to make R1 NPO. R1's physician order, from V5 (R1's Hospice Physician), dated [DATE], showed an order for R1 to be NPO. A physician order for R1, dated [DATE], showed R1's NPO order was discontinued. An order for R1 to receive pleasure feedings was noted on [DATE]. R1's progress notes, dated [DATE]-[DATE], showed R1's condition continued to decline. R1 expired in the facility, under hospice care, on [DATE] On [DATE] at 12:57 PM, V10 (R1's POA) stated the facility did not designate a staff member for her to contact when she had questions about R1's cares. V10 stated, I kept getting inconsistent messages depending on who I talked to. I talked with (V3, ADON). I talked with (V1, Administrator). I talked with (V8, Registered Nurse/RN). (R1) started having trouble swallowing on [DATE]. I knew what was coming. She has been on hospice a long time and suffered enough. By Monday ([DATE]), I requested for her to be NPO. She couldn't swallow at all. She was gurgling at that point. Initially, (V3, ADON) told me she was ok with my request for NPO. On Tuesday ([DATE]), (V3, ADON) tells me (R1) can't be NPO because there is some regulation saying she can't be. (V1, Administrator) tells me she can't be NPO because it's some corporate rule. (R1) was actively dying. I was concerned she would choke if they fed her. I just wanted her to die comfortably. On [DATE] at 10:02 AM, V2 (Director of Nursing/DON) stated the facility had not designated a staff member to act as liaison between hospice, the facility, and V10 (R1's POA). This surveyor asked V2 for access to all R1's hospice visit notes, R1's hospice care plan, and the facility's contract with R1's hospice provider, as none of this information was in R1's electronic medical records, or in a binder in the facility. At 10:33 AM, V2 (DON) stated, We don't have any of (R1's) hospice charting or care plan. I had to request it from hospice. I am still looking for the contract. On [DATE] at 12:29 PM, V8 (RN) stated, By that Monday ([DATE]), (R1) couldn't swallow at all. We weren't feeding her anyway. (V10, R1's POA) told me she wanted (R1) to be NPO. (V7, Hospice Nurse) told me there was an order to be NPO. The next day, (V3, ADON) said she couldn't be NPO. I don't know why. From Tuesday on, we didn't feed her because she couldn't swallow. V8 (RN) stated she was never able to find a hospice binder with R1's hospice charting. V8 stated she had never seen R1's hospice plan of care. On [DATE] at 12:09 PM, V3 (ADON) stated R1's NPO order was discontinued because it was unethical to not feed R1 if R1 wanted to eat. V3 (ADON) denied she told V10 (R1's POA) the NPO order was discontinued because of a regulation. V3 stated she had never reviewed R1's hospice care plan, hospice progress notes, or R1's health care Power of Attorney form. On [DATE] at 10:15 AM, V7 (Hospice Nurse) stated, By Monday ([DATE]), (R1) could not swallow at all. (V10, R1's POA) wanted an order for her to be NPO, so I got an order from (V5, R1's Hospice Physician) to make her NPO. On Tuesday, I got a message from (V3, ADON) saying (R1) couldn't be NPO and she must be a pleasure feed. I had no idea why (V3) was saying (R1) couldn't be NPO. V7 stated the facility had not designated a staff member for her to contact and communicate with in regards to R1's hospice cares. V7 stated she would speak with the nurse caring for R1 on the days she would visit R1. On [DATE] at 1:24 PM, V1 (Administrator) confirmed the facility had to call R1's hospice provider on [DATE] to get copies of R1's hospice charting, including R1's hospice plan of care. V1 (Administrator) stated the facility did not designate a staff member to act as liaison between hospice, the facility, and V10 (R1's POA). V1 stated, Hospice staff will communicate with us when they are here seeing our residents, but we need to make sure we have access to any resident's hospice charting, including the hospice care plan. I spoke with (V10, R1's POA) and tried to explain why we wanted pleasure feeds for (R1). She still wanted (R1) to be NPO. I am not sure if anyone from our Social Services department met with (V10) at all during this time. The Memory Care Director (for R1's unit) resigned a couple of weeks ago. She would normally meet with family. The facility's Hospice Program policy, dated ,d+[DATE], showed, When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms.

Based on interview and record review, the facility failed to ensure a signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician. This applies to 1 of 28 residents (R96) reviewed for Advanced Directives in the sample if 28. The findings include: R96's Facesheet, dated 9/10/24, shows R96 has a current advance directive of Full Code. R96's Facesheet also shows V13 (R96's Family Member) is R96's Healthcare Surrogate. On 9/10/24 at 10:50 AM, R96 said someone from the facility spoke with him and V13 about changing his Advanced Directive information approximately two to three weeks ago. R96 could not recall who they spoke with. R96 said his current wishes are to continue with finalizing his Do Not Resuscitate (DNR) status, stating he has been through enough already. R96's Social Service Quarterly Assessment, dated 8/14/24, completed by V12 (Corporate Social Services) states, Wife (V13) expressed interest in completing a POLST form. Wife requested copy of the form be left at reception desk for her to retrieve during her visit. R96's POLST form, uploaded to the medical records on 8/30/24, shows R96 and V13 signed the form on 8/17/24. On 9/11/24 at 9:55 AM, V10 (Director of Social Services) said obtaining a resident's preferred Advanced Directive status is part of the admission process. V10 will speak with the resident or their representative and inquire what their wishes are, and will get the appropriate paperwork completed based upon their wishes. If the resident has a previously completed POLST form, the facility will retrieve a copy, upload it to the medical record, and update the Advanced Directive in the medical records to match the residents preference. V10 said the POLST form is not valid until the resident's physician signs it, and that process usually takes 24 to 48 hours once the resident and family representative sign it and return it to the facility. V10 was not familiar where in the process R96 was with his POLST form. At 12:40 PM, V10 said a call was placed to V13, but V13 did not answer. On 9/11/24 at 4:01 PM, V1 (Administrator) said R96 went to the hospital on 8/29/24, and returned to the facility on [DATE]. The facility was unable to provide documentation prior to the exit on 9/11/24 showing the facility followed up with V13 or R96's physician any time between 8/14/24 and 8/29/24, or after R96's readmission on 9/6/24.

Based on interview and record review, the facility failed to follow its abuse policy by reporting and investigating allegations of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She was out on the patio and R115 came out there. She told V14 (Social Worker), who no longer works at the facility. V14 told her she would take care of it. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated R56's allegation of abuse were not reported to her, and she has not done any abuse investigation. The facility's abuse policy, dated September 2020, shows, Policy: This facility affirms the right of our residents to be free form abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect of abuse of our resident this will be done by: .6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports . Abuse Prevention Program: .4. Identification: Employees are required to immediately report any occurrences of potential mistreatment they observed, hear about, or suspect to a supervisor or the administrator . Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation 6. Investigation: a. Appoint an investigator. Once an allegation has been, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident.

Based on interview and record review, the facility failed to ensure staff reported allegations of sexual abuse to the Administrator immediately. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She told V14 (Social Worker), who no longer works at the facility. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated V14 (Social Worker) never reported to V1 (Administrator), who is the abuse coordinator. V1 stated allegations of abuse should be reported to her. R115's care plan, dated July 29, 2024, shows, (R115) demonstrates socially inappropriate behaviors as evidenced by attempting to/actually touching females in the facility. R56's and R115's electronic medical records do not show any documentation regarding the incident.

Based on interview and record review, the facility failed to investigate an allegation of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She was out on the patio and R115 came out there. R115 came over to R56 and grabbed her breast. She asked him to stop and then continued to go down her shirt and up her shirt touching her breast again. She told V14 (Social Worker), who no longer works at the facility. V14 told her she would take care of it. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated she spoke with R56 the night before. R56 refreshed her memory and reminded her of the situation on the patio. R56 did inform V14 (Social Worker) that R115 touched her blouse in the breast area. V14 (Social Worker) never reported it to V1 (Administrator), who is the abuse coordinator. V1 (Administrator) stated she did not do any investigation into R56's allegation that R115 touched her breast on the patio last summer. If it was reported to her, she would have done an abuse investigation. R56's SSD (Social Service Department) Brief Interview for Mental Status, dated August 14, 2024, shows she is cognitively intact. R115's SSD Brief Interview for Mental Status, dated July 23, 2024, shows he has a mild cognitive impairment. R115's care plan, dated July 29, 2024, shows, (R115) demonstrates socially inappropriate behaviors as evidenced by attempting to/actually touching females in the facility. R115's and R56's electronic medical records do not show any documentation regarding the incident(s). The facility did not provide any abuse investigation regarding R56's allegation.

Based on observation, interview, and record revie,w the facility failed to ensure schedule II controlled substances were stored in a separately locked compartment for 2 of 28 residents (R54 and R92) reviewed for medication storage in the sample of 28. The findings include: 1. R54's Physician's Order Sheet, printed on 9/10/24, shows an order for Hydromorphone solution (Schedule II controlled substance) 4 milligrams/milliliter (mg/ml) to be given as needed for pain or shortness of breath. On 9/9/24 at 10:17 AM, there was a bottle of R54's Hydromorphone in the refrigerator that was located in the medication room on the second floor. The refrigerator had a lock located on the side of it, but the lock was not locked. 2. R92's Physician's Order Sheet, printed on 9/10/24, shows an order for Hydromorphone solution (Schedule II controlled substance) 4mg/ml to be given as needed for pain or shortness of breath. On 9/9/24 at 10:17 AM, there was a bottle of R92's Hydromorphone in the refrigerator that was located in the medication room on the second floor. The refrigerator had a lock located on the side of it, but the lock was not locked. On 9/10/24 at 2:20 PM, V2 (Director of Nursing) said Hydromorphone should be stored in a double locked medication cart, or in the refrigerator in the medication room. V2 said the door to the medication room is locked, and the refrigerator should be locked as well. The facility's Storage/Labeling/Packaging of Medications Policy, dated 1/2022, shows,Schedule II controlled medications are stored under a double-lock system accessible only to licensed staff.

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn when providing care to a resident on enhanced barrier precautions (EBP) for 1 of 28 residents (R78) reviewed for infection control in the sample of 28. The findings include: R78's Physician's Order sheet shows an active order, dated 12/28/22, for, EBP for Device Care or Use of Feeding Tube. R78's Care Plan shows she requires tube feeding and stoma site care and has an intervention of: Enhanced Barrier Precautions will be implemented during high contact resident care activities. On 9/9/24 at 10:21 AM, there was a sign on R78's door showing she was on EBP. V4 and V5 (Certified Nursing Assistants) went into R78's room and provided incontinence care to R78 and changed her bedding. V4 and V5 did not have a gown on while providing the care. On 9/10/24 at 2:01 PM, V9 (Infection Preventionist) said residents on tube feeding should be on EBP. V9 said staff should wear PPE (gloves and gown) anytime they are going to be providing care to the resident. The facility's Enhanced Barrier Precautions Policy, dated 12/14/24, shows, EBP (Enhanced Barrier Precautions) 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 High-Contact Resident Care Activities include the following: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP. Some examples may include feeding tube .

Based on interview and record review, the facility failed to ensure a resident received an influenza vaccine following admission to the facility. The facility also failed to ensure a resident was offered a second pneumonia vaccine. This applies to 2 of 5 residents (R116, R90) reviewed for immunizations in the sample of 28. The findings include: 1. R116's Face Sheet current Face Sheet shows she was last admitted to the facility on [DATE]. R116's Informed Consent Influenza Immunization Vaccine 2023-2024 shows the box marked for Unless medically contraindicated, I give the facility permission to administer the influenza immunization vaccine. The back of this same form shows: Legal Representative Signature: (Typed R116's son's name), and dated 10/25/23. On 9/11/24 at 12:44 PM, V9 (Infection Preventionist) stated, I followed up with the son and he refused the vaccine- the nurse did the consent, but then the son refused. V9 was asked where this was documented, and V9 stated she just put refused on the immunization page in R116 EMR (electronic medical record), but didn't document anything more about it. R116's EMR shows she did not receive the influenza vaccine in 2023. The facility Influenza Vaccination Policy, dated 12/14/23, states, All new admissions will be offered the influenza vaccine during October 1st through March 31st unless ordered otherwise or has already received the influenza vaccine. If consented or declined, it will be documented in the residents' medical records. Historical information will be entered if available. 2. R90's current Face Sheet shows R90 was last admitted to the facility on [DATE]. R90's Informed Consent for Pneumococcal Immunization Vaccine, dated 9/6/23, shows the box checked stating: I have already received Pneumococcal Vaccine PCV13. On 9/11/24 at 12:44 PM, V9 (Infection Preventionist) stated, We will go back to the family and get a consent for the other vaccine. He got the (PCV) 13, so he can't get the other one for 5 years. R90's (IDPH- State Health Department) Shot History Details Report (reviewed by the facility on 9/11/24) shows R90 received the PCV13 Vaccine on 1/1/2009, the PPSV23 on 1/1/2010, and the PCV13 again on 10/24/2020. The facility policy entitled Pneumococcal Vaccination, dated 12/11/23, states, It is it the policy of this facility that residents will be offered immunization against pneumococcal disease in accordance with the Advisory Committee on Immunization Practices (ACIP) recommendations and Previously received only PCV13: 1 dose PCV20 or 1 dose PPSV23. If PCV20 selected, administer at least 1 year after the last PCV13 dose. If PPSV23 is selected, administer at least 1 year after the last PCV13 dose .

Based on interview and record review, the facility failed to ensure allegations of sexual abuse were reported to the police for 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: On 8/26/24 at 9:41 AM, R1 said V5 (Certified Nursing Assistant/CNA), was behind the curtains and touched her breast. R1 said she told a nurse and a Social Worker about the incident. R1 said no one has followed up with her about the incident to investigate or communicate a plan. R1 did not provide any other details about the incident and reported seeing V5 in the facility, but said he does not come near her. R1 said she feels nervous sometimes when she sees V5. On 8/26/24 at 11:12 AM, V1 (Administrator) said V2 (Assistant Administrator) did the investigation into the sexual abuse allegations from R1 against V5. V1 said she does not know if the police were informed of the allegations. On 8/26/24 at 11:33 AM, V2 said they did not file a police report because R1's sister did not want them to. On 8/26/24 at 11:58 AM, V3 (Director of Nursing) said he did not notify the police of R1's allegations of sexual abuse. R1's current care plan initiated on 6/18/24 shows R1 is cognitively intact and her own decision maker. The facility's sexual abuse investigation, initiated on 8/9/24, regarding allegations from R1 against V5 was reviewed in its entirety. No police report was included and no police report number was recorded. R1's statement does not mention anything about the police. The facility's Abuse Policy (dated 9/20) shows the facility will report reasonable suspicion of a crime and local police are to be called.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer prior to a Stage 3 for 2 residents (R82,R55), failed to identify a pressure ulcer prior to a Stage 2 for 2 residents (R136,R126), failed to implement pressure reducing interventions for 1 resident (R55), failed to provide repositioning for 1 resident (R136). These failures resulted in R82 developing an avoidable Stage 3 pressure ulcer. These failures apply to 4 of 8 residents (R82,R55,R136,R126) reviewed for pressure ulcers in the sample of 32. The findings include: 1) R82's electronic face sheet, printed on 12/17/21, showed R82 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R82's facility assessment, dated 11/8/21, showed R82 has severe cognitive impairment and has no pressure injuries. R82's wound assessment form, dated 11/18/21, showed, Stage 3, 0.7cm x 0.5cm x 0.1cm, 50% slough, and scant bloody exudate. R82's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were initials on 11/2/21, 11/10/21, 11/17/21, and 11/23/21, indicating the skin check had been completed for R82 on a weekly basis. There were no progress notes prior to 11/18/21 showing any alteration in R82's skin. R82's care plan, updated 12/15/21, showed, (R82) is noted actual for skin integrity noted right ischial pressure injury due to needing assist with personal care, incontinent of bowel and bladder and staff provides extensive assist with bed mobility. G-tube site redness, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R82's physician wound assessments of R82's right ischial wound showed, 11/24/21 Pressure ulcer stage 3. 12/8/21 subcutaneous debridement to right ischial. Tissue debrided was necrotic subcutaneous. R82's wound assessment, dated 12/17/21, showed no improvement in the size of R82's pressure ulcer from the previous week. On 12/16/21 at 9:49 AM, V6 (Wound Care Nurse-Licensed Practical Nurse) provided wound care to R82. V6 removed a foam dressing from R82's right ischial area, exposing R82's wound. V6 stated, She has a facility acquired Stage 3 pressure ulcer. The first time I assessed it, it was a Stage 3. The wound physician or nurse practitioner visits (R82) every week now for her wound. On 12/17/21 at 9:25 AM, V6 stated, (R82's) wound was identified at a stage 3. It should have been identified when there was redness or pain. If it would have been identified earlier we could have put preventative measures are in place. Any opening of the skin should definitely be reported to the nurse so we can implement measures to reduce the risk of the wound worsening. (R82) likes to be up in the chair all day but we try to get her to lay down after meals. This wound definitely should have been identified before a stage 3. There would have been skin alterations that the staff should have seen. It was identified on 11/18/21 as a stage 3. I never had any reports prior to 11/18/21 of any skin alterations for (R82). On 12/17/21 at 10:36 AM, V20 (Wound Care Advanced Practice Nurse) stated, (R82) has a Stage 3 pressure ulcer to her right ischial. The first time we saw her on wound rounds was on 11/24/21. It should have been identified prior to a stage 3. If it was identified earlier it would not have progressed this far. It may have just stayed as moisture associated skin breakdown for this particular resident. In my opinion, this wound was avoidable for (R82). The facility's policy titled, Prevention And treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Procedure .8. At least daily, staff should remain alert for potential changes in the skin condition during resident care. 2. R55's MDS (Minimum Data Set), dated 10/15/21, showed cognitive impairment; no behaviors; extensive assistance needed for bed mobility, dressing, toilet use, and personal hygiene; total dependence for transfers and bathing; at risk for pressure ulcers. R55's Care Plan, dated 10/21/21, showed R55 has an actual alteration in skin integrity noted with cancer lesion on multiple areas of R55's head presenting as a scab and open wounds, and to the right chest related to [CONDITION(S)] of skin. R55 needs assist with personal care, incontinent of bowel and bladder and extensive assist with bed mobility related to muscle weakness. Inspect skin daily with care. Position body with pillows/support devices. R55's care plan was not updated with the unstageable pressure ulcer to his right heel. The Skin/Wound Progress note completed by the floor nurse, dated 12/13/21 for R55, showed R55 had a wound to the right heel that was red with serous drainage and measured 2 cm x 4 cm. The WASA (Wound and Skin Assessment Form) completed by the wound nurse,dated 12/14/21 for R55, showed R55 had a new area of pressure to R55's right heel identified on 12/13/21, was unstageable, and measured 2.5 cm x 2.5 cm. Additional comments on the form showed, Staff to offload heel with pillow. On 12/15/21 at 8:32 AM, R55 was asleep sitting in R55's wheelchair in R55's room. R55 had gripper socks on and R55's heels were resting on the foot rests of R55's wheelchair. On 12/15/21 at 3:48 PM, R55 was sitting in R55's wheelchair with gripper socks on both feet. R55 was using R55's heels to propel R55's wheelchair backwards in R55's room. The foot rests were not in use on R55's wheelchair. On 12/16/21 at 9:50 AM, R55 was sitting in R55's wheelchair in R55's room with gripper socks on both feet. R55's foot rests were not in use on R55's wheelchair and R55's feet were on the floor. R55 used R55's heels to move R55's wheelchair backwards from the doorway of R55's room. On 12/16/21 at 11:15 AM, V6, LPN (Licensed Practical Nurse/Wound Nurse), stated, (R55) has a facility acquired unstaged pressure injury. We do a dressing change daily and when he is in bed it is elevated with pillows. (R55) has foot rests to his wheelchair to offload his heels when he is up. The pressure ulcer to his heel was first identified on 12/13/21 and it was unstageable when we first found it. It was alerted to me the same day it was found. I educate staff on skin and what to look for and the CNA's (Certified Nursing Assistants) are taught to look for any changes to the skin and report it right away. I tell staff to look for redness, irritation, complaints of pain, and dry areas. They are to tell the nurse and the nurse will tell me. On wound rounds the wound nurse practitioner will stage it. On 12/16/21 at 1:11 PM, V2, DON (Director of Nursing), stated, Pressure should be identified upon admission, during showers, and during nursing care. They should be looking for any redness, open areas, and moisture related skin condition. They should check any area that the residents states they have pain. We try to identify pressure ulcers at a stage 1. Preventative measures should be utilized such as cushions to wheelchairs, low air loss mattress for pressure ulcers at a stage 3 or 4, or with multiple stage 2 pressure ulcers. Offloading heels if the resident has hard time or needs extensive assistance from staff. If the resident is in a wheelchair we can put a boot on if have a sore on their heel; we can use pillows with the foot rests to offload the heels. On 12/17/21 at 11:45 AM, V36 (Wound Care Nurse Practitioner) stated, R55 has a new pressure ulcer to his right heel. It wasn't there last week when I saw him and we check all of his skin. I was told he uses his heels to propel his wheelchair. It could have developed quickly depending on how much he was digging his heels in when he propels his chair. R55's heel is macerated with slough. Once the wound was identified they should have put preventative measures in place right away. If there aren't any measures in place they should call me or the primary doctor for orders. Weekly assessments and measurements should be done. Sometimes they don't always stage a wound until we come in. The wound should be assessed when it is identified. The Wound Care Nurse Practitioner's note, dated 12/17/21 for R55, showed, Pressure ulcer of the right heel, Stage 3. Plan of care - heels; offload with heel protectors or pillow. The facility's Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify the presence of pressure injuries and/or skin alterations. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. At least daily, staff should remain alert for potential changes in the skin condition during resident care. Develop a care plan for either actual or potential alteration in skin integrity and change as needed. Revise care plan approaches as needed based on resident's response and outcomes. The facility's Weekly Assessment of Skin Alteration form policy (3/2021) showed, Based on the findings of the completed WASA form: Determine appropriate interventions/changes and implement as needed on the care plan. 3. R136's electronic face sheet, printed on 12/16/21, showed R136 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R136's Minimum Data Set (MDS), dated [DATE], showed R136 is cognitively impaired, requires extensive assist for bed mobility, is at risk for developing pressure ulcer/injuries, and was admitted without pressure ulcer/ injuries. R136's Braden Scale for predicting pressure score risk, dated 12/7/2021, shows R136 is a high risk for developing pressure injuries. R136's Weekly Assessment of Skin (WASA), dated 12/7/21, shows R136 to have a stage 2 pressure ulcer to R136's sacrum and staff are to turn and reposition her every 2 hours with pillows. The assessment showed R136 had DTI's to both heels and they should be offloaded. R136's Unavoidable Pressure Injury or Condition, dated 12/8/21, shows heel protectors, offload with pillows, turning and repositioning in bed/wheelchair. R136's undated care plan showed, Position body with pillows/support devices initiated, heel protector boots to offload heels initiated, turn and reposition every two hours and as needed. R136's wound care note, dated 12/8/21, showed R136 had a sacral wound measuring 3 centimeters (cm) by 3 cm with a depth of 0.1 cm. The note also showed R136 had deep tissue injuries (DTI) to both heels with the right heel being the largest at 5 cm by 6 cm with zero depth. The note showed all three wounds should be offloaded. On 12/16/21 at 1:08 PM, V6, Wound Care Nurse, stated, The sacral area has an open stage 2. The other area is unstageable and classified as a DTI (Deep Tissue Injury). The stage 2 used to be a blister but now opened up. The area to the right heel has 2 areas black in color with burgundy color edges which is a DTI. This is a DTI to the left heel also. On 12/14/21 at 11:06 AM, R136 was lying in bed flat on R136's back. There was no heel positioning devices to keep R136's heels off the bed. The heel protector boots were sitting on the wall heater next to R136's bed. On 12/16/21, continuous observations were made from 8:30 AM until 12:54 PM. During this time, R136 was sitting up in R136's reclining wheelchair. R136 was not repositioned for a total of 4 hours and 24 minutes. On 12/17/21 at 10:41 AM, V20 (Wound Care Nurse Practitioner, WCNP) stated R136 should be repositioned every 2 hours and sitting for 4-5 hours is unacceptable. V20 stated, (R136) was not assessed to sit for longer than 2 hours. On 12/16/21 at 8:18 AM, V33 (Registered Nurse) RN stated (R136's) heels should have been elevated to prevent injury, and from putting pressure on the heels while in the bed. On 12/17/21 at 10:10 AM, V27 (Assistant Director of Nursing, ADON) stated, (R136's) pressure interventions are turning and repositioning, and laying her down. It is important to have interventions so that the pressure injury improves and does not get worse. V27 stated, For (R136's) program, they should position her every two hours when in bed. V27 stated, (R136) is only in the chair in the morning, they put her in the chair between 8:00 AM- 9:00 AM and they will put her down after lunch between 12:30 PM -1:00 PM. On 12/17/21 at 9:50 AM, V34 (License Practical Nurse/Hospice Nurse) stated, Even though she is on hospice the staff should be repositioning her every 1.5 to 2 hours. Any amount of repositioning is good and they should put a pillow under her hip and get her to her side. V34 stated, She has an air mattress but they still need to reposition her. Her heel boots are important for prevention. The facility's Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement preventative measures and appropriate treatment modalities for pressure injuries. 4. R126's face sheet showed diagnoses, including but not limited to: right-sided paralysis following [CONDITION(S)] disease, protein-calorie malnutrition, diabetes mellitus, heart disease, dysphagia, and hypertension. R126's facility assessment, dated 11/30/21, showed severe cognitive impairment and staff assistance required for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The assessment also showed R126 is frequently incontinent of urine and stool. R126's care plan showed a focus area related to skin integrity. Interventions included: Inspect skin daily with care. R126's Braden Scale, dated 11/30/21, showed at risk for pressure ulcer development. R126's December 2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order sheet showed an order started 2/22/21 for: [MEDICATION(S)] ointment 0.44-20.6% ([MEDICATION(S)]-[MEDICATION(S)]) apply to sacral topically every shift. On 12/16/21 at 9:30 AM, V16 and V18 (CNAs-Certified Nurse Aides) provided incontinence care to R126. The brief was removed and R126 was turned to R126's side. An eraser size open area was observed on R126's sacral area (upper buttock). V16 and V18 said they had also changed R126 earlier that morning, and provided pericare after R126 was found incontinent of urine. The aides stated any open areas to resident skin should be reported right away. The aides stated nursing staff already knew about R126's open areas, so they did not report anything yesterday or today. At 9:45 AM, R126's electronic record was reviewed with V19 (Registered Nurse). V19 stated there was no documentation in R126's electronic record related to open areas on his sacrum or any wound treatments in place. V19 said there are orders for an ointment to be applied to R126's sacrum every shift, therefore, any skin changes should have been noticed easily before today. V19 said, The open area should be reported to the wound care nurse right away so it can be assessed and monitored. Without treatment, it could get worse. On 12/16/21 at 10:41 AM, R126's sacrum area was examined by V19 and the surveyor. V19 said, Yes, that is an open area and does appear to be a stage two pressure ulcer. I will report it to the wound care nurse now. It has not been noticed until just today. On 12/16/21 at 1:54 PM, V2 (Director of Nurses) stated skin changes should be reported right away and a progress note done. The treatment nurse should be notified right away. It is important to capture the skin issue with the least amount of staging. There is a greater potential to heal the open area the earlier it is found. Not identifying and reporting the pressure ulcer means there is no way to begin the healing process. On 12/17/21 at 11:20 AM, V20 (Wound Care Nurse Practitioner) stated today is the first time V20 has seen the resident. V20 said there is a stage two pressure ulcer on the sacrum. V20 said, (R126) is a [CONDITION(S)] resident (stroke) and is prone to pressure ulcer development. This could have been avoided with thorough incontinence care and better turning. It is a preventable pressure ulcer. R126's wound assessment, dated 12/17/21, showed a stage two pressure ulcer to the coccyx measuring 0.5.x 0.8 x 0.1 centimeters, 100% open dermis, with light serous exudate. The facility Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . At least daily, staff should remain alert for potential changes in skin condition during resident care.

Based on observation, interview, and record review the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not wearing N95 masks for new admissions on transmission based precautions (contact/droplet precautions). The facility also failed to perform hand hygiene upon exiting rooms that are on transmission based precautions and after providing incontinence care to prevent the spread of cross contamination. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 147 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on February 12, 2021 when the facility stopped wearing N95's during resident care with new admissions on transmission based precautions. V1 Administrator was informed of the Immediate Jeopardy on March 10, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2021; however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The CMS 672 resident census and conditions report dated March 8, 2021 shows that there are 147 residents residing in the facility. The census order listing report provided by the facility on March 10, 2021 shows that there are 12 residents (R341, R193, R47, R194, R195, R196, R241, R117, R191, R192, R132, & R20) currently on contact/droplet isolation because they are new/readmitted admissions. The resident immunization report provided by the facility on March 10, 2021 shows, 85.7% of residents have been vaccinated for COVID-19. On March 10, 2021 at 10:18 AM, V1 Administrator stated, anyone who was admitted after the facility's last COVID-19 vaccine clinic is not vaccinated for COVID-19. Their last COVID-19 vaccine clinic was on February 18, 2021. R241, R191, R132, R341, R193, & R196 have not been vaccinated. 1. On March 8 & 9, 2021, during the annual survey, all staff were observed throughout the building, going in and out of contact/droplet isolation rooms and then rooms not on transmission based precautions, wearing only a surgical mask and face shield (not an N95). Each resident has a sign on their door from CDC called use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19 that shows, preferred PPE- use N95 or higher respirator. On March 9, 2021 at 1:37 PM, V3 Infection Control Nurse stated, since there is no positive COVID-19 cases in the facility the staff was just wearing a surgical mask and face shield. New admissions are on strict contact/droplet isolation where they also wear a gown and gloves. They only wear an N95 mask if they have a positive COVID-19 case or COVID-19 unit. The facility's COVID-19 testing plan and response strategy: interim guidance dated January 28, 2021 shows, Policy: The facility is committed to reducing the spread and transmission of COVID-19 and will continue to follow all guidance and recommendations from the CDC, state and local health departments. The facility's interim guidance: admission/readmission to long term care facilities dated May 11, 2020 shows, New and returning residents with unknown COVID-19 status may be considered for admission/readmission providing they are medically stable and following clinical discharge from the hospital . At the time of admission, the resident will be admitted to a single room within the designated facility transition area and will remain on contact/droplet precautions for 14 days from the date of admission. The facility's use of N95 respirators: interim guidance last updated February 12, 2021 shows, Respirator Usage: 1. 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 . 2. Unless otherwise directed, when caring for residents with known or suspected COVID-19 or residents who are quarantined upon admission, staff should don an N95 respirator before entering into the resident room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply . The CDC's preparing for COVID-19 in nursing homes last updated November 20, 2020 shows, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professional) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . 2. R20's Nurses' Notes dated 2/14/21 shows she was admitted to the intensive care unit at a local hospital with [DIAGNOSES REDACTED]. she was re-admitted to the facility on [DATE]. On 3/8/21 at 11:10 AM, there was contact/droplet isolation signs on the outside of R20's door. V4 CNA (Certified Nursing Assistant) was in R20's room removing R20's soiled gown and put a new one on. V4 did not perform hand hygiene upon exiting R20's room. At 12:00 PM, V6 LPN (Licensed Practical Nurse) went into R20's room with a surgical mask on and gave R20 an insulin shot and an oral medication. V6 did not wash her hands upon exiting V6's room. 3. R241's Face Sheet shows he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/8/21 at 10:09 AM, V5 CNA provided care to R241 and had a surgical mask on. V5 wiped a moderate amount of stool from R241's buttocks, touched R241's clean sheet, pillow, and R241's body without changing gloves or performing hand hygiene. At 12:15 PM, V6 gave insulin to R241 and had a surgical mask on. On 3/9/21 at 1:37 PM, V3 Infection Control Nurse stated, hand hygiene before and after care. If staff's hands become soiled during care, then they should remove their gloves and do hand hygiene again. The facility's Hand Washing and Hand Hygiene Policy dated 6/4/2020 shows, Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items. The Immediate Jeopardy that began on February 12, 2021 was removed on March 10, 2021 when the facility took the following actions to remove the immediacy. 1. Facility has obtained enough N95 masks to be able to provide staff the ability to wear these when treating and caring for residents that are newly admitted and under isolation/quarantine precautions. Corrected 3/10/21. 2. Staff has been in-serviced on the need to wear N95 masks when entering any isolation room utilizing transmission based precautions. Corrected 3/10/21 for staff on duty. All other staff will be in-serviced by 3/12/21. 3. Staff has been inserviced on the need to perform hand hygiene immediately after exiting an isolation room. Corrected 3/10/21 for all staff on duty. All other staff to be in-serviced by 3/12/21. 4. Clinical staff have been in-serviced on the need to perform proper hand hygiene during peri-care. Corrected 3/10/21 for staff on duty. All other clinical staff will be in-serviced by 3/12/21. 5. QA audits on hand hygiene in isolation rooms have begun immediately and are conducted on all shifts by the 2 Assistant Directors of Nursing. These will continue daily x one week and then weekly x 2 months. Corrected 3/10/21. 6. QA audits on peri-care related hand hygiene have begun immediately and are conducted on all all shifts by the 2 Assistant Directors of Nursing. These will continue daily x one week and then weekly x 2 months. Corrected 3/10/21. 6. Aggressive supply chain procurement and management of N95 masks has begun immediately. Corrected 3/10/21. 7. Staff continues to use environmental and source control measures as recommended by the CDC and per facility policy to supplement the above measures to prevent the spread of any infection within facility. Corrected 3/10/21.

Based on observation, interview and record review the facility failed to ensure adequate supervision was provided for a resident at risk for aspiration for one of three residents (R1) reviewed for dysphagia. After R1 was left with his meal tray unsupervised, R1 was found making gurgling noises and subsequently died on [DATE] due to asphyxia. This failure resulted in an immediate jeopardy. The immediate jeopardy started on [DATE] when the facility staff first became aware of R1's speech therapy recommendations for supervision during meals. The immediate jeopardy was identified on [DATE]. V1 Administrator was informed of the Immediate Jeopardy on [DATE] at 9:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was: removed on [DATE] at 4:55 PM, but the noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of training. The findings include: R1's State of Illinois Certificate of Death Worksheet certified [DATE] shows R1 expired [DATE] . cause of death: asphyxia, due to (or consequence of): choked on food bolus. R1's Face sheet shows R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Minimum (MDS) data set [DATE] shows R1 is cognitively impaired. R1's Video swallow study (done on [DATE] in the hospital) shows penetration of thin liquids and nectar liquids via a cup .penetration and aspiration as described. R1's Hospital Nurse Report Sheet date [DATE] shows R1 is on a mechanical soft diet with honey thickened liquids and needed assistance with feeding. R1's Speech Therapy Evaluation and Plan of Treatment dated [DATE] shows Patient had choking episode in hospital and downgraded to mechanical soft. Patient then completed Video Fluoroscopy Swallow Study and downgraded to honey thickened liquid due to aspiration/penetration Behaviors Impacting Safety: Reduced attention to task, Decreased safety awareness, Poor self-monitoring skills and Inability to make needs known . Patient with delayed swallow response difficulty initiating swallow and decreased safety awareness. R1's Speech Therapy Progress Report dated [DATE] shows Patient (R1) is at risk for aspiration/choking with puree/honey thickened liquids/nectar thickened liquids when not strictly following safe swallow strategies. R1's Modified [MEDICATION NAME] Swallow Study dated [DATE] shows mild-moderate dysphagia .requires supervision/cueing for safe and effective oral intake .strict adherence to swallow precautions by patient/staff for safe oral intake .diet recommendations: small bites, monitor rate, aspiration precautions, small sips, multiple swallow (2), alternate solid/liquid, supervised feeding. R1's Speech Treatment Encounter Note dated [DATE] shows a repeat Video Fluoroscopy Swallow Study was done with recommendations for mechanical soft/nectar thickened liquids diet Educated patient/wife at lengths regarding results of study, specific strategies of repeat swallows due to pharyngeal residuals, small bites/sips, and recommendations. Discussed results with R1's Registered Nurse V17. R1's Speech Treatment Encounter Note dated [DATE] shows max cues needed for repeat swallow. Instructed patient (R1)/wife in oral motor/pharyngeal/laryngeal exercises. Patient required max cues to follow due to cognitive deficits. R1's Speech Therapy Progress Report dated [DATE] shows R1 and Caregiver training: development & training in use of compensatory strategies: small bites, small drinks, upright at 90 degrees for all oral intake, double swallow to clear pharyngeal residuals, 1:1 assistance. Educated patient's RN (V17) Supervision for Oral Intake=Close supervision (1:1 assistance with all oral intake for swallow strategies.) On [DATE] at 4:40 PM, V23 Speech Therapist said she was treating R1 due to his [DIAGNOSES REDACTED]. V23 stated R1's biggest problem was that he took large amounts of food at one time and was unable to swallow all of the food in his mouth with the first swallow. R1 needed to be instructed to then take a sip of liquid or swallow a second time to clear the food, which is very common with [MEDICAL CONDITION]. V23 said if the food or drink built up in his mouth R1 could possibly choke. V23 said R1 was able to feed himself, but needed one on one supervision to make sure the bites and sips were small enough, and he took a drink or a second swallow to clear the food in his mouth. V23 said R1 is cognitively impaired and his memory was not good so he needed repetitive cueing. V23 stated if no one is watching him directly, his food tray should not be left at the table with R1. V23 said she trained V25 Certified Nursing Assistant (CNA) and V26 Activity Aide/trained feeding assistant to watch R1 closely and to monitor the size of the bites of food and drink, and to take a drink or second swallow to clear his mouth. V23 said she also communicated R1's swallow strategies with R1's regular nurse V17. V23 said R1 was still receiving speech therapy up until his death. On [DATE] at 1:49 PM, V25 CNA said on [DATE] during the noon meal she had fed R1 several times while making rounds in the dining room and helping the residents. V25 said R1 had eaten about 80% of the facility food tray and was finished eating. V25 said there was some food from the family on the table in front of R1 as well as the remainder of the facility tray. V25 stated I was making a peanut butter and jelly sandwich for another resident and could only see the back of R1 when she heard a weird noise. I looked at R1 and he was making a gurgling noise but no gestures so I called the nurse. V25 said sometimes R1 feeds himself. On [DATE] at 1:42 PM, V26 Activity Aide said when she came back from break, V25 had already fed R1 and R1 was finished eating and was calm and sitting at the dining room table with the food (facility tray and his family's food that they brought in for him) still in front of R1. V26 stated she was at another table feeding another resident when she heard R1 cough and make a troubled breathing sound so she called the nurse. On [DATE] at 11:34 AM, V17 RN (R1's primary nurse) stated on [DATE] at the noon meal, R1 was feeding himself, R1 can do it, and the girls were in the dining room to assist. Our food was on the table in front of him and a little tray of food from his wife was on the table as well. I was charting at the Nurses station, I could see R1 but his back was to me. The aides alerted me that R1 didn't look good. R1 was making a gurgling noise like he had something in his mouth that he couldn't swallow. I called out his name and shook him but he wouldn't answer. I did the [MEDICATION NAME] at the table he was still not answering so I called a code and lowered him to the floor. R1's Progress Note by V17 on [DATE] shows at 12:50 PM V17 was called into dining room to check R1. Upon arriving R1 was sitting up in his wheelchair. R1 was unable to answer upon calling his name and noted coughing. [MEDICATION NAME] maneuver initiated, code blue and 911 called. Transferred R1 to the hallway floor. V27 Nurse Practitioner (NP) here and did another [MEDICATION NAME] maneuver, liquid came out. CPR initiated by nurses. V24 R1's Doctor (MD) was present and assisting staff during code blue. R1 Progress Note by V24 MD on [DATE] shows Code blue called overhead .R1 was in the dining room and brought to the hallway in the wheelchair. R1 was not responding and did not have a pulse. Suspect R1 may have choked while eating lunch. [MEDICATION NAME] maneuver attempted by V27 NP multiple times. Small amount of liquid food came out of mouth. R1 remained unresponsive and pulseless CPR initiated immediately by staff. 911 was called R1 had episode of vomiting during code. R1 was intubated by Emergency Medical Service (EMS). Despite all efforts by all staff and EMS, heart rhythm was not regain. R1 was pronounced by EMS. On [DATE] at 10:45 AM, V24 MD said R1 had swallowing issues which is not uncommon with dementia and was working with speech therapy. V24 stated at minimum R1 needed supervision to eat and speech recommendations should be followed. On [DATE] at 11:40 AM, V21 Physical Therapy Supervisor said the speech therapist will educate the staff on the specific recommendations for the residents and then staff should endorse to the next shift. V21 said speech recommendations are typically not an order in the computer and specific swallow strategies are not put in the resident's Care Plan. On [DATE] at 11:41 AM, V19 RN said R1 ate in the small dining room and was on a mechanical diet. V19 said R1 was physically able to feed himself. On [DATE] at 11:52 AM, V20 Memory Care Director said R1 sat in the assisted dining room for meals and due to his cognition and needed cueing at times, but could feed himself. On [DATE] at 12:07 PM, V1 Administrator said R1 sat in the small dining room for meals and required staff supervision. R1's initial Care Plan dated [DATE] shows R1 requires nutritional support with swallowing related to [MEDICAL CONDITION] .R1 is able to feed himself. R1's Care Plan was updated on [DATE] with interventions to alternated liquid and solid, position resident as appropriate for meals, and to assist with meals as needed. R1's care plan was last updated on [DATE] (swallow strategies recommended on [DATE] per speech therapist) with R1 has a swallowing problem related to dysphagia- R1 will not choke or aspirate. R1's Care Plan does not include swallow precautions recommended by R1's swallow study or the speech therapist. The facility's Feeding a Resident Policy dated ,[DATE] shows When finished with his/her meal .remove all equipment and supplies from the eating area. The facility's Meal Service Policy dated ,[DATE] shows assure that each resident receives the amount of assistance necessary remove tray to appropriate area when resident had finished eating. The facility was unable to provide a safety/supervision policy. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice was corrected on [DATE] when the facility took the following actions to remove the immediacy and correct the noncompliance. On [DATE] the Administrator, DON, and the Interdisciplinary Team conducted: -Staff were in-serviced on identifying residents at risk for aspiration and their specific feeding requirements. -Staff were in-serviced on supervising residents needing assistance until the end of their meal. -Staff in-serviced on the need to remove food away from residents who need supervision immediately at the conclusion of the meal or when the supervision cannot be maintained. The facility Quality Assurance Team (including the Medical Director, Administrator, Assistant Administrator, Admission Director, Dietary Supervisor, MODS, DON, and facility consultant) on [DATE] conducted a review of all residents who are at risk for aspiration and choking. -A manager or nurse is assigned to monitor dining rooms, as well as resident rooms, at each meal to ensure that supervision is being conducted as needed for those resident in need. -QA audits were initiated in March and are now being conducted daily for one month to test staff knowledge of supervision needs in the dining room and which residents are in need. These will then transition to monthly X 3 months. -QA audits are being conducted to ensure that resident's trays are removed promptly at the conclusion of feeding or when staff is unable to supervise a resident requiring assistance. These will occur daily x one month and then will transition to monthly x 3 months. -Administration will conduct daily rounds to ensure supervision is provided to residents identified with a supervision need or those identified with aspiration precautions. -The list of residents identified at risk for aspiration will be kept in a binder at each nurses' station, accessible to all staff. Staff in-servicing on this list has been initiated and is ongoing. -Staff re-education on the signs and symptoms of choking, and what to do if someone appears to be choking, was initiated. All in-servicing initiated [DATE] is ongoing and will be completed with all staff on our completion date of [DATE]. The Administrator or designee will be responsible for ensuring all compliance of the items mentioned above. On [DATE], the Administrator, Medical Director, DON, and the Interdisciplinary Team conducted a review of the following policy: -Meal Service including appropriate supervision until the end of the meal and removing meal tray after a resident is done eating. -Aspirations Precautions -Choking -Changes in diet consistency