Inspection of September 4, 2025

1 finding

F770D · No harm, potential for more than minimal, isolated

Based on interview and record review, the facility failed to ensure laboratory services were completed as ordered and in a timely manner for 1 (R1) of 5 residents reviewed for laboratory services in the sample of 5.Findings include:R1 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Systolic (Congestive) Heart Failure; Hypertensive Heart Disease with Heart Failure; Chronic Obstructive Pulmonary Disease; Type 2 Diabetes Mellitus Without Complications; Arthritis Due To Other Bacteria, Left Knee; Adjustment Disorder With Depressed Mood; and History of Falling.On 08/26/2025 at 01:08 PM Surveyor verified that R1 remains hospitalized at this time and is not available for observations nor interview.On 08/27/2025 at 01:48 PM V3 (Director of Nursing) said, I was not aware that R1 had weekly labs that were ordered post R1's last hospitalization and readmission on [DATE]. Nurses receive hand off report from the discharge facility, the receptionist gets medical records, uploads them into the electronic medical chart and then they bring it to the nurses. Any order that comes from the hospital, should be verified by nurses with attending physician to make sure they are appropriate for the resident. The attending physician may or may not agree with the discharge orders. The nurses should then transcribe all discharge orders into electronic medical chart. Laboratory service orders have to be also transcribed on to the hard copy and placed in the binder for laboratory staff to pick them up each morning when they come to collect residents' specimens.On 08/28/2025 at 10:00 AM V6 (Licensed Practical Nurse) said, I vaguely remember readmitting R1 on 7/17/2025; it's been a month. I don't remember if R1 returned with any new orders for labs. When a resident gets readmitted with new lab orders, I put them in the system (electronic medical chart). R1 was readmitted on Friday (07/18/2025), her labs were going to be drawn on Monday, and the results were supposed to be faxed to infectious disease doctor. They were standing labs, meaning, they are automatically scheduled to be done on a regular, weekly basis. I believe I placed R1's labs in the system as a standing order. Additionally, we place lab orders on a hard copy and place them in the bin for phlebotomist to pick it up and be able to determine which resident needs which labs to be drawn.On 08/28/2025 at 10:25 AM V3 (Director of Nursing) said, I think what happened was, R1 had a standing order for laboratory services; however, upon readmission, V6 (LPN) placed lab order to be done on Monday (07/21/2025) and repeated a week after (07/28/2025) instead of routine, weekly laboratory service. The most recent order should have been placed as routine, weekly laboratory service order. I am unable to produce the original order from 07/18/2025 at this time, it disappeared from the system. There were no further labs drawn after 07/21/2025 and 07/28/2025 until infectious disease clinic called and said they are missing R1's weekly labs. We then placed an order on 08/15/2025 for labs to be restarted on 8/18/2025 (Monday) and continued weekly every Monday. Additionally, nurses placed a one-time order for labs to be drawn on 08/16/2025. R1's labs were drawn after that on 08/25/2025 as per schedule and R1 was hospitalized later in a day on 08/25/2025 for chest pain. All together, we missed labs on 08/04/2025 and 08/11/2025 due to V6's (LPN) mistake while placing lab order.On 08/28/2025 at 12:03 PM V15 (Assistant Director of Nursing) said, I was called by infectious disease clinic to be made aware of R1's missing labs. The clinic staff appeared to be upset and was demanding R1's labs be drawn and sent to the clinic weekly. I explained that I wasn't aware of the order, but I will try to resolve it as soon as I can. The clinic staff proceeded to hang up on me. I gathered all available lab results and sent it to the clinic, I gave them a call; however, I didn't get a response. I tried again and I was able to speak to the clinic staff and confirmed that the clinic received available blood work results; however, did not get further directions.Per record review, R1's discharge order dated 07/18/2025 reads in part, Please draw weekly labs: CBC w DIFF, BUN, Creatinine, and LFT's, Fax results weekly to xxx-xxx-xxxx.Per record review, R1's laboratory service reports show collection dates on 07/21/2025, 07/28/2025, 08/16/2025, and 08/25/2025. Per R1's hospital readmission order dated 07/18/2025, laboratory services should have been provided on weekly basis and were not done on 08/04/2025, 08/11/2025, and 08/18/2025.The facility Job Description: Staff Nurse (Registered Nurse/License Practical Nurse) reads in part, Arrange for diagnostic and therapeutic services, as ordered by the physician; obtain sputum, urine, and other lab tests as ordered.

Inspection of April 17, 2025

1 finding

F688D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review, the facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence. This failure affected two (R1, R2) residents out of four residents who were reviewed for services and equipment. Findings include: R1 [AGE] year-old resident admitted to the facility on [DATE] to 2/26/2025 with diagnoses including but not limited to: enterocolitis to clostridium difficile, urinary tract infection, benign prostatic hyperplasia, hyperlipidemia, hypertension, epilepsy, Cerebral vascular accident with left hemiparesis, and dysphagia. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a Brief Interview for Mental Status (BIMS) score of 6/15, which suggests that R1 is cognitively impaired. R2 [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: tracheostomy, chronic kidney disease, encephalopathy, adrenal insufficiency, pituitary mass, Hypothyroidism, urinary retention, dysphagia, chronic respiratory failure, and percutaneous endoscopic gastrostomy. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 99, which suggested that R2 was not able to complete the interview. On 4/16/2025 at 12:00 PM V9 (Licensed Practical Nurse), I was the regular nurse for R1 while R1 was at the facility. R1 was on bed rest because of right-sided weakness. R1 required assistance with eating, and activity of daily living, and had a urinary catheter. I don't recall ever seeing R1 without the urinary catheter and R1 used to go to see the urologist for that. On 4/16/2025 at 1:30 PM V8 (Restorative Aide) said that R1 has two programs during the shift. One is the placement of the splint and bed mobility, but I only assisted R1 out of bed to go to the doctor's appointment. On 4/16/2025 at 1:36 PM V11(Family friend) said, I went to R1's doctor's appointment and had to bring R1's wheelchair to the facility because R1 did not have one and staff did not get R1's out of bed unless R1 had a doctor's appointment. On 4/16/2025 at 1:06 PM V7(Restorative Nurse) said, After I complete the assessment on admission, I make recommendations and start a program, also I complete annual, quarterly, and change of condition assessments. The goal is to maintain current ability or improve. After residents are discharged from therapy, the restorative nurse will follow recommendations per physical therapy and add at least two programs for the restorative aides to work with each resident. Every floor has a restorative aide responsible for the program. R1 has two programs and R2, I do not see any program added to R2 ' s tasks. I do not know why it is not there. On 4/16/2025 at 11:58 AM V5(Licensed Practical Nurse) said, that catheters are changed as needed when there is a leakage, clogged, or a lot of sediments. R2 does not get out of bed, wheelchairs are provided by nursing after physical therapy recommendations. I don't know why R2 does not have a wheelchair. V5 then checked current orders and orders say, may be up as tolerated. On 4/16/2025 at 11:58 AM V10(Certified Nursing Assistant) and V4(Certified Nursing Assistant) provided care to R2 and they both said, not getting R2 out of bed before. On 4/16/2025 at 3:10 PM V2(Director of Nursing) said that when residents are admitted to the facility during our morning meeting, physical therapy services are discussed as a team, and if residents have Medicare services or insurance physical therapy is started as ordered per physician. R2 did not have his Medicare information and I spoke with R2's family member on 4/7/2025 and the facility still did not have that. R2 has not had a wheelchair, physical therapy screening, or evaluation since admission. R2's has not been up since admission. I expect the staff to follow physician ' s orders and follow up on any information needed to care for the residents. I do not see any restorative program for R2. I know that the family member wanted R2's up for his birthday last week. On 4/16/2025 at 2:26 PM V6(Physical Therapy Supervisor) said, I check orders daily and the census to know who I have to complete evaluation or screening. If a resident does not have orders, I go with the restorative nurse and screen and make recommendations. If a resident comes in with Public Aide insurance, the restorative services will see residents because it will be cheaper for them. R1 has the evaluation and therapy notes. After therapy was completed, the restorative services were initiated with two programs, but for R2 I do not have screening or physical therapy evaluation. R2 did not have a payer source and I was told not to see until his insurance information was available. On record review, R1's physician order dated 10/29/2024 reads May be up as tolerated. R2's physician order dated 3/6/2025 reads, may be up as tolerated and may evaluate and treat physical therapy/occupational therapy. On 4/16/2025 at 3:20 PM V1(Administrator) said, typically if a new admission resident needs therapy and the insurance information is not available the administrator will approve services pending insurance approval and will order any chair recommended per physical therapy. I do not see any physical therapy evaluation, screening, or restorative assessment for R2. I would expect the residents to be evaluated per physical therapy services, and restorative services and make recommendations. The facility is working with R2's family members to bring Medicare information. I know that R2's family wants therapy and an appropriate chair to get the resident out of bed. On 4/17/2025 V2(Administrator) said, the facility do not have a policy for equipment ordering for new admissions. On 4/16/2025 at 2:58 PM, V1 provided Facility Policy Titled, Direct Therapy Services (dated 03/10/2022), which includes: The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. Residents are provided direct therapy services upon the written order of their physician. 2. All direct therapy services provided to the resident must be ordered by the resident ' s attending physician. 5. To assist the resident in maintaining or improving their functional and physical status, the resident may be assessed for restorative nursing program(s) which are not considered specialized rehabilitative services . Facility provided their policy titled, Restorative Nursing Program (dated 03/10/2022), which includes the following: All residents will be assessed on admission, as change of condition warrants, and quarterly thereafter, for participation in the Restorative Nursing Program (RNP). An individualized program will be developed based on the resident's needs as appropriate. The program(s) will be reflected on the interdisciplinary care plan and consistently carried out by staff.

Inspection of March 21, 2025

8 findings

F692G · Actual harm, isolated

Based on interviews, observation, and records reviewed the facility failed to identify and evaluate interventions for one (R70) of 13 residents reviewed for nutrition in sample of 54. This failure resulted in R70 having an unplanned significant weight loss of 28% over 7 months. The findings include: R70's diagnosis include but are not limited to Hypertension, Gastro Esophageal Reflux Disease, Incontinence, Muscle Weakness, Chronic Pain, Anxiety, Dysphagia, Facial Weakness following Cerebral Infarction, Hemiplegia and Hemiparesis, Major Depressive Disorder, Muscle Wasting and Atrophy, Non Pressure Chronic Ulcer of Foot (Bunions), Chronic Pain, Recurrent Depressive Disorder, Pneumonia, and Osteoarthritis. On 3/20/25 at 12:35PM V24, CNA, said R70 has contracted hands but she can participate with feeding. V24 said R1 needs assistance, it changes with her sometimes she feeds herself. On 3/20/25 at 12:40PM R70 in her room, in bed, lunch of chopped meat and potatoes and gravy with spoon in it. R70 said I didn't touch it. On 3/20/25 at 12:45PM V12, RN said R70 appetite is poor, she feeds herself. V12 said she refuses what we do. V12 said she is supposed to go to the gastric doctor. V12 said R70 don't eat, we did a calorie count. On 03/20/25 at 10:22 AM V9, Registered Dietician, said I asked about the MDS for R70. V9 said R70 definitely had 10% loss in 6 months and 4.2% loss for 1 month. V9 said R70's weight in July 2024 was 146 pounds, she had a 28% loss of weight. V9 said in January 2025 R70's weight was 113.2 pounds and her current weight is 111 pounds. On 03/20/25 at 11:04 AM V6, MDS Nurse, said I do section K (Swallowing/Nutritional Status) of the MDS, I gather information from the Registered Dietician. V6 said I then enter the information into the assessment. On follow up interview at11:34 AM V6 said R70 had a significant weight loss x 1 month and 6 months. V6 said I made a correction for the 1/9/25 MDS. V6 said R70 was 146 pounds 6 months ago. V6 said I am not part of the weight meeting. At 12:05PM V6 said I updated the care plan and notified the nurse. On 3/21/25 at 11:12AM V20, Nurse Practitioner, said R70's weight loss started in October 2024. V20 said sometimes R70 will eat and other times not at all. V20 said the CNAs told us that R70 was not eating at all even though R70 told us she ate. V20 intervention include trying to get her into a GI doctor, encourage her to eat, we provided supplements, and appetite stimulants. V20 said for the calorie counts we see she may eat breakfast and no lunch or dinner. V20 said we discussed hospice with the progression of her Rheumatoid Arthritis, and I increased her pain medication. V20 said R70 said she doesn't want a feeding tube. She went recent to GI, I called the office, we are questioning her cognitive ability. V20 said R70's agrees to eat but then she does not do it. V20 said we are going based on what the CNAs tell us. V20 said the staff were supposed to do weekly weights based on my conversation with the Dietician. V20 said of course R70 is someone we would be concerned for weight. V20 said R70 is a slow feed, since her hands are arthritic she needs a lot of time. On 3/21/25 at 12:53PM V9, said the extent of the calorie count is all they do with it. There is not a section with the calorie calculation, not for this facility. On 3/20/25 the surveyor requested from V1 evidence of Weight Committee procedures #2, 3, 4 and 5 for R70. Information was not provided by 3:30PM On 3/21/25 11:05AM requested from V1 documentation for weight committee, at 1:27PM the documentation has not been provided. 3/21/25 1:25PM V14, Regional Nurse Consultant, said we are still working on getting the progress notes. Review of Progress notes for R70 written by V9 include 12/10/24; 12/11/24 and 2/17/25 No documented evaluation of calorie count. Review of Progress Notes written by V20 include notes on 11/6/24 and 2/5/25, there is no evaluation of calorie count. Nurse progress notes include 12/9; 12/16; 24; 1/3/25; 1/4/25; 1/9/25; and 1/10/25. No evaluation of calorie count. On 3/21/25 at 2:02PM the facility provided the progress notes for R70. R70 MDS dated [DATE] section K0300 states 0 for weight loss. Current weight is 113 pounds The corrected MDS V6 presented on 3/20/25 notes Weight loss 2- yes, not on prescribed weight loss regimen. Three day Calorie Count reviewed for R70 dated 12/10/25 at 10:45AM and 6:23PM and 12/12/25 at 9:38PM. No total of calorie count, protein count, or total intake percentage. Care Plan reviewed for R70 nutritional support. Interventions include meal monitoring and recording, monitor labs. Review of R70's Order Summary Report includes Check Weight weekly x 4 ordered 1/8/25 and end date 2/5/25. Review of R70's January Medication Administration Record includes 1/8/25; 1/15/25; and 1/29/25 with weight NA. 1/22/25 weight is 113.2. Monthly Weight Report for R70 includes weights December 2024 118.8 pounds; January 116.0 pounds; 109.0 February; and March 111.3 pounds. (V9 said R70's weight in July 2024 was 146 pounds, she had a 28% loss of weight since. Policy for Weight Committee dated 2023 states the purpose to reduce the risk of altered nutritional status. Committee will discuss residents with significant weight change, root cause for weight loss and intervention. The committee will also identify individual with insidious weight loss, gradual weight loss, and develop plan of care. The weigh committee will meet weekly to discuss residents with weekly weights. The committee will evaluate the nutritional status of the resident, identify root cause and develop interventions. Information discussed in Weight Committee to be documented via progress note and care plan as needed. The Weight Committee meeting will be obtained via PCC exception reports. Policy for Weights dated 9/2020 states residents will be weighted to establish a baseline weights and identify trends of weight loss and weight gain. Report any weight loss or gain greater than 5% within one month, 7.5% within three months or 10% within 6 months. Policy for Calorie Count dated 9/20 states a calorie count is to monitor adequacy of resident's calorie intake. 5. If a resident refuses a meal or does not eat any of the items, document the reason why the meal was missed and indicate amount consumed with a zero. (See calorie count, this is not documented.) 6. Dietary services will evaluate and document results and will make appropriate recommendations.

F851F · No harm, potential for more than minimal, widespread

Based on interviews and records reviewed the facility failed to submit accurate and complete data on the Payroll Based Journal. This failure has the potential to affect all 184 residents in the facility. The findings include: On 03/19/25 at 12:55 PM V1, Administrator, said we have no staffing waivers. On 03/20/25 at 09:35 AM V14, Nurse Consultant, said the Interim Director of Nursing, is here at least 5 days, for at least 8 hours. V14 said the DON clocks in (the surveyor requested time cards for 14 days). On 3/20/21 at 10:21AM V1 said Payroll Based Journal (PBJ) data is submitted quarterly and resident census is not included. On 03/20/25 at 12:08 PM V1, Administrator, provided January - March 2025 PBJ Reports. V1 reported unfortunately, for the date of July 2024, August 2024, and September 2024 - there was an error in submission with the integrated file. Therefore, no data was shown for 4th Quarter of 2024. CMS and IDPH were notified of the submission error. On follow up interview, of the same day, V1 was asked by the surveyor for evidence of Director of Nursing included in PBJ and after saying she would check with corporate, V1 said it is not there. Review of the facility PBJ report submitted for the quarter and provided for the surveyors review has no Director of Nursing included. The Centers for Medicare & Medicaid Services Electronic Staffing Data Submission Payroll Based Journal Long Term Care Facility Policy Manual Version 2.6 June 2022, states facilities are required to submit facility census and Director of Nursing Hours on the PBJ.

F641E · No harm, potential for more than minimal, pattern

Based on interview and record review, the facility failed to accurately code the minimum data set (MDS) assessment for four (R9, R34, R48 and R160) of eight residents reviewed for hospice. In addition, the facility failed to accurately code the weight assessment for one resident (R70) who was identified to have a greater than 10 percent weight loss in 6 months but not identified on the MDS for one of thirteen reviewed for nutrition in a total sample of 54. Findings Include: R160 R160 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular accident. R160's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of documents a code 0 which indicates No. R160 hospice admission orders dated 8/29/24 terminal diagnosis of senile degeneration of the brain with 6 months or less to live. On 3/21/25 at 10:15AM, V6(minimum data set, MDS nurse) said a resident receiving hospice services on their minimum data set, MDS section J1400 should be coded as a yes if the documentation is available. Staff have up to 7 days to try to obtain certification if paperwork is not available in the medical record. CMS RAI version 3.0 manual dated October 2024 documents under J1400 coding instructions: code yes if the medical record includes physician documentation: 1)resident is terminally ill; or 2) the resident is receiving hospice services. R9 R9 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R9 Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of documents a code 0 which indicates No. R9 hospice admission orders dated 1/14/23 terminal diagnosis of Alzheimer's with 6 months or less to live. R9's physician certification dated 12/19/24 documents: the patients prognosis is six months or less if the disease runs its normal course. On 3/21/25 at 10:15AM, V6(minimum data set, MDS nurse) said a resident receiving hospice services on their minimum data set, MDS section J1400 should be coded as a yes if the documentation is available. Staff have up to 7 days to try to obtain certification if paperwork is not available in the medical record. CMS RAI version 3.0 manual dated October 2024 documents under J1400 coding instructions: code yes if the medical record includes physician documentation: 1)resident is terminally ill; or 2) the resident is receiving hospice services. R34 R34 is a [AGE] year old with the following diagnosis: Parkinson's disease, type 2 diabetes, and neuromuscular dysfunction of the bladder. On 3/20/25 at 3:05PM, V14 (Regional Nurse Consultant) stated R34 originally admitted to hospice in January 2023 but was discharged from hospice in December 2023. V14 reported R34 readmitted to hospice in December 2024. The Hospice Certification Statement dated 1/10/23 documents the physician certified that R34 is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The Recertification Statement dated the effective date of certification as 12/10/24. The physician certified that R34 is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. This certification is good until 2/7/25. R34 was again recertified for hospice on 2/8/25 by the physician with a life expectancy of six months or less if the terminal illness runs its normal course. The Care Plan dated 12/11/24 documents R34 was admitted to hospice due to Parkinson's disease. All interventions are documented on 12/11/24. The Minimum Data Set (MDS) Section J dated 12/18/24 documents R34 does not have a life expectancy of less than six months. This is not correctly coded. On 3/21/25 at 10:15AM, V6(minimum data set, MDS nurse) said a resident receiving hospice services on their minimum data set, MDS section J1400 should be coded as a yes if the documentation is available. Staff have up to 7 days to try to obtain certification if paperwork is not available in the medical record. CMS RAI version 3.0 manual dated October 2024 documents under J1400 coding instructions: code yes if the medical record includes physician documentation: 1)resident is terminally ill; or 2) the resident is receiving hospice services. R48 R48 is an [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes, and atrial fibrillation. The Hospice Certification Statement dated 1/15/25 documents the physician certified that R48 is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. R48 is certified to receive hospice services through 4/14/25. The Care Plan dated 1/16/25 documents R48 requires hospice. All interventions are documented on 1/16/25. The Minimum Data Set (MDS) Section J dated 1/17/25 documents R48 does not have a life expectancy of less than six months. This is not correctly coded. On 3/21/25 at 10:15AM, V6(minimum data set, MDS nurse) said a resident receiving hospice services on their minimum data set, MDS section J1400 should be coded as a yes if the documentation is available. Staff have up to 7 days to try to obtain certification if paperwork is not available in the medical record. CMS RAI version 3.0 manual dated October 2024 documents under J1400 coding instructions: code yes if the medical record includes physician documentation: 1)resident is terminally ill; or 2) the resident is receiving hospice services. 40066 R70's diagnosis include but are not limited to Hypertension, Gastro Esophageal Reflux Disease, Incontinence, Muscle Weakness, Chronic Pain, Anxiety, Dysphagia, Facial Weakness following Cerebral Infarction, Hemiplegia and Hemiparesis, Major Depressive Disorder, Muscle Wasting and Atrophy, Non Pressure Chronic Ulcer of Foot (Bunions), Chronic Pain, Recurrent Depressive Disorder, Pneumonia, and Osteoarthritis. On 03/20/25 at 10:22 AM V9, Registered Dietician, said I asked about the MDS for R70. V9 said R70 definitely had 10% loss in 6 months and 4.2% loss for 1 month. V9 said R70's weight in July 2024 was 146 pounds, she had a 28% weight loss. V9 said in January 2025 R70's weight was 113.2 pounds and her current weight is 111 pounds. On 03/20/25 at 11:04 AM V6, MDS Nurse, said I do section K (Swallowing/Nutritional Status) of the MDS, I gather information from the Registered Dietician. V6 said I then enter the information into the assessment. On follow up interview at 11:34 AM V6 said R70 had a significant weight loss x 1 month and 6 months. V6 said I made a correction for the 1/9/25 MDS. V6 said R70 was 146 pounds 6 months ago. V6 said I am not part of the weight meeting. At 12:05PM V6 said I updated the care plan and notified the nurse. MDS dated [DATE] section K0300 states 0 for weight loss. Current weight is 113 pounds The corrected MDS V6 presented on 3/20/25 notes Weight loss 2- yes, not on prescribed weight loss regimen.

F550D · No harm, potential for more than minimal, isolated

Based on interviews and records reviewed the facility failed to meet residents' needs when they utilize the call lights for assistance. This failure affected 5 ( R283; R75; R121; R115; and R16 ) residents reviewed for call light concerns out of a sample of 54 residents. Findings include: A.During Resident Council interview on 03/18/25 at 11:21 AM R19, Resident Council President gave consent for the surveyor to review the council meeting notes. R283 said If I pull the light they come when they want. I call and sometimes I might wait up to an hour. R283 said yesterday I requested an oatmeal that my sister brought me at 4:00am, I used to work nights so that is when I eat. R283 said they didn't bring it in until 8:00AM with breakfast. R283 said I can hear them talking, laughing, and carrying on in the hallway. R283 said why can't they just bring me what I ask and then they can carry on and I'll be taken care of? On 03/19/25 at 11:04 AM R75 and R121 said the staff will turn the call light off and say I will be back in a minute and they don't come back. R75 said it feels like the call lights are on and they forget about you. R75, R121, and R19 said if they comeback at all to help you it takes a long time. R121 said it takes more than half hour to get help for towels, when your sick, or just need some help. On 3/20/25 at 12:45PM V12, RN (Registered Nurse), said R283 told her that he would like food at night, but we didn't know that before. V12 said we will have it for him now that we know. R283 minimal data set section C (Cognitive Pattern) brief interview for mental status dated 3/3/25 documents a score of 15, cognitively intact. R121 minimal data set section C (Cognitive Pattern) brief interview for mental status dated 2/10/25 documents a score of 15, cognitively intact. R75 minimal data set section C (Cognitive Pattern) brief interview for mental status dated 1/10/25 documents a score of 15, cognitively intact. B. R115's minimal data set section C (Cognitive Pattern) brief interview for mental status dated 3/3/25 documents a score of fourteen which indicate cognitively intact. On 3/18/25 at 11:05AM, R115 said, she pushed the call light on the overnight shift because she was vomiting and coughing but no staff came to answer her call light all night. Concern form dated 3/18/25 documents: R115 stated, she pressed call light on night shift and no one came. Follow-up action taken: In-service provided to staff nurse. Time date and person notified of outcome of concern 3/18/2025 at 1:45pm. C. On 3/19/25 at 12:28PM R16 stated facility staff take hours to answer the call light. R16 reported R16 waits the most on night shift. R16 stated about one month ago R16 waited four hours to be changed. R16 reported asking an unknown CNA to be changed around 4:00AM but no staff came to change R16 until around 8:00AM on the next shift. R16 stated telling V11, Unit Manager, about not being changed and call light wait time. R16 reported V11 did not follow up with R16 with R16's concerns. On 3/20/25 at 10:22AM V11 stated V11 heard R16 telling the surveyor about the long call light response time. V11 denied R16 talking to V11 previously about the call lightwait time. The surveyor asked V11 if V11 addressed the concern R16 voiced about the call lights. V11 denied talking to R16 about call light wait because R16 did not come up and talk with V11 personally about the issue. A concern form dated 3/18/25 for R115 states resident states she pressed the call light on night shift and no one came. Follow up action documented 3/18/25 states Inservice provided to nurse. January Resident Council Minutes for January 22, 2025 notes Department/Concern documents Residents have began to complain about call light response time again. A call light inservice dated 3/18/25 was provided by the facility. Call light Policy no date documents: To ensure that resident needs are met.

F604D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review, the facility failed to keep residents free from physical restraints for two (R2 and R10) out three residents reviewed for restraints in a total sample of 54. Findings Include: R2 is a [AGE] year old with the following diagnosis: cerebrovascular disease, neuromuscular dysfunction of the bladder, and acquired absence of bilateral legs above the knee. On 03/18/25 at 9:35am R2 was observed sitting across from the nurse's station in a manual wheelchair with back rest not reclined. A tan/gray canvas strap device tied in a knot to left and right arm rest of wheelchair. Blanket was over chest/abdominal area so the front of R2 was not able to be seen. On 03/18/25 02:43 PM, R2 was lying in bed. Lap belt strap noted tied to each arm rest on the wheelchair. On 03/19/25 12:40 PM, R2 was sitting in a manual wheelchair straight up. The lap belt was tied to each side of the wheelchair and velcroed around R2's waist. V19 (CNA) stated R2 wears this strap while up in a wheelchair due to R2 sliding out. R2 was asked to moved R2's arms to try to remove the strap and R2 could not remove the strap unassisted. R2 wears a splint to the right hand and has lack of control to the left arm. 03/21/25 at 11:32AM - V18 reported the facility is a restraint free facility. V18 stated R2 should not be wearing a lap belt and the lap belt needs an order. V18 reported R2 does not have the strength or dexterity to remove the lap belt unassisted. V18 reported restraints are not used because the objective is to not restrict movement. V18 stated a physician must be called and an order must be placed if the lap belt is used. V18 reported R2 uses a splint to the right hand due to a contracture and receives passive range of motion to both hands for joint mobility. V18 stated the lap belt has been discontinued because R2 needs to be using a high back reclining chair. V18 reported the high back reclining chair is more comfortable and safer for R2 than to use a manual wheelchair and lap belt. V18 stated R2 does not have the hand strength or dexterity to remove the lap belt unassisted. V18 reported if the lap belt is currently being used then a physician needs to put in an order and a consent must be obtained. 3/21/25 12:12PM V14 (Regional Nurse Consultant) stated if a lap belt is in use the resident must be able to remove the belt themselves. V14 reported if it cannot be removed without assistance then it is considered a restraint. V14 stated a physician order and consent is needed for a lap belt. V14 reported it also must be documented that the restraint is taken off for rest period during the day and skin checks must also be documented. The Restorative Nursing assessment dated [DATE] documents R2 uses a manual wheelchair and a splint to the right hand during the day. R2 will continue to receive a passive range of motion program to right hand and the two middle fingers of the left hand for contractures. There is no documentation that a high back reclining wheelchair should be in use for R2. There is also no documentation that a lap belt is currently being used for R2. The Restraint Consent dated 1/10/25 documents consent was received from R2's family for the use of the lap belt. There is no witness signature on the form. Two signatures are needed for consent. The Minimum Data Set Section P dated 1/12/25 documents no physicals restraints are in use for R2. The Physician Order Sheet was reviewed and there is no current order for a lap belt to be used. The Care Plan dated 1/20/12 documents R2 is at high risk for falls related to dementia and multiple sclerosis. An intervention dated 7/5/18 documents R2 should use a high back wheelchair in a slight recline position when not having meals. There is no intervention in this care plan that a lap belt should be used while sitting in a wheelchair. The Care Plan dated 5/23/12 documents R2 has limited range of motion related to multiple sclerosis, contracted muscles, and lack of coordination. The Care Plan dated 3/20/25 documents R2 has difficulty sitting upright in a basic wheelchair and uses a high back reclining chair to maintain comfort and promote proper body alignment secondary to stroke, poor muscle control and posture, and multiple sclerosis. R10 is a [AGE] year old with the following diagnosis: chronic kidney disease stage 3, bipolar, schizoaffective disorder, and chronic obstructive pulmonary disease. 03/18/25 09:48 AM R10 has the upper side rails in place on both sides of the bed. Bed bolsters are also noted on each side of the bed. R10 was lying on R10's back. The surveyor asked R10 to roll over to the side. R10 reached for the upper side rail but was unable to move legs to roll to the side due to the close positioning of the bed bolsters. 03/19/25 9:22 AM - R10 again is lying on R10's back. The side rails and bed bolsters are still in the same place. The surveyor again asked R10 to roll to the side and R10 was unable. 03/21/25 at 10:52AM- R10 is lying on R10's back. Bilateral side rails and bilateral bed bolsters are in place. V17 stated R10 has a behavior of getting out of bed and lying on the floor so an interventions was to put bolsters in place. V17 reported R10 has not had the behavior of getting out of bed and lying on the floor since the end of last year. V17 stated R10 needs assistance with turning and repositioning and is mechanical lift for transfers. V17 removed the blankets from R10. The surveyor and V17 asked R10 to attempt to get out of bed. R10 was unable to turn to the side unassisted and was unable to lift legs over the bolsters. V17 reported R10 has calmed down and has not attempted to get out of bed since the end of last year. The surveyor asked V17 what is it called when a resident cannot get out of bed unassisted due to the side rails and bed bolster being in place and the V17 responded that it is considered a restraint. 11:32AM V18 (Restorative Nurse) stated R2 is dependent and needs assistance with all ADL care and mobility. V18 has poor trunk control and is non-ambulatory. V18 reported R2 has had falls in the past but had not had one in the past 90 days. V18 stated R2 has bed bolsters in place. V18 reported R10 has a behavior of sliding out of bed to lie on the floor. V18 denied ever seeing R10 slide out of bed or dangle R10's legs out of the bed but stated that is what staff tells V18. V18 stated R10 has side rails up for assistance with turning. V18 confirmed a restorative assessment was completed by V18 on 3/18/25. V18 denied noting any new changes and reported R10 was still able to get out of bed to at the time of assessment. V18 stated during the assessment the resident is asked to turn to the side and move around the bed but staff still assist the resident. V18 stated if a resident cannot get out of bed unassisted and the bed exit is being blocked by side rails and bed bolsters then it is considered a restraint. V18 defined a restraint as restriction of movement. V18 reported the facility is a restraint free facility. 12:12PM V14 (Regional Nurse Consultant) stated R10 has a habit of putting the legs out of the bed and that R10 is confused at baseline. V14 was unsure of the time frame but stated R10 has not had a fall in a while. V14 was not able to state what interventions R10 has in place for falls or getting out of bed. The surveyor notified V14 that throughout the survey R10 has had both side rails and bilateral bed bolsters in place. The surveyor then told V14 that R10 was instructed to attempt to get out of bed with the side rails and bed bolsters in place but was not able to get out. The surveyor asked V14 what it is called when a resident cannot get out of bed due to it being blocked with side rails and bolsters and V14 responded it would be considered a restraint. The Restorative Nursing assessment dated [DATE] documents R10 uses bilateral quarter side rails. A recommendation is to have R10 in the bed mobility program to assist with turning side to side. The Side Rail assessment dated [DATE] documents R10 does not have a history of falls within the last six months. It documents the side rails would not keep R10 from voluntarily getting out of bed. The Minimum Data Set Section P dated 2/4/25 documents no physical restraints are in use for R10. The Physician Order Sheet was reviewed and there is no current order for any restraints to be used. There is no documented consent for restraints. The Care Plan dated 11/06/2015 documents R10 is at risk for falls due to bipolar and heart disease. R10 is noted to crawl out of low bed to floor and slides from the geri-chair. An intervention dated 8/26/24 documents bed bolsters are applied to the mattress. The policy titled, Restraint (Physical/Devices), dated 09/2020 documents, Policy: It is the philosophy of this facility to support a restraint free environment. In accordance with federal and State laws, the use of the device will only be considered when determined to be necessary through the assessment and care planning process. CMS Definition: Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Procedure: .2. Restraints will be ordered by a physician, based on the assessment of the resident capabilities, based on consultation with health care professionals, and demonstrated by the care planning process as a therapeutic intervention will promote the care and services necessary for the resident to attain or maintain the highest practicable physical, mental, or psychosocial well-being.

F644D · No harm, potential for more than minimal, isolated

Based on interview and record review, the facility failed to coordinate getting residents (R16, R156, R76 and R84) a level II PASRR assessment for residents with severe mental illness diagnosis for four out of five residents reviewed for PASRR screening in a total sample of 54. Findings Include: R16 is a [AGE] year old with the following diagnosis: major depressive disorder and post traumatic stress disorder (PTSD). R156 is a [AGE] year old with the following diagnosis: bipolar disorder. R76 admitted in the facility on 5/31/2017 with diagnoses but not limited to: Dementia, Bipolar Disorder and Major Depressive Disorder. R84 admitted in the facility on 6/20/23 with diagnoses of but not limited to: Dementia with other behavior disturbance, schizoaffective disorder, and anxiety. R156 was unable to be interviewed due to mental status. On 3/19/25 at 12:28PM, R16 stated R16 is diagnosed with depression and PTSD. R16 confirmed R16 receives medication daily for managing symptoms. R16 reported R16 also attends psychotherapy sessions for mental health diagnosis. R16 denied being aware if a Level II screen was completed. On 03/19/25 11:08 AM, Reviewed Notice of PASSR Level 1 Screen Outcome dated 3/20/25 reads in part: PASSAR Level 1 Determination: Refer for Level II Onsite. Suspected or Confirmed PASSAR Conditions: (MH) Mental Health Disability. On 03/20/25 12:23 PM, reviewed Notice of PASSR Level 1 Screen Outcome dated 3/20/25, reads in part: PASSAR Level I Determination: Refer for Level II Onsite. Suspected or confirmed PASSAR Conditions: (MH) Mental Health Disability. On 3/20/25 12:47 PM -V7 (Admissions Director) stated V7 gets PASRRs from the hospitals but to renew them. V7 reported social services is responsible for renewing them. V7 reported V7 has never had a need for level 2. V7 was unsure of all the diagnosis that need a level II screen but confirmed if a resident has bipolar then a level II is needed. V7 stated the facility also has marketing team that helps to review PASRRs and will notify the facility if anything is incorrect or missing. 3/20/25 1:03PM - V4 (Social Services) stated that if there is a mental diagnosis the facility submits for a referral for a level II. V4 reported any diagnosis like major depression, schizophrenia, bipolar, or any other mental disorder would qualify for level II assessment. V4 admitted to reviewing the level I assessments when they are complete. V4 stated they have found level I PASRRs have that been completed incorrectly that should have been a level II assessment. V4 was unable to name which residents had incorrect assessments. V4 reported Maximus will usually come within a week to complete a level II screen if needed. V4 stated the importance of completing a level II screen gives the facility interventions to provide for a resident with a mental health diagnosis. V4 was unaware of R156's exact diagnosis but reported if R156 does have a serious mental illness then a level II should have been completed. V4 reported completing the level I screen, and the program generated a level II was not needed. V4 reported refuting the findings with maximus on today 3/20/25. V4 was unable to state R16's mental health diagnosis. V4 stated R16's level I screen was completed yesterday and findings include R16 does not need a level II screen. V4 denied refuting the findings with maximus. V4 was unable to answer why PTSD was not listed on the level I screen as part of R16's diagnosis. The PASRR Level 1 Screen dated 3/19/25 documents the determination as no level II required due to no serious mental illness. R16's diagnosis of PTSD is not listed on the Level I screen that was submitted by the facility. The PASRR Level 1 Screen dated 2/13/24 documents the determination as no level II required due to no serious mental illness. The facility was unable to provide any other documents in the Level I screen besides the determination. The request for a level II screen was submitted to maximum on 3/20/25 at 11:13AM.

F684D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review, the facility failed to follow doctor's orders for one resident(R89) with a diagnosis of lymphedema by not following physician recommendations of elevating bilateral legs for one of three residents reviewed for quality of care. Findings Includes: R89 has diagnosis of Dementia, Pulmonary Hypertension, Lymphedema and Atherosclerotic Heart Disease. During the survey, (3/18-/3/21/25) R89 was observed with legs flat in the bed in her room. There were no additional pillows available for use to place under her legs. On 3/21/25 at 11:48AM, V23(restorative nurse) said he was not aware of any recommendations to elevate R89's legs. On 3/21/25 at 11:53AM, V22(memory care director) said she was not aware of any recommendations to elevate On 3/21/25 at 11:59AM, V21(nurse practitioner) said she would expect any doctor recommendations to be followed as ordered. V21 said if any resident refuses, she would expect to be notified and the behavior to be documented. V21 said R89 was recommended to keep her legs elevated to help with circulation and prevent fluid from pooling. V21 said she was not aware of any resident refusals. R89's legs. R89's physician progress notes dated 3/7/25 documents: reported patient lymphedema is getting worse in bilateral lower extremities. Keep legs elevated at all times. Under plan documents: elevate legs when in bed on three pillows. R89's physician progress notes dated 3/14/25 documents: follow up for bilateral lower extremity edema pitting. Discussed with staff Keep legs elevated. Under plan documents: elevate legs when in bed on three pillows. R89's progress notes do not indicate any refusal of legs being elevated. R89's point of care task list does not indicate to assist with leg elevation. R89's care plan documents: R89 with Lymphedema Date Initiated: 03/17/2025. Interventions include Encourage and cue resident to elevate edematous extremity while seated or in bed as able and as tolerated. Assist as needed with positioning. Date Initiated: 03/17/2025.

F695D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review, the facility failed to date oxygen tubing and to properly store nebulizer mask while not in use for one of three (R13) residents reviewed in a total sample size of 54. Findings Include: R13' physician order sheet dated 3/18/25 documents: respiratory: oxygen per nasal cannula at two to four liters per minute continuous .order dated (3/13/25). Albuterol sulfate nebulization solution 1.5milliliter inhale orally via nebulizer every six hours as needed for respiratory symptoms order dated (3/13/25) On 3/18/25 at 10:48am, R13 was observed with a nasal cannula on with oxygen running. R13's oxygen tubing was not dated. R13's nebulizer mask was observed laying in R13's second night stand drawer which was partially opened without a bag. V6 (nurse) said, R13 was readmitted last night. R13's oxygen tubing should be dated and R13's nebulizer mask should be stored in a plastic bag to prevent contamination. On 3/20/25 at 3:59pm, V14 (regional nurse consultant) said, the oxygen tubing should be dated so that staff will know when to change it. Nebulizer mask should be stored in a plastic zip lock bag when not in use for infection control. A nebulizer mask should never be laying inside of the drawer without a bag. Oxygen therapy device- nasal cannula policy dated 9/2020 documents: A nasal cannula will be changed monthly and as needed. Equipment Change Schedule Policy documents: Equipment will be changed following established schedule to prevent cross contamination. Oxygen tubing, nasal cannula and mask are changed every month and as needed.

Inspection of October 18, 2024

2 findings

F580G · Actual harm, isolated

2 findings

F686G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to prevent a resident who is incontinent of bowel and bladder and requires extensive assistance from staff for ADL (Activities of Daily Living) care, from developing a pressure ulcer. These failures affected one (R18) of four residents reviewed for pressure ulcers and resulted in (R18) developing a Stage 3 sacral wound after being admitted to the facility with skin intact. Findings include: R18 is an [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including but not limited to chronic kidney disease stage 4, hypertensive heart disease, type 2 diabetes with Diabetic Peripheral Angiopathy, anemia, dementia, etc. 03/28/23 10:22 AM, resident was observed sleeping in bed with pressure relieving mattress activated, resident was unable to answer any questions. Braden scale assessment dated [DATE] document a score of 14 (moderate risk) for pressure ulcer. New admission skin assessment dated [DATE] documented old bruise to bilateral upper extremities, old scab to heels, skin intact, no concerns. Facility' pressure ulcer list received 03/27/23 documented that R18 has a facility acquired pressure ulcer. Physician order dated 1/4/2023 stated to conduct skin checks one time a day, every Thursday. Documentation of weekly skin checks not provided during the course of this survey. Minimum Data Set (MDS) assessment 3/15/2023 section G (functional status) coded resident as requiring extensive to total dependence on staff for all activities of daily living (ADL). Section H (Bowel and Bladder) of the same assessment coded resident as always incontinent for bowel and bladder. Care plan initiated 1/5/2023 documents the following: resident has potential for alteration in skin integrity CKD, DM, COPD, Osteoporosis, Dementia, Emphysema, Anemia, Long term use of Anticoagulants, depression, and hx of falls. Skin Observation completed old bruising to the bilateral upper extremities, Toenails thick yellow, heels firm, and dry/closed black scab to the LLE Interventions include Inspect skin daily with care, Pericare after incontinent episodes, Barrier cream to areas exposed to moisture/incontinence, etc. ADL care plan initiated 1/9/2023 documents: resident has an ADL Self Care Performance Deficit Decreased Functional Ability, Fluctuating ADLs, Poor coordination. Interventions include Assist with ADL tasks as needed, Check skin for changes during bathing etc. Review of facility concern/grievance log showed a documentation of concern from resident's daughter dated 1/29/2023, stating that the C.N.A for the morning shift did not change resident on that day (sent the previous day), she showed resident's wet clothing to the afternoon shift staff. Further review of medical record shows the following documentation: 2/15/2023 10:00 Skin / Wound Progress Note Per Nurse request: Resident observed with MASD to the Perineum area and Buttocks. Primary made aware. Daughter updated. Orders received and carried out. Preventive measures in place. WC will monitor/ follow. Further review of medical record shows the following progress note dated 2/15/2023: Daughter called and asked for writer to evaluate her mom's buttock Sacral area. writer completed a body assessment small opening noted to the resident sacral area. writer cleansed and barrier protection applied. resident changed and re positioned made as comfortable as possible. No pain verbalized or observed at this time. call light is within reach Will have wound care to follow up for treatment. 2/15/2023 11:12 Nurses Note, Note Text: wound care has evaluated the buttock sacral area. Writer awaiting orders. daughter of resident notified of the findings. She has no questions or concerns currently. plan of care will continue as ordered. Wound assessment dated [DATE] documented two wounds; Wound 1- perinium buttocks diaper dermatitis and Wound 2 - sacral 3, with light exudate measuring 3.5 x 2.0 x 0.1. Wound note assessment dated [DATE] documented a stage 3 pressure ulcer to the sacrum measuring 9.8 x 9.8 x 0.2 and volume of 19.21. 3/29/2023 at 12:00PM, V9 (LPN/wound care) said that the wound team picked up resident on 2/2/2023 for Moisture Associated Dermatitis (MASD) to the perinium. The MASD was caused by moisture and being wet, resident is incontinent of bowel and bladder. V9 added that on 3/7/2023, resident was seen by the wound doctor who categorized her wound as a stage 3 facility acquired pressure ulcer to the sacrum measuring 3.5 x 2.0 x 0.1. The current treatment is Medi honey adapted or calcium alginate and Metro Cream External Cream 0.75 % (Metronidazole (Topical)), apply as needed. V9 said that resident was admitted to the facility with intact skin. Some of the interventions to prevent the development of pressure ulcer include timely incontinent care, turning and repositioning and completion of skin checks. V9 added that she does not know what happened, she was not here all the time. Document presented by V4 (DON) titled, Prevention and Treatment of Pressure Injury (dated 3/02/2021), states in part, that it is the policy of the facility to identify residents at risk for developing pressure injuries, identify the presence of pressure injuries and other skin alterations, implement preventive measures and appropriate treatment .through individualized resident care plan. Under procedures, the policy states that at least daily, staff should remain alert for potential changes in the skin condition during resident care.

F689G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to have effective and resident-centered interventions in place to prevent falls for a resident with a history of falls. This failure applied to one (R5) of eight residents reviewed for falls and resulted in (R5) having five falls in under two months, two of which resulted in injuries, including an odontoid fracture and requiring three stitches to the left side of her head. Findings include: R5 is an [AGE] year old female originally admitting to the facility on [DATE] with multiple diagnoses including but not limited to the following: fibromyalgia, polyosteoarthritis, AFib, dementia, hypothyroidism, depression, osteoporosis, psychosis, pain, CKD III, bipolar disorder, type II DM, HTN, and moderate protein calorie malnutrition. Facility falls incident reports show R5 has had unwitnessed falls on 1/2/23, 1/16/23, 1/22/23, 2/1/23, and 2/22/23. It is to be noted that the falls 2/1/23 and 2/22/23 resulted in injuries requiring R5 to be hospitalized . Facility incident report dated 2/1/23 states in part but not limited to the following: R5 stated that she fell on the floor and rolled out of the bed. R5 ambulated with her walker to the nurse's station. R5 has complained of headache, pain to back of neck and upper back pain. Complete body assessment done: swelling and a bump to right side of forehead right above eyebrow noted. Redness and bruising below right eye with minimal bleeding noted. R5 transferred to hospital for further evaluation. Hospital records dated 2/1/23-2/13/23 state in part but not limited to the following: Admitting diagnosis of closed type II fracture. Patient presented after unwitnessed fall at nursing home. Recommended no surgical intervention, C-Collar. Assessment/plan: Ground level fall, type II odontoid fracture, T11 subacute fracture, and chronic thoracic compression fracture. Reviewed imaging results from MRI cervical spine without contrast, CT thoracic spine without contrast, and lumbar spine 2D reformatted. Facility incident report dated 2/22/23 states in part but not limited to the following: R5 ambulated out of room pushing wheelchair and nurse noted lump and small laceration to forehead. R5 stated I was sitting on the toilet and I fell asleep. I fell off the toilet and hit my head. R5 stated she had a headache. Received order to send to emergency room for evaluation. R5 returned to facility with dry dressing and three sutures to forehead. Hospital records dated 2/22/23 states in part but not limited to the following: Diagnoses: fall with closed head injury and forehead laceration Facility progress note dated 2/22/23 states in part but not limited to the following: R5 will be returning to facility with 3 stitches to the left side of her forehead. On 3/27/23 at 10:15 AM, this surveyor observed R5 to be in room with door closed. R5 was observed sitting in chair in room wearing own clothes and shoes. No fall mats were noted on either side of resident bed at this time. On 3/28/23 at 11:00AM, R5 was observed to be in room with door closed. Upon entrance, resident was standing in bathroom brushing her hair by herself. 3/28/23 at 11:30AM, V16 (Agency Licensed Practical Nurse) was interviewed regarding the resident's she was assigned to. V16 said she currently has no residents who are a high fall risk. It is to be noted that R5 was assigned to V16. V16 says they are notified about residents who are high fall risk by the previous nurse on duty, by the certified nursing assistants (CNA's) on duty, or within a daily communication. V16 said she was not notified of any resident being a high fall risk. 3/28/23 at 12:00PM, it was noted that R5's bedroom door was still closed. V6 (Restorative RN/Fall Coordinator) was interviewed regarding R5. V6 said R5 is at a very high risk for falls. She says some of the interventions we have in place for her are we moved her room to the first floor with no roommates and close to the nursing station, her room is clutter free, the bed is in the lowest position or an appropriate position for her to transfer independently, all items are within close reach, she is provided with a wheelchair and rolling walker for mobility aid. We have tried fall mats when she was on the second floor but they decreased her ability to ambulate safely. At this time, R5 was shuffling through room making bed and organizing clothes. V6 said agency nurses are notified of residents who are at a high risk for falls through reports, meetings, and in their plan of care. On 3/29/23 at 9:55AM, V6 (Restorative RN/Fall Coordinator) said that all R5's falls have been unwitnessed. Said R5 would come out of her room and let the staff know that she had fallen. I updated the resident's plan of care to add interventions and discontinue interventions if they are not appropriate anymore. Facility most recent Minimum Data Set, dated dated dated [DATE] states in part but not limited to the following: R5 needs supervision defined as oversight, encouragement, and cueing with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, and extensive assistance with personal hygiene. R5 needs supervision or touching assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed/bed to chair transfer, toilet transfer, and walking. R5's care plan originally initiated 4/27/2018 states in part but not limited to the following: Focus: R5 has an ADL self-care performance deficit secondary to activity intolerance, confusion, decreased motivation, and fatigue. ADLs noted to fluctuate from time to time due to dementia. Requires supervision/cues/encouragement. R5's care plan originally initiated 4/18/2018 states in part but not limited to the following: Focus: R5 is at risk for falls r/t impaired memory, judgement, and safety awareness, history of falls, osteoarthritis, AFib, dementia, presence of pacemaker, use of wheelchair, use of walker, and use of antidepressant medication. Interventions: Bilateral floor mats dated 2/14/23; Encourage R5 to report falls to staff as they happen dated 1/2/23; low bed dated 2/14/23; encourage appropriate use of assistive devices; keep items within reach; provide an environment clear of clutter. Facility policy dated 8/2020 states in part but not limited to the following: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: contributing diagnoses and comorbidities, history of fall incidents, assistance required with ADL's, balance issues, behaviors, and/or cognitive status. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Inspection of November 1, 2022

1 finding

F600G · Actual harm, isolated

Based on interview and record review, the facility failed to prevent an incident of staff to resident sexual assault, the facility also allowed the same staff member to provide care to R1 after the abuse investigation was concluded.This failure affected 1 of 3 (R1) residents reviewed for abuse. This failure resulted in R1 having his penis grabbed, pulled and scratched by facility staff (V7), R1 also said he felt uncomfortable having V7 providing care for him after this incident. Findings Include: On 10/26/22 at 3:17pm, R1 who was assessed to be alert and oriented to person, place and time, said, V7 (C.N.A.) entered my room during normal rounds to check my adult brief. My brief was open. I had a foley at the time. V7 (C.N.A.) wrapped her hand around my penis and pulled it. I asked V7 what she was doing. V7 replied, I'm playing. I told V7, I don't play like that. I told V4 (Nurse). I felt uncomfortable. I didn't report the incident initially, because I was embarrassed. V7 scratched my penis. V7 still works with me which makes me uncomfortable. On 10/27/22 at 10:40am, V4 (nurse) said, R1 reported that on 8/11/22, V7 manhandled him and played with his penis, he did not describe how V7 manhandled him. I reported to V1 (administrator). R1 has never made a false allegation against staff. On 10/27/22 at 4:36pm, V1 (administrator) said, sexual abuse is physical contact that the residents perceived as inappropriate. On 10/28/22 at 12:18pm, V2 (Director of Nursing, D.O.N.) said, I would not have an employee accused of abusing resident working with that resident. On 10/28/22 at 12:59pm, V3 (Assistant D.O.N.) said, V7 worked with R1 after the allegation of abuse. V7 worked with R1 on 10/12/22, 10/14/22, 10/18/22, 10/19/22, 10/21/22, 10/24/22, 10/25/22 and 10/26/22. On 10/28/22 at 1:53pm, V1 said, V7 should not be working with R1. V7 should not be work with R1, if R1 reported he felt uncomfortable with V5 providing care. A staff member accused of abuse still working with any residents that made an allegation of abuse would be considered a form of mental abuse. I am not aware of R1 making false allegation againt staff. On 10/28/22 at 2:39pm, V7 (C.N.A.) said, I am in the room with staff when R1 is receiving care. I witness other staff providing R1 care. IDPH reportable dated 9/5/22 document: IL (R1) said, his usual cna (V7) touched him in a way that was inappropriate and uncomfortable. IL (R1) said the cna (V7) was playing with his penis, and in the event may have scratched. Abuse Policy dated 9/20 documents: The facility affirms the right of our residents to be fee from abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. This includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Mental Abuse includes, but is not limit to, humiliation, harassment and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal contact which has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation.

Inspection of September 21, 2022

2 findings

F686G · Actual harm, isolated

2 findings

F684G · Actual harm, isolated

Based on interview and record review, the facility failed to follow the plan of care and monitor the side effects of constipation a opioid pain medication and failied to monitor the effectiveness for use of a laxative to reduce the risk of constipation for 1 of 4 residents reviewed for opioid use and constipation. This failure resulted in R2 being sent to the local hospital and assessed and treated for [REDACTED]. Findings include: On 7/9/18, review of R2's medical record showed that R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was discharged to a local hospital on [DATE]. Review of R2's hospital record shows that R2 was admitted with [DIAGNOSES REDACTED]. Review of R2's medical record MAR and Physician order [REDACTED]. R2 was also on medication to enhance bowel movement to treat the constipation. R2's complaints of constipation was not properly followed up or communicated to the hospice care nurse or the physician. R2 complained of stomach pain and pain medication was recorded given with no documentation of assessment for constipation. Review of MAR dated 5/1/2018 - 5/31/2018 showed that Senna tablet 8.6mg two tablets was ordered 5/18/18 to be given every 24 hours as needed. And in (MONTH) (YEAR), [MEDICATION NAME] suppository 10mg was ordered 6/13/18 to insert one suppository rectally every 12 hours as needed for bowel movement. The MAR did not show that [MEDICATION NAME] suppository was administered before R2 was discharged to the hospital. Review of MAR dated 5/1/2018 - 5/31/2018 showed that Senna tablet was only given once on 5/25/18 at 2250 (10:50pm) and documented that it was effective. In (MONTH) it was recorded given on 6/8/18 and 6/12/18 with effectiveness recorded as unknown. Review of R2's medical record Progress note did not show any documentation that showed that R2 was assessed by the floor licensed nurses assigned to R2 for complaints of constipation or any encouragement to increase fluid intake. On 7/9/18, the facility was unable to provide any communication book for continuity of care for R2. V4 ADON (Assistant Director of Nurses) stated I looked for it and was unable to find it now will continue to search for it. V10 (Restorative/Clinical Support Supervisor) stated the hospice communication book is supposed to be at the nurses station for the nurses. After searching, V10 then stated I will have to let V4 know about it. On 7/10/18 at approximately 3:02pm, during interview with V9 LPN (Licensed Practical Nurse) who was assigned to R2 at the time of transfer to the local hospital. V9 stated (R2) attributed the care rendered to R2 to R2 signing for hospice care stating the family wanted a lot more to be done for (R2). V9 acknowledged that V9 did not check for R2's last BM (Bowel Movement). V9 explained that (V9) was not trained on hospice care. Review of R2's medical record progress note dated 6/15/18 timed 19:29 (7:29pm) V9 documented that R2 complained that R2 did not have any bowel movement for one week. On 7/11/18 at approximately 3:43pm, V34 (Physician) stated that on 6/6/18 (V34) followed up on R2 for admission assessment because (V34) was notified that R2 will be discharged . V34 stated I had to see R2 that day. V34 stated R2 is very ill with end [MEDICAL CONDITION] and it will not be advisable to have R2 live alone or with V28 (Family) who will be gone most of the time. V34 stated I made a suggestion to R2 to consider Hospice care because they have good resources to care for R2's needs. V34 explained that R2's family (V28) .were notified of this and R2 was evaluated for hospice care and was admitted . When V34 was asked about the responsibility of the facility in taking care of R2's symptoms of side effects of medications that includes but not limited to dehydration and constipation despite being on hospice care. V34 stated the facility should still take care of every concern verbalized or noted, V34 stated R2's hospital record was reviewed and medications were continued. V34 explained that for constipation, medications and offer fluids for dehydration. V34 explained that oftentimes no invasive procedure is recommended. On 7/10/18 and 7/11/18, the facility was still unable to provide hospice communication book, V3 DON (Director of Nurses) stated the contracted Local hospice services agent did not live their books (referring to communication form) with us but I will try and get it. On 7/16/18 at approximately 11:15am, both V1 and V3 stated they have being trying to get the Hospice communication book. Both V1 and V3 stated the resident has the right to change his or her mind after signing for a treatment or care. V3 stated the nurses are responsible for assessing for symptoms and proper nursing care concerning any complaint of illnesses. Review of R2's plan of care under Focus documented that R2 has potential for constipation initiated 5/30/18 and under Goal pointed out goals that includes but not limited to R2 will show no sign and symptoms of constipation and will have regular bowel movement. And interventions / tasks pointed out to administer meds (medication) for constipation per Medical Director Order, to monitor for signs of constipation that includes but not limited to decrease bowel sounds abdominal pain, distension, decrease in appetite and fever. This plan of care was not followed.

F689G · Actual harm, isolated

Based on interview and record review the facility failed to monitor kitchen utensils from being utilized as tool to unscrew window saftey screws and failed to monitor the stock piling of linen to use as an escape device to leave through the window on the third floor nursing unit for 1 of 3 residents reviewed for safety and monitoring. This failure resulted in R7 leaving through a window on the third floor falling to the ground and being pronounced dead at the local hospital. The facility also failed to follow the manufacture recommendation and plan of care of utilizing (2) person assist for transfers utilizing the mechanical lift during a transfer for 1 of 4 residents (R4) reviewed for safe tranfers. Findings include: On [DATE], review of R7's medical record admission record indicated that R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per facility report R7 was found outside adjacent to the building with sheets tied together from the 3rd floor window to the ground. R7 was transferred to a local hospital where R7 was pronounced dead. Review of R7's medical record documented that R7 is a high functioning, alert and oriented to time place and persons. R7 has a behavior of taking things that belong to other residents. R7 was a full code, attempt CPR (Cardio [MEDICAL CONDITION] Resuscitation). During this investigation, V16, V17, V18, V20, V21, V22 CNA (Certified Nurse's Aides), V19 and V23 LPN (Licensed Practical Nurse) were interviewed concerning any behavior, signs that can indicate that R7 is planning to escape. They all described R7 as pleasant, very helpful, and compliant with care regimen. V16, V17, V18, and V19 stated on the day of incident R7 did not show any sign of depression or being sad. V18 and V23 stated R7 went about the day in the regular way through-out the night there was no abnormal behavior that will make them suspect that R7 is sad or depressed or planning to escape. V18 assigned to R7 explained that she worked a double shift from 3:00pm [DATE] to 7:00am [DATE]. V18 stated I did not suspect that R7 was going to escape. V18 stated that R7 was last seen at around 10:00pm on [DATE] when R7 was going to bed and was asleep till around 4:00am when R7 woke up and went in the TV (Television) room watching TV. V18 stated that she asked R7 about the program R7 was watching and R7 responded that there no other program to watch. V18 explained that she then started assisting other residents. V18 stated around 5:00am or 5 something (unsure of the exact time), V18 heard V23 screaming and calling V18 and V23 informed V18 that R7 had fallen out of the window. When asked about what V18 saw in R7's room, V18 stated the window to R7's room was opened and sheet (Linen) was tied to the bed and out of the window. V18 stated I saw R7 laying on the grass. V18 further explained that she did not see R7 picked up linens and did not know where R7 got all the linens from. On [DATE] at approximately 7:25pm, V20, V21, and V22 (CNA)'s stated the rounds are supposed to be made every one to two hours to make sure the residents are accounted for with incontinent care done at the same rounds. They all stated the linens are kept in the linen cart in the hallways on all the floors, and the residents are not allowed to get into the carts by themselves to get linens. On [DATE], V16, V17, V18, V19 and V23 stated they did not hear any noise to indicate that R7 was trying to escape through the window. Random observation on [DATE] and [DATE] showed linen carts in the hallways unattended to. Interview with V15, V17, V18, V19, V20, V21, and V22 (CNA), they all acknowledged that the linens are kept in the linen carts in the hallway. They all stated that the residents are not supposed to go in the linen cart without supervision. Review of R7's medical record did not show any record for risk of elopement assessment until after the incident on [DATE]. On [DATE], V14 (Memory Care Director) presented R7 behavior Assessment sheet dated [DATE]. V23 stated that the only behavior assessment done was done [DATE] after (R7) went out of the window. V14 stated R7 expressed wanting to go and visit friends. Review of the facility surveillance video cameras shows that the cameras were centered only at the nurse's station not in the hallways. V1 (Administrator stated) this was designed to monitor the staff to make sure the rounds are being made. The back door camera did not show who is leaving or coming in through the back door. Review of R7's plan of care initiated [DATE] with target date of [DATE] documented under goals that R7's goal includes but not limited to being able to get home to visit with his friends, this goal was not individualized in care plan for desire to go home and how R7 will achieve this. R7's plan of care for discharge initiated [DATE] for returning to community where R7 lives with friends, this was marked D/C (discontinue) with remarks that pointed out that this is not feasible due to the assistance R7 needs and for safety reasons manifested by Dementia. On [DATE], V14 (Memory Care Director) presented R7 behavior Assessment sheet dated [DATE]. V23 stated that the only behavior assessment done was done [DATE] after (R7) went out of the window. V14 stated R7 expressed wanting to go and visit friends was not addressed as a problem because R7 did not exhibit any behavior previous to this incident to indicate any suspicion of elopement. On [DATE], observation of R7 room with V1 (Administrator), V1 stated the room has been cleaned with all furniture put back into place after the local law enforcement department inspected the room. V1 stated that R7 attached (tied) the linen sheet to the bed and open the window, bursting out the window and went out of the window. V1 stated no one knows how R7 got the linens tied together in going out of the window. V1 explained that R7 must have somehow opened the locking system by sliding it, V1 was able to open the window easily. During this observation new screw-able nails were noted on the panel of metal used in holding the window together to the wall then V1 stated we have just repaired it, you (referring to Surveyor) can see the nails are new. When asked about how the facility monitors the safety features on the window V1 stated the staff monitors it daily. On [DATE] at approximately 3:07pm, V1 informed the surveyor that the local law enforcement department wanted the facility to look for screws or any window brackets in R7's room and to notify the department when found. V1 then explained that a butter knife was found in R7's night stand and window locks were noted in the AC (Air-condition) unit. V1 stated we don't know how (R7) got the knife, but it seems (R7) used the knife to unlock the screws. V1 then added we have to start counting the utensils now. V1 further explained that R7's roommate stated R7 brought out the linens from under R7 bed so the linens will now be locked up on the 3rd floor. V1 stated the staff did not know how R7 got the knife to un-screw the window nails. V1 stated we will now have to count the cutleries from down stairs (Referring to the kitchen) and when they are returned. V1 stated the linens will now be locked away and not placed in the hall way because R8 (Roommate) said R7 brought out the linens from under (R7)'s mattress. On [DATE], V16, V17, V18 (CNA) and V19 (LPN) were interviewed concerning whether a code for elopement was called. They all stated it was not called that V23 (LPN) was just screaming. On the [DATE] , V33 (Maintenance Director) and V2 (Assistant Administrator) stated that the linens are kept in the cart on all the floors but after the incident the carts are placed in locked coded room on the 3rd floor. On [DATE] at approximately 11:27am, when V1 was asked about what the QA (Quality Assurance) are working on based on the incident with the securing of the window concerning the type of screw used to secure down the window. V1 Replied we are waiting on the decision from the cooperate office. On [DATE] at approximately 12:23pm, the surveyor asked V26 how R7's need for wanting to visit friends was addressed, V26 stated R7 did not have any interventions for this. The facility presented the Local Police Department's On Scene Investigation report dated [DATE] at 0800hrs (8:00am) that pointed out that R/D (Responding Detective) observed the following at the scene that includes but not limited to, a number of sheets tied together from the corner of (R7) bed frame extending out of window which was closed atop of sheets. Missing metal clamps from the side of the window allowing full extension. The R/D was unable to locate any window brackets or screws. According to the facility Final Investigation report presented, the facility concluded by pointing out that per police department (R7) appeared to have being planning his escape and had hidden his sheets tied together under (R7)'s mattress. The facility located butter knife in (R7)'s nightstand and the window safety locks stuffed down inside the heating/ cooling unit in (R7)'s room. No opportunities had been presented for the facility staff to have reasonably anticipated that this event. On [DATE] at approximately 11:10am, V5 CNA (Certify Nurses' Aide) was observed in the room assisting R4 to transfer from bed into the wheelchair using a transfer mechanical lift device by herself. At approximately 12:49pm, V5 was asked about use of Mechanical lift devices, V5 replied I'm supposed to use (have) two people (referring to staff) when using the mechanical lift device. V5 explained that the facility is short of staff on the floor and was waiting for V6 LPN (Licensed Practical Nurse) assigned with her to come because other CNA's were assisting with shower so she just did what she could by using the mechanical lift by herself before V6 came. At approximately 12:58pm, V6 stated with use of mechanical lift device, two persons are needed. V6 acknowledged that R4 needs two person assist for transfer. V6 explained that when (V6) walked into the room V5 was transferring R4 by herself. Review of R4's MDS (Minimum Data Set) section G dated (MONTH) 17, (YEAR) showed that R4 was coded for transfer, pointing out that R4 is totally dependent on full staff performance every time and with two plus physical assistance. And under G0400 for functional limitation in range of motion was coded 2 for both upper and lower extremity which placed R4 as a risk for injury. Review of R4's plan of care with initiated date of ,[DATE]/ 17 and target date of [DATE] pointed out that R4 requires use of mechanical lift with 2 assist for transfer. And under interventions/ task it indicated to provide 2 staff assistance for transferring. This plan of care was not followed putting R4 at risk for injury. On [DATE] at approximately 2:16pm, V10 (Restorative / Clinical Support Supervisor) stated that at least two staff are needed to prevent fall and injury. The facility policy on Total Mechanical Lift dated ,[DATE] pointed out under equipment that 2 (two) caregivers are required to operate the mechanical lift. This guideline was not followed.

Inspection of November 22, 2016

2 findings

F157G · Actual harm, isolated

Based on interview and record review, the facility failed to follow its own policy governing physician notification by failing to notify one resident's (R3) physician of a change in condition regarding worsening of arterial wounds, for one out of three residents reviewed for change in condition, out of a sample of five residents. This failure resulted in R3's admission to the hospital on [DATE] for bilateral gangene to both feet and subsequent above the knee amputation of R3's right lower limb. Findings include: On 11/16/16 at 12:15pm, Z1 (complainant) stated that R3 developed a blister on the right foot while at the facility. Z1 stated that both of R3's feet were always wrapped when Z1 visited. Z1 stated that on 11/2/16, Z1 finally saw R3's feet and discovered that the skin on R3's right foot was black and told the facility to transfer R3 out. Z1 stated that since then, R3 has had the right foot amputated just above the knee due to lack of care R3 received at this facility. R3's emergency room documentation dated 11/6/16 reads [AGE] year old male seen in emergency department for bilateral foot gangrene. R3 is with family member who states that she has been noticing discoloration of R3's toes and heels for past couple of weeks. Skin - left dry exchar at posterior heel, right dry eschar at posterior heel and dry ischemic changes of digits 1 and 2, discoloration of remaining 3 digits, gangrenous appearing and foul smell from right foot, and dry eschar at lateral aspect of right foot. Ischemic changes of right digits. Impression - right foot gangrene and left heel decubitus ulcer. R3's emergency room notes read Left heel 6 cm x 6cm necrotic decubitus. Right heel 4.5 cm x 5 cm and right lateral foot 3 cm x 4 cm - both necrotic base, positive gangrene to right great toe and second toe. Vascular surgery evaluation. R3's facility wound care evaluation notes dated 10/19/16 read Right great and second toe eschar has become moist in the inferior parts. Debrided the moist areas, some purulent drainage noted, culture taken. R3's lab report dated 10/22/16 reads Wound culture final [MEDICAL CONDITION] - growth many. R3's clinical notes dated 10/24/16 read that Z2 (Attending physician) was notified on 10/24/16. R3's notes dated 10/24/16 read Relayed lab results to Z2. Z2 is going to see R3 in the facility. There is no further follow up to R3'[MEDICAL CONDITION] lab result. On 11/17/16 at 3pm, E1 (Administrator) stated that she does not know what happened. R3's surgical consult report dated 11/6/16 reads RLE (right lower extremity): mummification of hallux and 2nd digit, necrosis of dorsum of foot to midfoot and involving toes, also extending to plantar aspect of foot down to the mid metatarsal region. Dry eschar 5 cm x 2 cm on lateral aspect of 5th metatarsal and dry eschar over heel 3 cm x 3 cm. Foul odor. R3's notes dated 11/9/16 read that R3 had a above right knee amputation. On 11/17/16 at 12:30pm, Z2 (Attending Physician) stated that he was not aware of how bad R3's right foot was until he was called by the nursing home on 11/6/16 with a report that R3's wounds were getting bigger. Z2 stated that he ordered R3 to be sent to the hospital. Z2 stated that he received R3's arterial doppler bilateral lower extremity report dated 10/24/16 which Z2 stated showed mild [MEDICAL CONDITION]. Z2 stated that he was not notified by the wound doctor or any nurse at the nursing home regarding how bad R3's right foot had become until 11/6/16. Z1 (complainant) stated that she visited R3 on 11/2/16 and Z1 stated she told the facility to send R3 to the hospital. On 11/17/16 at 3:30pm, E2 (Director of Nursing) stated that as soon as she saw R3's right foot on 11/6/16, she sent R3 to the hospital. On 11/17/16 at 1:00pm, E8 (Wound Nurse) stated that he can't remember if he reported to Z2 that R3's right foot was black. E8 stated refer to WASA (Weekly Assessment of Skin Alteration) forms. E8 stated that he called Z2 on 11/6/16 because R3's wounds were getting bigger and Z2 stated to send R3 to the hospital. Z2's clinical notes dated 11/6/16 read R3 admitted to the hospital with [REDACTED]. R3's WASA form dated 8/1/16 reads right heel 2 cm x 2 cm. R3's WASA form dated 10/21/16 reads right heel 4 cm x 6 cm, 90% eschar, on 10/27/16 right heel measured 4 cm x 6cm x 0.3 cm, 90% eschar, on 11/2/16 right heel measured 5 cm x 7 cm x 0.3 cm, 90% eschar. R3's WASA forms dated 10/21/16, 10/27/16 and 11/2/16 read that Z2 was notified on 9/28/16. R3's WASA form dated 10/14/16 reads Right great toe 0.5 cm x 1 cm. R3's WASA form dated 10/14/16 0.5 cm x 1 cm, no eschar. MD notified on 8/1/16. R3's WASA form dated 10/21/16 reads Right toes (great toe) 2 cm x 3 cm x 0.2 cm, 100% eschar. MD notified on 8/1/16. There was no documentation in R3's WASA forms that that Z2 was notified that R3's right great toe worsened in size and had eschar. R3's WASA form dated 10/21/16 reads Right lateral foot 1 cm x 1cm. R3's wound care evaluation form dated 10/26/16 reads Right lateral foot post debridement size 4 cm x 3.5 cm, color black, 80% eschar. R3's WASA forms dated 11/2/16 read Right lateral foot 4 cm x 3.5 cm, 75% eschar, MD notified 9/7/16. There was no documentation that Z2 was notified in a timely manner regarding R3's right lateral foot increasing size and 75/80% eschar, black in color. The facility's change in condition policy dated 2/14 reads Purpose is to ensure that the resident's physician/physician on call/NP and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified of changes in a resident's condition. Procedure - Attending physicians or physician on call/NP and responsible party will be notified of all changes in condition.

F309G · Actual harm, isolated

Based on interview and record review, the facility failed to treat [MEDICAL CONDITION] ([MEDICAL CONDITION]- Resistant Staphylococcus Aureus) infection in one out of three resident's (R3), reviewed for wounds in a sample of five, who was identified with a wound to the right great toe. This failure resulted in R3's lack of treatment for [REDACTED]. Findings include: R3 was admitted to the nursing home on 7/29/16. R3's face sheet lists the following Diagnoses: [REDACTED]. R3's WASA (Weekly Assessment of Skin Alteration) form dated 10/14/16 reads Right great toe 0.5 cm x 1 cm. R3's WASA form dated 10/14/16 0.5 cm x 1 cm, no eschar. MD notified on 8/1/16. R3's WASA form dated 10/21/16 reads Right toes (great toe) 2 cm x 3 cm x 0.2 cm, 100% eschar. MD notified on 8/1/16. R3's facility wound care evaluation notes dated 10/19/16 read Right great and second toe eschar has become moist in the inferior parts. Debrided the moist areas, some purulent drainage noted, culture taken. R3's lab report dated 10/22/16 reads Wound culture final [MEDICAL CONDITION] - growth many. R3's clinical notes dated 10/24/16 read that Z2 (Attending physician) was notified on 10/24/16. R3's notes dated 10/24/16 read Relayed lab results to Z2. Z2 is going to see R3 in the facility. There is no further follow up to R3'[MEDICAL CONDITION] lab result. On 11/17/16 at 3pm, E1 (Administrator) stated that she does not know what happened. On 11/17/16 at 12:30pm, Z2 (Attending Physician) stated that he was not aware of how bad R3's right foot was until he was called by the nursing home on 11/6/16 with a report that R3's wounds were getting bigger. Z2 stated that he ordered R3 to be sent to the hospital. Z2 stated that he received R3's arterial doppler bilateral lower extremity report dated 10/24/16 which Z2 stated showed mild [MEDICAL CONDITION]. Z2 stated that he was not notified by the wound doctor or any nurse at the nursing home regarding how bad R3's right foot had become until 11/6/16. Z1 (complainant) stated that she visited R3 on 11/2/16 and Z1 stated she told the facility to send R3 to the hospital. On 11/17/16 at 3:30pm, E2 (Director of Nursing) stated that as soon as she saw R3's right foot on 11/6/16, she sent R3 to the hospital. On 11/17/16 at 1:00pm, E8 (Wound Nurse) stated that he can't remember if he reported to Z2 that R3's right foot was black. E8 stated refer to WASA forms. E8 stated that he called Z2 on 11/6/16 because R3's wounds were getting bigger and Z2 stated to send R3 to the hospital. Z2's clinical notes dated 11/6/16 read R3 admitted to the hospital with [REDACTED]. R3's emergency room documentation dated 11/6/16 reads [AGE] year old male seen in emergency department for bilateral foot gangrene. R3 is with family member who states that she has been noticing discoloration of R3's toes and heels for past couple of weeks. Skin - left dry eschar at posterior heel, right dry eschar at posterior heel and dry ischemic changes of digits 1 and 2, discoloration of remaining 3 digits, gangrenous appearing and foul smell from right foot, and dry eschar at lateral aspect of right foot. Ischemic changes of right digits. Impression - right foot gangrene and left heel decubitus ulcer. R3's emergency room notes read Left heel 6 cm x 6cm necrotic decubitus. Right heel 4.5 cm x 5 cm and right lateral foot 3 cm x 4 cm - both necrotic base, positive gangrene to right great toe and second toe. Vascular surgery evaluation. R3's surgical consult report dated 11/6/16 reads RLE (right lower extremity): mummification of hallux and 2nd digit, necrosis of dorsum of foot to midfoot and involving toes, also extending to plantar aspect of foot down to the mid metatarsal region. Dry eschar 5 cm x 2 cm on lateral aspect of 5th metatarsal and dry eschar over heel 3 cm x 3 cm. Foul odor. R3's notes dated 11/9/16 read that R3 had a above right knee amputation. The facility's infection control policy p.9 reads Contact precautions may be considered for residents who [MEDICAL CONDITION] ([MEDICAL CONDITION]- Resistant Staphylococcus Aureus). Contact precautions are intended to prevent transmission of infectious agents including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. There was no follow up from the facility to determine if R3 needed contact precautions or any other treatment for [REDACTED].

Inspection of August 12, 2015

1 finding

F314G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to prevent, identify, and treat a pressure ulcer for 1 of 3 residents (R1) all reviewed for pressure sore, and failed to implement interventions to prevent a pressure sore from developing for 1 of 3 residents (R5) all reviewed for pressure sores. This failure resulted in R1 being admitted to the hospital and being assessed and treated for [REDACTED]. Findings include: R1 was admitted [DATE] with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated 3-19-15 indicates a BIMS (Brief Interview for Mental Status) score of 06 of a possible high score of 15 related to cognitive functioning. This MDS also indicates R1 was always incontinent of bowel and bladder, and was totally dependent on two staff members to transfer. R1 required the extensive assistance of two staff members for bed mobility and to dress. R1 used a wheelchair for mobility, and a full body lift to transfer. Functional Limitation in Range of Motion assessment dated 3-19-15 indicates R1 had a right wrist contracture, for which she wore a hand splint. E5 (Wound Nurse/Clinical Manager) stated 8-5-15 at 2:32pm R1 lived at the facility for two years. The only skin alterations R1 experienced were the MASD to her buttocks area discovered 2-14-15, as well as a fluid-filled blister to her left shoulder found 2-12-15, as a result of R1 scratching at her shoulder. This blister was treated with antibiotic/zinc ointment daily until healed 2-26-15. R1's Treament Administration Records (TARS) February through April 2015 indicate ointments were administered to both of these areas, as ordered. E5 stated she was unaware of any right malleolar ulcer. E1 (Administrator) stated 8-6-15 at 10:30am she has been the administrator since May, 2014, and attends daily Stand Up meetings on each nursing floor Monday through Friday, where significant events/changes in resident care are discussed. E1 was unaware of a pressure ulcer to R1's right lateral malleolus. E2 (Director of Nursing) stated 8-6-15 at 10:30am she was not the DON at the time of R1's admission to the hospital 4-26-15, and was the facility's Restorative Nurse at that time. CNA's should be checking the condition of resident skin daily when they are dressing residents. Any new skin alterations should be reported to the nurse, who will then call the Wound Nurse (if present in the facility) or the Physician/Nurse Practitioner for wound treatment orders. In addition, CNA's document any skin alterations twice weekly on resident Shower Sheets, and report any new findings to the nurse. Review of R1's Shower Sheets February through May 2015 do not indicate any skin alteration to the right malleolus area. Z11 (Nurse Consultant) stated 8-5-15 at 3:17pm their is no mention in R1's entire medical record of a right malleolar ulcer. Z7's (Former Nurse) note dated 4-26-15 at 1:49pm indicate R1 was sent to the hospital ER (emergency room ) for evaluation of low blood pressure and change in consciousness. This note indicates, in part head to toe assessment done small open area on right button (buttocks?) noted barrier cream and dry dressing applied to area no other lacerations, redness or bruises noted. Z7 could not be reached for comment despite several attempts. Hospital records indicate R1 arrived in the ER 4-26-15 at 1:52pm. Upon admission to the ER, R1 had a right lateral malleolar decubitus ulcer which was foul smelling with mild purulent drainage, which was subsequently diagnosed as a wound infection [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphlococcus Aureus). R1 was admitted to the Telemetry Unit of the hospital with [DIAGNOSES REDACTED]. R1's Braden Scale 3-17-15 indicated she was at mild risk for skin alterations. R1's nursing Monthly Summary dated 4-17-15 indicated she did not have and wounds or skin conditions. R1's care plan contains the focus Actual impaired skin integrity related to MASD but no mention of a right malleolar ulcer. This care plan includes the intervention inspect skin with care daily. Z5 (R1's Attending Physician) stated 8-6-15 at 3:01pm he was not aware of R1's right malleolar ulcer, stating he expects nursing to report any new ulcerations to him, so treatment can be ordered. R5 has [DIAGNOSES REDACTED]. R5's MDS dated [DATE] indicates she requires the extensive assistance of two staff members to transfer. R5 was identified by the facility 8-3-15 as having a facility acquired pressure ulcer. R5's Braden Scale dated 7-21-15 indicates a score of 17, placing her at mild risk for pressure ulcers. R5's care plan includes the focus Alteration in skin integrity, and indicates she had a history of [REDACTED]. R5's care plan includes the intervention off load heels. On 8-3-15 at 1:43pm, R5 was seated in a specialty char near the third floor nurses' station. This chair was in the reclining position. R5 had her knees bent, and heels placed directly against the footrest of this chair, occasionally pushing on her feet, her heels rubbing against the footrest. R5 did not have any shoes on, only socks. A dressing could be seen applied to her left foot, sticking out from under her left sock. E5 was present, and stated R5 had a Deep Tissue Injury to her left heel, and had been known to rub her heels against the footrest of the specialty chair. E5 stated R5 should be wearing shoes. E5 then looked at the computer, and saw E10's (Wound Nurse) WASA (Weekly Assessment of Skin Alteration) note dated 7-30-15. This note described R5 left heel as having a Deep Tissue injury measuring 7cm (centimeters) x 3.5cm, unstageable. This note also indicated per family, they bought to resident one pair of shoes bigger than her size which the resident was using. Educated the family on the importance of having the right size of shoes. Dressing applied, no complain of pain. Off load heels and turning schedule placed. Family and MD (Medical Doctor) aware. Will continue to monitor. On 8-3-15 at 2:10pm, R5 was taken to her room by E5 in the specialty chair (which has wheels) for a dressing change to her left heel. R5 continued to bend her knees and apply pressure to both heels. R5's left heel had a dark purple deep tissue injury area, as yet unopened, measuring approximately 7cm x 3.5cm. E5 cleansed the area with normal saline, then applied providine iodine, as ordered by her physician. Surveyor requested E5 remove R5's right sock. R5's right heel had a pronounced deep indentation in the place she was pressing it against the specialty chair footrest. E5 saw this, and picked up a pair of white athletic shoes placed by R5's bed. Surveyor questioned E5 if she knew these were the shoes E10 indicated in his WASA note as being too big, or where these a new pair? E5 did not know, and put the shoes back on the floor. E10 stated 8-5-15 at 11:25am he was first notified by a floor nurses' call 7-30-15 R5 had a suspected deep tissue injury to her left heel. E10 assessed R5 and suspected R5's shoes were too large. This, along with R5's behavior of rubbing her heels against the specialty chair's footrest caused the deep tissue injury. E10 called to notify the family of this, but did not remove the shoes from R5's room, or label them do not use. Surveyor then went with E10 to R5's room, and found the white athletic shoes on R5's windowsill. E10 identified these were the same shoes he felt were too large for R5, causing the problem. E2 (Director of Nursing) stated 8-5-15 at 3:24pm R5 was assessed for the specialty chair in April, as a comfort measure for when she became tired. The facility does not require a physician's orders [REDACTED]. This assessment was done 4-24-15. If a resident is seen to be putting pressure or rubbing his/her heels on the footrest of a chair, staff should first try to get the resident to straighten his/her legs; if not successful, the resident should have his/her heels off-loaded with pillows. If a nurse suspects shoes may be causing or contributing to the formation of a pressure ulcer, those shoes should be removed from the resident's care area, bagged, and labeled do not use so staff who are unaware of the problem do not inadvertently place the shoes on the resident. Z9 (R5's Attending Physician) stated 8-6-15 at 3:36pm he was noted of R5's left heel deep tissue injury 7-30-15, and gave orders for the providine iodine dressings daily. To protect residents from skin damage, they should wear comfortable, proper-fitting shoes. Resident's feet should be elevated to off-load pressure on heels. Facility policy titled Prevention and treatment of [REDACTED].

Inspection of December 1, 2011

1 finding

F333G · Actual harm, isolated

Base on record review and interview the facility failed to ensure that 2 residents (R4, R1) received the right medication and right dose freeing them from significant medication errors. 1. R4 was admitted to the facility on [DATE] for End Stage [MEDICAL CONDITION], Diabetes and Hypertension, with a plan for long term skilled nursing care. The MAR (Medication Administration Record) for the month of November list an order for [REDACTED]. Review of the facility's medication error incident reports reveals that on September 19, 2011 at 5:00pm R4 received a dose of Insulin, instead of the [MEDICATION NAME] 5,000 units that was ordered for 6:00pm. According to E5's, (Licensed Practical Nurse) statement of events, E5 filled a 1 ml (milliliter) syringe with what was assumed to be [MEDICATION NAME], but was Novolg insulin, then injected 100 units subcutaneous into the R4. Review of the nursing progress notes dated September 19, 2011 at 6:30pm denotes that R4 became cold, clammy, lethargic with a blood glucose level of 52 after the administration of what was presumed to be [MEDICATION NAME]. The physician was then notified, [MEDICATION NAME] was given to help increase the blood sugar, 911 was called and R4 was sent by ambulance to the hospital. On December 1, 2011 at 2:15pm E2, Director of Nursing stated that the incident report and events listed were correct and verified her signature as the person who conducted the investigation and completed the medication error incident report. Review of E5, employee file denotes a disciplinary action report referencing the above incident violation, requiring E5 to be further monitored for 2 weeks when administering medication. Review of the hospital medical records documents that on September 19, 2011, R4 was treated in the emergency room , them admitted to the ICU (Intensive Care Unit) with a diagnosed of [DIAGNOSES REDACTED]. Hospital stayed equaled 4 days, then R4 was transferred to another long term care facility per family request. 2. R1 was admitted into the the facility on October 27, 2011 and was being treated for [REDACTED]. According to the MAR (Medication Administration Record), R1 missed 3 doses of the medication on November 25-26. Review of the medication error incident report dated November 30, 2011 documents this error and disciplinary action was taken against the nurse. On December 1, 2011 at 3:30pm, E2 stated the medication was dispensed by pharmacy at 50mg tabs and R1 was given 5 tablets to equal the dose. Review of the nursing progress notes and medication incident report dated November 30, 2011, documents that R1 had complaints of pain upon urination.

Inspection of August 12, 2011

1 finding

F323G · Actual harm, isolated

Based on observation, interview and record review the facility failed to prevent an avoidable accident, by not ensuring bed wheel locks were in good working condition for 1 of 3 residents R1, R1 subsequently fell and sustained a head injury requiring hospitalization when the wheels on his bed failed to lock, The facility also failed ensure bed wheel locks were in good working condition for 1 of 3 residents R8, and for 9 of 9 beds on the second floor nursing unit. Based on interview and record review the facility failed to properly transfer 2 of 3 residents R6,R11. R6 was assessed to require extensive 2 person physical assist with transfers and identified to with poor balance related to bilateral lower extremity weakness subsequently sustained a fall after being assisted by 1 staff member in the shower. R11 was repositioned in bed by 1 staff member pulling R11 up with a incontinent pad. Based on record review and interview the facility failed to provide adequate 1:1 supervision for 2 of 3 residents R9/R10, both R9/R10 were assessed to require 1:1 supervision. Findings include: 1). According to the facility's occurence report dated 3/20/11 11:35pm denotes that R1 was invloved in a fall incident, the fall is noted as un-witnessed, the report indicates that R1 said that he was attempting to stand up, and hit his head on his closet. The report indicates that R1 sustained a laceration to the left side of the forehead. According to the occurence report enviromental conditons present at time of incident indicates that bed locks were not working. Accoridning to nurse note 3/21/11 3:30am denotes that R1 fell out of bed at 11:35am was found on the floor on his left side with a gash to his left forehead. The note indicates that pressure was applied and 911 called, 11:40pm 911 arrived and R1 was noted as alert and verbal, R1 noted as being trasferred to the hospital for evaluation. The noted indicates that R1 returned to the facility from the hospital at 3:30am with sutures to the left side of the forehead. On 6/2/11 at 3:00pm E2 (director of nursing), said that bed locks should be applied when residents are in bed, during transfers for support. On 6/2/11 at 10:45am in room 218-3 survey team observed facility staff transfer R8 from the wheel chair to the bed. R8 was observed being transferred via 2 person assist E4/E6 (certified nurse aide). E6 applied the wheel locks on the bed, and locked R8's wheelchair. E4 and E6 stood R8 up and pivoted R8 toward the bed and as R8's leg hit the bed the bed moved and rolled backwards. E6 said that the brakes were applied but don't seem to work. At closer observation the foot board was loose and fell off the bed as it was manipulated by E6. On 6/2/11 at 2:00pm with E2 (director of nursing), and Z2 (nurse consultant), the survey team toured the 2nd floor nursing unit. The survey team observed residents in bed, and observed along with E2 and Z2 that the following beds would not lock. Room 239-1, 234 1,2,&3, 210-1&2, 211-1, and bed 1 in both rooms 214 and 215. During the observation all rooms and bed mentioned the wheels locks were observed to be no engaged at the time of the observation. On 6/2/11 at 2:15pm in the 2nd floor hallway E2 / Z2 said that when residents are in bed that staff are expected to ensure that the beds are in a locked position. After E2 applied the wheel locks all beds mentioned were still able to roll front to back and side to side. On 6/2/11 at 4:00pm E1 (administrator), said that quality assurance identifed that the wheels on the beds wer a problem. E1 said that some beds were identified and wheels were fixed. E1 was unable to verbalize what beds were identified and which wheel locks were replaced. E1 said that after the survey team identified the inoperable wheel locks on the second floor that the facility maintenace staff would do an facility wide audit. 2). According to the facility's occurrence report R6 was involved in a fall incident on 2/10/2011 1:45pm. the report indicates that a cna (certified nurse aide), called for help, the report indicates that R6 was eased to the floor while cna tried to a protective under garment on R6. R6 was noted as loosing balance cna attempted to hold on to R6 under right arm but noted not strong enough to hold R6. The report indicates status prior to fall R6 transferring by (1 ) staff member. According to the Minimum Data Set, dated dated dated dated 1/30/11 section G transfer assessment indicates that R6 requires extensive assistance and 2 person physical assistance. R6 balance was also assessed surface to surface transfer requires human assistance for stabilization. R6 is also assessed impairment to both lower extremities. According to the facility's occurrence report dated 5/9/11 3:00am indicates that R6 was sitting on the floor with 1:1 cna present. The nurse indicates in report that R6 was observed sitting on the floor with her back against the bed alert and verbal. The report indicates when the 1:1 cna was asked what happened the cna informed the nurse that she left R6 to get another cna for assistance with R6. When the cna returned R6 was found on the floor, the cna stated I was only gone for few minutes. On 06/3/2011at 11;00am, E2 (director of nursing), said that when residents are being monitored 1:1 that staff are not to leave the resident, and that the cna should have used the call light for assistance. According to the facility's occuurrence report dated 5/9/11 at 1:45pm R6 was invloved in a 2nd fall incident on 5/9/11. The report indicates that R6 knees buckled while being transferred from a shower chair to the wheelchair, ans was lowered to the floor by cna. On 6/3/11 at 2:50pm E9 said that after assisting R6 with a shower and was attempting to stand R6 to transfer R6 from the shower chair to the wheelchair. E9 said that upon standing R6 complained of feeling dizzy. E9 said that she sat R6 back down and attempted to stand R6 again when R6's knees gave way and she eased R6 to the floor. E9 said that she didn't call for assistance after R6 complained of dizziness, and said she thought R6 was okay after the initial complaints of dizziness. According to the nurses notes dated 3/4/11 at 12:30pm R11 complained of severe back pain, note indicates that pain medication was given. Nurse note 2:00pm indicates that pain medication not effective, and R11 physician was notified. The note indicates that the physician gave orders for new medication and x-rays to be obtained. According to the portable x-ray results dated 3/5/11 exam of the lumbar spine indicates mild compression fracture of T12. R11 physician was notified of the x-ray results, and gave orders. Nursing notes 3/7/11 R11 still complaining of pain to the lower back, R11 physician was notified and gave orders to send R11 to the hospital for evaluation. According to the hospital records dated 3/7/11 R11 was assess and treated for [REDACTED]. On 6/17/11 E1 (administrator) said that she was aware of R11 compression fracture, E1 was unable to verbalize how R11 was fractured. E1 said that the facility didn't investigate R11 compression fracture as an injury of unknown origin. On 6/17/11 at 1:30pm R11 was assessed to be alert and oriented to person, place, and time. R11 said that (1) staff was attempting to reposition her in the bed using the incontinent pad, R11 said that as the staff tried to pull her up by herself using the incontinent pad R11 said she felt a sharp pain in the lower back area. R11 said that she screamed out in pain. R11 said that no one asked her how she injured her back. R11 said that she was given pain medication and x-rays were taken. Durng the interview R11 identified the certified aid that repositioned her using the incontinent pad as E13. On 6/17/11 at 2:00pm E1 (administrator), said that E13 no longer works at the facility. According to E13's employee file E13 was terminated from the facility on 3/30/11 for failure to comply with providing and/or appropriate care, neglectful during patient care. On 8/12/11 at 2:00pm both E2 (director of nursing), and Z2 (nurse consultant), said that when a resident is being repostioned using the incontinent pad that the transfer requires two staff, E2 said that there should be one staff member on each side of the pad lifting the resident. E2 said that during orientation the restorative nurse instructs new certified nurse staff on how to repostion residents, and that pulling a resident from behind using the incontinent pad is not a facility practice. 3). According to R10's plan of care dated 6/4/11 R10 is identified as making attempts to get out of bed even with frequent reminders form staff. The intervention dated 6/4/11 indicates assign 1:1 all shifts. R10 is assessed with [REDACTED]. R10 is current residing on the second floor nursing unit. According to R9's plan of care dated 6/2/11 R9 is identified to be high risk for falls, and history of falls. R9's plan of care interventions include resident needs 1:1 intervention. According to the facility staffing schedule 6/4/11 7a - 3p shift 1 cna (certified nurse aid) was scheduled for 1:1 supervision, on the 3p-11p shift there was no cna scheduled for 1:1 supervision and on the 11p- 7a shift there was 1 cna scheduled for supervision, both R9/R10 were in the same room and both plans of care indicated 1:1 supervision required. On 6/5/11 7a-3p 1 cna scheduled for supervision, 3p-11p no cna scheduled for 1:1 supervision, 11p-7a 1 cna scheduled for supervision, again both R9/R10 were in the same room both had treatment plans requiring 1:1 supervision. On 6/6/11 there was 1 cna again scheduled for 1:1 supervision for all three shifts, R9/R10 both required 1:1 supervision. 6/7/11 staffing indicated 1 cna for each shift for supervision but indicated on the staffing sheet 1:2 supervision for both R9/R10. According to the both R9/R10's plan of care they were assessed to require 1:1 supervision. According to the staffing schedule 6/8, 6/9, 6/10 all three days 1:2 supervision was noted for R9/R10. According to R9/R10's treatment plan both required 1:1 supervision. On 6/22/11 at 2:00pm E6 (supervisor), said that she was aware that both R9/R10 did reside in the same room, and said that she was aware that both required 1:1 supervision. E6 said that she was told by E2 (director of nursing), to schedule 1 staff person to provide supervision for both residents. E6 said that 1 staff for 2 residents isn't 1:1 supervision but was considered close supervision. According to the facility's occurrence report dated 5.29/11 indicates that R9 fell out of the wheel chair flat on her face, vitals signs recorded. R9 was assessed with [REDACTED]. According to the facility's investigation R9 was being monitored when by staff 1:1 when R9 stood and fell to the floor, and facility staff was sitting across from R9 but was unable to get to R9 before the fall. According to the hospital transfer record dated 5/31/11 indicates that R9 requires a sitter., and that R9 has a history of multiple falls out of bed at home. On 6/22/11 at 4:45pm E1 (administrator), said that 1:1 means 1 staff member for that individual resident. E1 was unable to verbalize why 2 residents requiring 1:1 supervision was placed in the same room, and why there was only one staff member scheduled to monitor the 2 residents both with history of falls and 1 with a recent history of falls while under 1:1 supervision. E1 was unable to provide survey with a policy or guideline for 1:1, however E1 noted that 1:1 means 1 staff per resident. According to the clinical record R9 was admitted to the facility on [DATE]. On 6/3/11 at 2:30pm Z2 (nurse consultant), said that R9's family informed the facility at time of admission, that R9 has a history of throwing herself from the chair. According to Z2 R9 was placed under 1:1 monitoring by staff. According to the nurses notes dated 5/29/11 5:00pm R9 was admitted to the facility, throughout the shift R9 was noted as having behaviors of yelling and throwing things. Nurses note 5:00pm R9 recieved haldol 5mg (anitpsychotic) by mouth with side effects noted by dizziness, drowsiness. Nurse note 7:00pm R9 nurse call physician and recieved an order for [REDACTED]. Nurse note 8:00pm R9 noted as throwing a cup of water, R9 is noted as recieving Ativan (anti-anxiety), by mouth with side effects noted clumsiness, dizziness, drowsiness, lightheaded, unsteadiness, and weakness. Nursing note 10:30pm R9 placed at the nurse station , nurse note 11:30pm indicates that R9 decided to standup and fell down to the floor, face first. R9 was assessed with [REDACTED]. According to the hospital record dated 5/30/11 8:36am CT if head without contrast related to change in mental staus, fall the finding of the scan include small acute subdural hematoma. R9 was admitted to the hospital and treated for [REDACTED]. E11 (certified nurse aide) was unavailable for interview during survey period, however the facility provided survey team with a written statement from E11 indicating that R9 fell at 11:30p, E11 indicates that she was told to watch R9 by the nurse. E11 said that R9 threw herself from the chair, E11 indicates she didn't expect R9 to do this. E11 indicates she was sitting across from from R9 sitting on a chair. E11 indicates it happened so fast, indicates that R9 was talking to her, the statement indicates that R9 said that she was tired and wanted to go back to bed.

Inspection of February 15, 2011

4 findings

F157G · Actual harm, isolated

Based on clinical record review and interview the facility failed to notify the physician in change of condition regarding pain management and full assessment of one resident R19 in a sample of 26 residents. Findings Include: R19 was observed on 2-9-2011 at 1:26 pm in an adult reclining chair in the bathroom during hygiene care, nonverbal, right side of inguinal area covered with a dressing, eyes opened and no facial or body movement noted. R19 ' s clinical record was reviewed immediately after observation. The Minimum Data Set((MDS) dated [DATE] documents the following pertinent diagnosis ' : Dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The following documentation was obtained from the nursing progress notes dated 12-14-2010: " 6pm- Certified nursing assistant(CNA) communicated to the nurse on duty that R19 ' s right knee was swollen and that the resident was making facial grimaces as the CNA got the resident up.Nurse made an assessment of R19 ' s swollen right knee and facial grimaces and nurse gave Tylenol. 7pm- Documents that the nurse performed range of motion to R19 ' s right knee. R19 was grabbing at the right knee during range of motion, the nurse paged the medical doctor. 7:30pm- Documents that an order was obtained from the doctor to give [MEDICATION NAME] 25 milligrams and obtain an x-ray of the knee femur and hip. The X-ray department was notified. 10:30pm -Documents that R19 was in bed and the change of condition was endorsed to the next shift to monitor. " Nursing progress notes documents on 12-15-2010 and 12-16-2010 the following: 12-15-2010 at 2 am- Received R19 in bed per report , swelling noted to right knee, slightly [MEDICAL CONDITION], right leg was elevated on a pillow , pain medication given to resident, will continue to monitor. 12-15-2010 at 9:30pm- Documentation stated that phone and fax was received from the x-ray department communicating distal fracture to the right femur. At 10 pm the medical doctor was made aware with orders to send the resident to the emergency room . The family was notified at this time. At 10:55pm the resident left to go to the hospital via ambulance on a stretcher. 12-16-2010 6am- Documents that R19 returned from the hospital at 3:10am with a knee immobilizer in place and a prescription for [MEDICATION NAME] ES 7.5 milligrams/750 milligrams take one every 4-6 hours for pain. According to the facility ' s policy on Change of Condition " The attending physician or physician on call /NP and responsible party will be notified with changes in a residents condition. The facility ' s policy on Pain Management Assessment states " Residents should be assessed and reassessed as necessary for pain. Interviews: On 2-9-2011 at 3:20 pm in the lower level conference room (Nurse) E9 was interviewed. Using the clincial record E9 was asked to communicate what happened on 12-14-2010 with her 6pm documentation. E9 responded that " on 12-14-2010 before dinner Certified Nursing Assistant, E10 informed me that R19 ' s right leg was swollen and that resident was cringing when it was touched. I told E10 that I would check on it during dinner. When I checked on it, I noticed that R19 ' s right leg was swollen and that she grimaced when it was touched. I told E10 to put the resident to bed after dinner and I would check it further. At 6 pm when R19 was put t o bed I gave Tylenol for the facial grimacing and swollen right knee. At 7pm I performed range of motion on the right knee, R19 was noted to grab her right knee during range of motion, this was unusual so I paged the doctor. The doctor responded at 7:30pm with orders to give [MEDICATION NAME] 25 milligrams every 8 hours, the doctor thought it was arthritis, I strongly suggested an x-ray, which the doctor ordered(X-ray of right femur, hip and knee). When I called the x-ray department , they were having problems with coming out to do the x-ray. The [MEDICATION NAME] was not working on a scale of 1 to 5 with 5 being the highest, I would rate R19 ' s pain as severe a 3to 4. I did not document this. I did not communicate to the doctor, the severity of R19 ' s pain, the ineffectiveness of the [MEDICATION NAME] or the problem with the x-ray department. " Certified Nursing Assistant, E10 was interviewed on 2-9-2011 at 4:45pm in the lower level conference. E10 stated the she remembers well what happened on 12-14-2010 with R19. " R19 was acting unusual when I went to get her up from bed to go to dinner. I told the nurse(E9) . I knew something was wrong, R19 was cringing and grimacing and her right knee was swollen, I told E9 all of that. The nures E9 came and checked R19 during diner and told me that the right knee was swollen and that grimacing was noted , E9 told me to put R19 to bed after dinner and that she would check R19 later. " E7(nurse) was interviewed on 2-10-2011 at 9:10 am in the lower level conference room. E7 is the 11pm to 7am nurse. E7 responded " I received report at 11:15pm about R19 ' s change in condition and that the doctor thought it was gout. All of the residents on the 3rd floor receive x-rays in situations like this because they can not communicate effectively what is wrong so an x-ray is ordered to make sure that there is no fracture or break. E7 stated that she only assessed the resident at 2am during diaper change and noted at this time unusual grimacing for which she gave Tylenol and did not notify the doctor of R19 ' s pain level. I did a pain assessment but did not document it. Further the x-ray was to be done in the morning, but the physician should have been notified and an order obtained to send the resident out to the emergency room or stat x-ray. I should have document ed/monitored more but I am one nurse for 60 residents. " On 2-10-2011 at 10:05 am in the lower level conference room (Nurse) E11 was interviewed. E11 stated that on 12-14-2010 around lunch time Certified Nursing Assistant, E8 informed me of facial grimacing during repositioning of R19, I told E8 to give her a shower after lunch and that is when I will check it. 30 minutes later I assessed R19 during the shower , I did not noticed anything unusual, I did not document my assessment. I felt bad when I returned two days later to work and discovered that R19 had a right leg fracture. " On 2-10-2011 at 11:45 am Certified Nursing Assistant E8 was interviewed via telephone outside of the facility. E8 responded that " on 12-14-2010 before lunch R19 was being repositioned and facial grimacing as if in pain was noted and reported immediately to nurse, E7. E7 wrote what I said on a piece of paper and told me that she would have someone check it later. " On 2-10-2011 at 2:20 pm in the lower level conference room via telephone the Medical Director , Z1 was interviewed . Z1 responded " A doctors decisions are based on what the nurse communicate to the doctor. There is always a potential for harm when range of motion is performed on a suspected fracture. I want the nurse to communicat to me everything about pain , whether pain mangement is effective or ineffective. "

F224G · Actual harm, isolated

Based on clinical record review and interview, the facility failed to provide a timely x-ray procedure ,appropriate treatment and pain management to avoid physical harm for one resident R19 out of 26 sampled residents. This deficient practice resulted in ineffective pain management, improper treatment a delayed [DIAGNOSES REDACTED]. Findings Include: R19 was observed on 2-9-2011 at 1:26 pm in an adult reclining chair in the bathroom during hygiene care, nonverbal, right side of inguinal area covered with a dressing, eyes opened and no facial or body movement noted. R19 ' s clinical record was reviewed immediately after observation. The Minimum Data Set((MDS) dated [DATE] documents the following pertinent diagnosis ' : Dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The following documentation was obtained from the nursing progress notes dated 12-14-2010: " 6pm- Certified nursing assistant(CNA) communicated to the nurse on duty that R19 ' s right knee was swollen and that the resident was making facial grimaces as the CNA got the resident up.Nurse made an assessment of R19 ' s swollen right knee and facial grimaces and nurse gave Tylenol. 7pm- Documents that the nurse performed range of motion to R19 ' s right knee. R19 was grabbing at the right knee during range of motion, the nurse paged the medical doctor. 7:30pm- Documents that an order was obtained from the doctor to give [MEDICATION NAME] 25 milligrams and obtain an x-ray of the knee femur and hip. The X-ray department was notified. 10:30pm -Documents that R19 was in bed and the change of condition was endorsed to the next shift to monitor. " Nursing progress notes documents on 12-15-2010 and 12-16-2010 the following: 12-15-2010 at 2 am- Received R19 in bed per report , swelling noted to right knee, slightly [MEDICAL CONDITION], right leg was elevated on a pillow , pain medication given to resident, will continue to monitor. 12-15-2010 at 9:30pm- Documentation stated that phone and fax was received from the x-ray department communicating distal fracture to the right femur. At 10 pm the medical doctor was made aware with orders to send the resident to the emergency room . The family was notified at this time. At 10:55pm the resident left to go to the hospital via ambulance on a stretcher. 12-16-2010 6am- Documents that R19 returned from the hospital at 3:10am with a knee immobilizer in place and a prescription for [MEDICATION NAME] ES 7.5 milligrams/750 milligrams take one every 4-6 hours for pain. According to the facility ' s policy on Change of Condition " The attending physician or physician on call /NP and responsible party will be notified with changes in a residents condition. The facility ' s policy on Pain Management Assessment states " Residents should be assessed and reassessed as necessary for pain. Interviews: On 2-9-2011 at 3:20 pm in the lower level conference room (Nurse) E9 was interviewed. Using the clincial record E9 was asked to communicate what happened on 12-14-2010 with her 6pm documentation. E9 responded that " on 12-14-2010 before dinner Certified Nursing Assistant, E10 informed me that R19 ' s right leg was swollen and that resident was cringing when it was touched. I told E10 that I would check on it during dinner. When I checked on it, I noticed that R19 ' s right leg was swollen and that she grimaced when it was touched. I told E10 to put the resident to bed after dinner and I would check it further. At 6 pm when R19 was put t o bed I gave Tylenol for the facial grimacing and swollen right knee. At 7pm I performed range of motion on the right knee, R19 was noted to grab her right knee during range of motion, this was unusual so I paged the doctor. The doctor responded at 7:30pm with orders to give [MEDICATION NAME] 25 milligrams every 8 hours, the doctor thought it was arthritis, I strongly suggested an x-ray, which the doctor ordered(X-ray of right femur, hip and knee). When I called the x-ray department , they were having problems with coming out to do the x-ray. The [MEDICATION NAME] was not working on a scale of 1 to 5 with 5 being the highest, I would rate R19 ' s pain as severe a 3to 4. I did not document this. I did not communicate to the doctor, the severity of R19 ' s pain, the ineffectiveness of the [MEDICATION NAME] or the problem with the x-ray department. " Certified Nursing Assistant, E10 was interviewed on 2-9-2011 at 4:45pm in the lower level conference. E10 stated the she remembers well what happened on 12-14-2010 with R19. " R19 was acting unusual when I went to get her up from bed to go to dinner. I told the nurse(E9) . I knew something was wrong, R19 was cringing and grimacing and her right knee was swollen, I told E9 all of that. The nures E9 came and checked R19 during diner and told me that the right knee was swollen and that grimacing was noted , E9 told me to put R19 to bed after dinner and that she would check R19 later. " E7(nurse) was interviewed on 2-10-2011 at 9:10 am in the lower level conference room. E7 is the 11pm to 7am nurse. E7 responded " I received report at 11:15pm about R19 ' s change in condition and that the doctor thought it was gout. All of the residents on the 3rd floor receive x-rays in situations like this because they can not communicate effectively what is wrong so an x-ray is ordered to make sure that there is no fracture or break. E7 stated that she only assessed the resident at 2am during diaper change and noted at this time unusual grimacing for which she gave Tylenol and did not notify the doctor of R19 ' s pain level. I did a pain assessment but did not document it. Further the x-ray was to be done in the morning, but the physician should have been notified and an order obtained to send the resident out to the emergency room or stat x-ray. I should have document ed/monitored more but I am one nurse for 60 residents. " On 2-10-2011 at 10:05 am in the lower level conference room (Nurse) E11 was interviewed. E11 stated that on 12-14-2010 around lunch time Certified Nursing Assistant, E8 informed me of facial grimacing during repositioning of R19, I told E8 to give her a shower after lunch and that is when I will check it. 30 minutes later I assessed R19 during the shower , I did not noticed anything unusual, I did not document my assessment. I felt bad when I returned two days later to work and discovered that R19 had a right leg fracture. " On 2-10-2011 at 11:45 am Certified Nursing Assistant E8 was interviewed via telephone outside of the facility. E8 responded that " on 12-14-2010 before lunch R19 was being repositioned and facial grimacing as if in pain was noted and reported immediately to nurse, E7. E7 wrote what I said on a piece of paper and told me that she would have someone check it later. " On 2-10-2011 at 2:20 pm in the lower level conference room via telephone the Medical Director , Z1 was interviewed . Z1 responded " A doctors decisions are based on what the nurse communicate to the doctor. There is always a potential for harm when range of motion is performed on a suspected fracture. I want the nurse to communicat to me everything about pain , whether pain mangement is effective or ineffective. "

F309G · Actual harm, isolated

Based on observation, clinical record review and interview the facility failed to evaluate, manage and address pain therapy for one resident , R19 in a sample of 26 residents. This deficient practice resulted in ineffective pain management and a delayed [DIAGNOSES REDACTED]. Findings Include: R19 was observed on 2-9-2011 at 1:26 pm in an adult reclining chair in the bathroom during hygiene care, nonverbal, right side of inguinal area covered with a dressing, eyes opened and no facial or body movement noted. R19 ' s clinical record was reviewed immediately after observation. The Minimum Data Set((MDS) dated [DATE] documents the following pertinent diagnosis ' : Dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The following documentation was obtained from the nursing progress notes dated 12-14-2010: " 6pm- Certified nursing assistant(CNA) communicated to the nurse on duty that R19 ' s right knee was swollen and that the resident was making facial grimaces as the CNA got the resident up.Nurse made an assessment of R19 ' s swollen right knee and facial grimaces and nurse gave Tylenol. 7pm- Documents that the nurse performed range of motion to R19 ' s right knee. R19 was grabbing at the right knee during range of motion, the nurse paged the medical doctor. 7:30pm- Documents that an order was obtained from the doctor to give [MEDICATION NAME] 25 milligrams and obtain an x-ray of the knee femur and hip. The X-ray department was notified. 10:30pm -Documents that R19 was in bed and the change of condition was endorsed to the next shift to monitor. " Nursing progress notes documents on 12-15-2010 and 12-16-2010 the following: 12-15-2010 at 2 am- Received R19 in bed per report , swelling noted to right knee, slightly [MEDICAL CONDITION], right leg was elevated on a pillow , pain medication given to resident, will continue to monitor. 12-15-2010 at 9:30pm- Documentation stated that phone and fax was received from the x-ray department communicating distal fracture to the right femur. At 10 pm the medical doctor was made aware with orders to send the resident to the emergency room . The family was notified at this time. At 10:55pm the resident left to go to the hospital via ambulance on a stretcher. 12-16-2010 6am- Documents that R19 returned from the hospital at 3:10am with a knee immobilizer in place and a prescription for [MEDICATION NAME] ES 7.5 milligrams/750 milligrams take one every 4-6 hours for pain. According to the facility ' s policy on Change of Condition " The attending physician or physician on call /NP and responsible party will be notified with changes in a residents condition. The facility ' s policy on Pain Management Assessment states " Residents should be assessed and reassessed as necessary for pain. Interviews: On 2-9-2011 at 3:20 pm in the lower level conference room (Nurse) E9 was interviewed. Using the clincial record E9 was asked to communicate what happened on 12-14-2010 with her 6pm documentation. E9 responded that " on 12-14-2010 before dinner Certified Nursing Assistant, E10 informed me that R19 ' s right leg was swollen and that resident was cringing when it was touched. I told E10 that I would check on it during dinner. When I checked on it, I noticed that R19 ' s right leg was swollen and that she grimaced when it was touched. I told E10 to put the resident to bed after dinner and I would check it further. At 6 pm when R19 was put t o bed I gave Tylenol for the facial grimacing and swollen right knee. At 7pm I performed range of motion on the right knee, R19 was noted to grab her right knee during range of motion, this was unusual so I paged the doctor. The doctor responded at 7:30pm with orders to give [MEDICATION NAME] 25 milligrams every 8 hours, the doctor thought it was arthritis, I strongly suggested an x-ray, which the doctor ordered(X-ray of right femur, hip and knee). When I called the x-ray department , they were having problems with coming out to do the x-ray. The [MEDICATION NAME] was not working on a scale of 1 to 5 with 5 being the highest, I would rate R19 ' s pain as severe a 3to 4. I did not document this. I did not communicate to the doctor, the severity of R19 ' s pain, the ineffectiveness of the [MEDICATION NAME] or the problem with the x-ray department. " Certified Nursing Assistant, E10 was interviewed on 2-9-2011 at 4:45pm in the lower level conference. E10 stated the she remembers well what happened on 12-14-2010 with R19. " R19 was acting unusual when I went to get her up from bed to go to dinner. I told the nurse(E9) . I knew something was wrong, R19 was cringing and grimacing and her right knee was swollen, I told E9 all of that. The nures E9 came and checked R19 during diner and told me that the right knee was swollen and that grimacing was noted , E9 told me to put R19 to bed after dinner and that she would check R19 later. " E7(nurse) was interviewed on 2-10-2011 at 9:10 am in the lower level conference room. E7 is the 11pm to 7am nurse. E7 responded " I received report at 11:15pm about R19 ' s change in condition and that the doctor thought it was gout. All of the residents on the 3rd floor receive x-rays in situations like this because they can not communicate effectively what is wrong so an x-ray is ordered to make sure that there is no fracture or break. E7 stated that she only assessed the resident at 2am during diaper change and noted at this time unusual grimacing for which she gave Tylenol and did not notify the doctor of R19 ' s pain level. I did a pain assessment but did not document it. Further the x-ray was to be done in the morning, but the physician should have been notified and an order obtained to send the resident out to the emergency room or stat x-ray. I should have document ed/monitored more but I am one nurse for 60 residents. " On 2-10-2011 at 10:05 am in the lower level conference room (Nurse) E11 was interviewed. E11 stated that on 12-14-2010 around lunch time Certified Nursing Assistant, E8 informed me of facial grimacing during repositioning of R19, I told E8 to give her a shower after lunch and that is when I will check it. 30 minutes later I assessed R19 during the shower , I did not noticed anything unusual, I did not document my assessment. I felt bad when I returned two days later to work and discovered that R19 had a right leg fracture. " On 2-10-2011 at 11:45 am Certified Nursing Assistant E8 was interviewed via telephone outside of the facility. E8 responded that " on 12-14-2010 before lunch R19 was being repositioned and facial grimacing as if in pain was noted and reported immediately to nurse, E7. E7 wrote what I said on a piece of paper and told me that she would have someone check it later. " On 2-10-2011 at 2:20 pm in the lower level conference room via telephone the Medical Director , Z1 was interviewed . Z1 responded " A doctors decisions are based on what the nurse communicate to the doctor. There is always a potential for harm when range of motion is performed on a suspected fracture. I want the nurse to communicat to me everything about pain , whether pain mangement is effective or ineffective. "

F323G · Actual harm, isolated

Based on record review, and interview, the facility failed to prevent 1 of 26 sampled residents(R22) and 1 resident outside of the sample (R27) from elopement. This failure resulted in both residents exposure to cold weather, and R27 sustaining a nose bleed. This failure has the potential to affect all residents in the facility. Findings Include: R22 is a [AGE] year old female with a [DIAGNOSES REDACTED]. She is non-ambulatory and utilizes a manual wheelchair for mobility, which she self propels. Per Occurrence Report for incident occurring on 1/12/11, R22 was last seen at 10:00 pm, on the first floor. She was noted missing from the facility at 10:15 pm. Following search she was found on the street corner outside the facility property, at 10:30 pm. She was combative and agitated upon her return to the facility. Per Occurrence Report there were no indications that the door alarms sounded (marked N/A- refer to attachment). Per progress notes on 1/12/11, staff were aware that R22 wanted to go outside to smoke and used profanity toward staff just prior to the incident. On 1/12/11, the reported temperature for Cicero, Illinois was between 22- 28 degrees Fahrenheit. The facility is on Ogden Avenue, a well traveled state highway. Per interview with E2 (DON) on 2/8/11, E2 stated R22 was not injured during the incident. R 22 was transferred to a secured unit, following the incident. (R27), on 1-23-11 at 6:53pm was found in the rear parking lot of the facility , sitting on the ground , nose bleeding. R27 was not wearing a coat . The estimated outside temperature on 1-23-11 was in the high to mid teens at 6:53pm. Review of the nurses notes dated 1-23-11 indicated that R27 was attempting, thruout the day, to leave the unit . Further review of R27 record indicates that upon admission on 11-20-10, R27 was identified as being a high risk for elopement. Review of the facility investigation report indicates that per employee interviews that no door alarm was heard at the time when R27 exited from the unit. The unit is with residents that are at risk for elopement/wandering. The unit has 4 alarmed doors. Interview with E13(Licensed Practical Nurse) on 2-10-11 at 3:00pm stated that the door alarm did not activate when R27 exited the unit. Interview with E14(Maintenance Director) on 2-10-11 at 2:45pm stated that the belief is that the door where R27 exited from , was probably not reactivated by staff. On 2-15-11, Surveyor received additional information from the facility via fax. Information received included a maintenance assessment of the unit door alarm system. The findings concludes that a "defective reset switch on enunciator panel." The defect was corrected on 2-11-11. The described defect possibly contributed in the door alarm not responding when R27 exited. Interview with E2(Director Of Nursing) on 2-15-11 at 11:00am stated that the defect quite possibly contributed in staff not hearing an alarm when R27 exited the unit.

Inspection of January 28, 2011

2 findings

F309J · Immediate jeopardy, isolated

Based on interviews and record reviews the facility failed to ensure that 1 of 11 residents (R4) received necessary care and services to maintain the highest practical physical, mental and psychosocial well being. R4 sustained an elevated temperature and became septic . R4 was not taken to the hospital in a timely manner, but over 28 hours later. R4 continued to deteriorate after her temperature spiked to 103.3F and become less responsive. R4 died 6 days later in the hospital [MEDICAL CONDITION] and dehydration. This failure resulted in an Immediate Jeopardy The facility failed to identify signs of deterioration of health and a change in condition . R4 was unable to drink orally and the facility was unable to start an intravenous line. The Administrator was notified of this failure which resulted an Immediate Jeopardy on [DATE]. This Immediate Jeopardy was removed on [DATE]. when the facility identified, assessed , inserviced staff and provided a plan of continual care of residents with elevated temperature and signs of change of condition. Although the Immediate Jeopardy was removed on [DATE] the , the facility remain out of compliance at a severity level 2 in order to allow for the implementation of the facility plan of correction for this deficiency. Findings include: R4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] around 6pm, R4 developed a elevated temperature of 103.3. A urinalysis and a culture and sensitivity was sent. Normal body temperature is 98.6. At 8 Pm, R4's temperature was record to be 100.2. Around 10: 15 Pm R 4's temperature was 100 degrees . R4's condition continued to change and she remained with an elevated temperature and change of responsiveness. R4's temperature's was not taken again nor was there a record of assessment until 4 hours later around 2 AM on [DATE] at which it was 101 degrees. R4's condition continued to deteriorate. R4 was not sent to the hospital even though she had become less responsive. E10 (Nurse) stated she was told by E9 ( Nurse Practitioner) to increase R4's current antibiotic's and antipyretic along with starting two liters of normal saline. Labs were also ordered at this time. Nursing notes reflect that at 2pm, 3 hours after the orders were written, an attempt was made by nursing to begin intravenous fluid. The attempt to open venous access was unsuccessful . E10 stated during interview that she did not know how to start an IV (intravenous). " Only certified nurses can start an IV here. I am not certified. The DON is certified she tried and could not get it she stated." When asked what happens next if the DON cannot get the line. E10 stated "we call a pharmacist or the doctor". This was not done. R4's temperature 99.1 at this time. It was a axillary temperature, which registers several degrees less than a core or oral temperature. At 5pm, R4's temperature elevated again to 103.2 (axillary). She still had not received intravenous fluids. The lab results were: WBC( white blood count ) was 28.8 normal is (,[DATE]). R4 other's urine results were also abnormal with protein and blood in her urine. R4's temperature at 6pm remained 103. At 9:30, R4 temperature was 101.4. R4's health continue to deteriorate and she became more unresponsive. Finally at 10:35 pm, R4 was sent out to McNeal Hospital two days after her temperature read 103. R4 never received the intravenous fluids as ordered..Nursing notes state that she was unable to tolerate oral fluids. R4 was again admitted to the hospital with [REDACTED]. According to the emergency room records R4 was admitted with a fever, [MEDICAL CONDITION] and increased white blood count. . R4 was also noted to be groaning in pain and unable to answer questions. R4's first symptoms of elevated fever begin at [DATE]@ 6pm., but R4 was not sent to the hospital until ,[DATE] at 10pm some 28 hours later. While in the emergency room , records indicated that R4's condition deteriorate more; her blood pressure went from 103/ 75 to 70/ 23. On [DATE] at 3:35 AM R4 was discharged from the emergency room to the intensive care unit. Her condition was noted to be poor. R4' health continued to deteriorate during this admission, and she never recovered during this hospital stay. According to her death certificate, R4 died from urosepsis and dehydration 6 days later. . Interview with Z1 ( MD) stated that "I had some concerns why it took so long for the facility to call me. I did not receive any calls regarding how her condition had deteriorated or I would have sent her out " I asked them why did they take so long? I would have had her sent out when her temperature reached 103, the nursing home cannot treat fevers that high". Interview with E10 ( RN) stated that she never started the IV she called the DON who also could not start it. E stated you must be certified to start IV fluids. The labs was not ordered stat as facility protocol in change of condition and the doctor was never called. E2 stated that she was also unsuccessful in starting ing a line. E10 stated during interview that pharmacy usually started the IV when they cannot get a line. But pharmacy was never called. This failure in the staff's lack of following procedures and identifying a change of condition resulted in a over 28 hour delay in emergency treatment which contributed to R4's death. The Immediate Jeopardy was removed on [DATE]. at 4:00pm. The administrator was notified per telephone conversation. The facility remains out of compliance at a severity level 2 because of the need to allow for completing and inservicing of all staff, and evaluating the effectives of the plan of correct ion. The facility submitted the following plan: On [DATE] Nursing staff was re-inserviced on identifying a resident 's change in condition including notifying the physician in a timely manner, notification of the medical director if unable to get a hold of the attending physician and documentation of such instances as appropriate, and following any doctor's orders in a timely manner. The DON, or designee will be notified of every residents change of condition. The DON or designee will review proper assessment procedures and policies and plan of care implementation to ensure prevention through early detection of potential harm. During the next 90 days in addition to regularly scheduled inserviced, the inserviced calender will reflect biweekly inserviced, in order the DON, ADON or Nurse Consultant to hold education sessions for staff regarding supervision of residents who exhibit changes in condition. These sessions will encompass subjects including, at minimum but not limited to; timely assessment of resident, timely assessment of reporting changes to Attending physician or Medical Director if necessary and notification of DON or ADON or Nursing Supervisor of significant change in condition of residents. specific skill sets for assessment of residents Change in Condition and the utilization of the Physician /Nurse resident Change in Condition tool. In addition, staff have been assigned inservice sessions on Silver Chair - the computerized learning educational system use in the facility. The sessions related to Nursling assessments and other related topics. Changes of Condition of residents will be reviewed by DON, ADON or their designee through randomly assigned Pre and Post Test, and /or other appropriate monitoring. Daily QA/QI tool will follow resident out comes and monitor staff compliance. Completions under this plan of care are submitted the QA/QI committee for review and follow-up. Completion Date; [DATE] and on going.

F323J · Immediate jeopardy, isolated

Based on interview and record review the facility failed to: -identify the signs and symptoms and warning signs of substance abuse. Failed to reevaluate the effectiveness of the plan of care. - to supervise and monitor 1 of 11 residents with a known history of drug abuse. - to ensure that 1 of 11 residents(R11) was not taking unprescribed over the counter medication. (Advil) - to include and monitor the amount, times, or schedule that the Advil was given or where the medication came from . - to obtain a physician order [REDACTED]. R11 died the morning after E7(CNA) found drug paraphrenia in his room and a positive cocaine test. This lack of monitoring and supervision resulted in R11 using a controlled substance. Review of the Coroner report identified the cause of death as an accident related to cocaine use. The administrator was notified of this failure which resulted in an immediate Jeopardy on [DATE] due to R11 accidental death and drug use. While th Immediate Jeopardy was abated [DATE], the facility remains out of compliance at severity level 2 because the facility has yet to inserviced all current staff on the all shifts and has yet to assess all possible affected residents. The new assessment tool and plan of care has yet to be fully implemented or evaluated. . Findings include: . 1) R11 was admitted to the facility on [DATE] with a diagnose which includes poly substance abuse. He was a dialysis patient also. Review R11's plan of care stated " R11 will be monitored for signs of substance abuse and use". The start date was [DATE]. According to social services notes dated [DATE], R11 was a loner and spent most of his time in his room. R11 was also said to be verbally abusive with irrational behavior at times. Interview with E8 (SSD) stated that R 11 told him he was not using cocaine, however "he has broken rules frequently and been caught smoking in his room" Nursing notes dated [DATE] stated that at 6:20 Am, R11 was alert and up and walking around and had been up all night. It also stated that he was having an verbal disagreement with his roommate (R16) at this time. R16 stated that R11 moved into his room from the second floor. R16 also stated that R11 would purposely block the entry way to the bathroom and did not like to move. " I reported him to staff. He was moved the next day to another room." I heard that one of the nursing staff moved the dresser and found a piece of tissue while moving him to the next room. In the tissue was a crack pipe with some brown stuff at the bottom. When I go up I heard a code blue. I asked what happened and was told that someone over dosed on medication. " E7 (CNA) stated during interview on [DATE] that as she was cleaning near R11's bedside table she saw a rolled up piece of paper towel. " I unrolled it and it was a clear pipe found on his side of the room" . E8( Social Service) stated that R11 had roommate problems. "It was reported to me that he denied the pipe was his but was positive for cocaine in his urine and died on Saturday". E4 ( Nurse) stated on [DATE] that she was informed by the E8 that an unknown substance was found in a pipe in R11 room. E4 further stated that she saw a bottle of Advil at his bedside. "He said he used it for pain". When asked where it came from, E4 stated she did not know but told R11 that he could not have it at the bedside. However, E4 did not remove the Advil from the bedside was unsure how R11 obtained the Advil. Review of R11's, Medication Administration Sheet does not reflect an order for [REDACTED]. E4's nursing notes dated [DATE] states that she was informed that urine was needed." I approached him several times to obtain a urine sample he keep saying "ok". . Nursing notes notes further stated that a urine staple was obtained [DATE] at 8 PM but was not picked up until the next AM. [DATE] at 4:30 AM. E4 stated during interview that she gave E1 Tylenol #3 for a complaint of pain at 5:10 am on [DATE]. E4 further stated "I was asked to come into R11's resident room because he did not look good at 5 :40 AM. E11 stated that "When I arrived in the room R11 was unresponsive and I called 911 and CPR was initiated". Review of his lab report of a urine specimen obtained the previous night showed R11 positive for Opiates and Cocaine/benzoylecgonine. Review of the Coroner's report stated that and autopsy done on [DATE] was positive for benzoylecgonine, a by product of cocaine, and also positive for codeine. The report also stated that the factors significantly contributed to his death are end stage renal disease and cocaine intoxication. The death was ruled an accident. An Immediate Jeopardy was called to the facility Administrator on [DATE]. The facility submitted the following plan: On [DATE]. The Social Service Director (SSD) and Assistant Administration identified residents that have a history of illicit drug abuse. The SSD or designee reviewed proper assessment procedures and policies and plan of care implementation to ensure prevent, through early detection, of potential harm. Facility staff was re-inserviced by the SSD and Assistant Administer on [DATE] to report immediately to the Administer /Asst. Administer SSD or Designee any such above stated findings. During the next 90 days , in addition to regularly scheduled inservices, the inservice calender will reflect biweekly inservices in order for the DON, ADON, Nurse Consultant, psychologist or Social Worker to hold education sessions for staff regarding residents that have a history illicit drug abuse. Theses session will encompass at minimum but not limited to: Recognizing the signs and symptom of drug abuse, immediately reporting of any illicit drugs or drug paraphernalia to Administrator or DON, observation of of residents rooms to monitor for the presence of OTC (over the counter) medicate without MD orders, education of residents, family and visitors regarding bringing illicit drugs or paraphernalia into the facility. In addition, staff has had additional inserviced sessions on Silver Chair, the computerized learning education system used in the facility. Staff will monitored for compliance by the DON, ADON, Assist Administer, Administer or their designee thru randomly assigned Pre and Post test and /or other appropriate monitoring; Twice weekly QA/QI tool will follow resident out comes and monitor staff compliance. QA/QI tool was reviewed and implementation of the plan of care is being monitored. The result of the monitoring completed under the plan of care are submitted the QA/QI Committee for review and follow -up. Completion Date; [DATE] and ongoing. 2) Based on interviews and record review the facit failed to provide supervision of resident (R10) who have had a history of [REDACTED]. R10 was admitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. According to R10 's transfer sheet from the hospital, he was assessed to be confused, forgetful, and alert to person only. R10 was also assessed to be unable to stand or walk, and need assistance to sit. R10 was assessed to be contracted, and stiff. Review of R10's interim plan of care for falls indicated that he had a recent fall in the hospital prior to admission. This placed him on the facility fall precaution program. On [DATE], Nursing notes and other reports indicate that E6 (Nurse) heard a thump and went into the dining room where R10 was awaiting to be fed for breakfast around 8:30 am. E6 stated that she heard a yell from the dinning area around that same time and when she arrived in the dining area, R10 was on the floor. R17 stated that he saw R10 in his wheelchair leaning forward trying to eat his food. " He dropped his food on th floor because of the location of the plate. I looked away and then I heard him fall to the floor. When they rolled him over he was bleeding". A diagram drawn by R17 showed that R10's plate of food was placed to the right of him causing him to reach past his coffee cup to reach his food. Nursing notes stated that resident sustained [REDACTED]. E6 stated during interview that she was not present when R10 fell nor was any staff. E6 also stated that when she heard the thump she ran to the dining area. E6 was unsure who placed R10 in the dining area, but stated that it was a resident who called out that R10 had fallen. E6 stated that when she ran in the dining room the resident was on the floor on his right side. "He was actively bleeding from his right side of eye. At 10am, on [DATE], nursing notes indicated that R10's eye continued to swell and turn purple and was bleeding. At 10: 20 AM, 911 was reported to be called and R10 was taken to the hospital. Nursing notes also stated that the resident was assessed to be a feeder who needed to be fed, and he had food in his mouth when he fell on the floor from his wheel chair. R10 fall assessment was done after the resident fell by E6 and scored to be extremely high risk at 22 points. emergency room notes dated [DATE], the Physical and History described R4 injuries as "right frontal head and face laceration above the right eye. A large hematoma with a right orbital and maxilla fracture. Right temporal lobe hemorrhage". The report states the chief complaint listed as a fall from wheelchair with laceration to face by RT eye". The emergency room report also verified the fractures of the eye and maxillary sinus with a large orbitofrontal hematoma. It further states that in the emergency room R11 became less responsive to stimulus. The Xray report dated [DATE] found "a large right frontal cephalohematoma which extends to the face". There is also a displaced fracture of the lateral wall of the right orbital. It also reports a fracture of the lateral wall of the right maxillary sinus . CT Scan report of the brain indicated that R10 had a large right subdural and intraparenchymal hemorraghic due to trauma related to a fall. R10 never recovered and died from his injuries. An Immediate Jeopardy called to the administrator on [DATE] at 4:00PM. The Facility took the following steps to remove the Immediate Jeopardy: The Immediately Jeopardy was removed on [DATE]. at 4:00 PM. The facility remains out of compliance at a severity level 2 because of the need to allow for completing inserviced of all staff and evaluating the effectiveness of the plan of correction. The facility submitted the following plan: On [DATE] Nursing staff identified residents in the facility that needed supervision and were also identified as a high risk for falls. These resident were reassessed to determine any additional needs which were addressed. These residents are in the falling star program and plans of care were updated as necessary. The nursing staff as well as other facility ( non-nursing) staff were inserviced on [DATE] by the the ADON and DON on the falling star program and supervision of residents while in the dining room, and further inservices are ongoing. During the next 90 days, in addition to regular scheduled inservices , the inservice calender will reflect further inservices on a biweekly basis. In order for the DON (Director of Nurses) ADON (Assistant Director of Nurse) or Nurses Consultant to hold education session for staff regarding supervision of resident who are at high risk for falls during meal times. These sessions will encompass, at minimum, but not limited to; observation of resident in dining area, observation of posture of resident, anticipation of resident needs while dining, , encouragement social interaction while dining and maintaining observation of resident. In addition, staff has been assigned inservice sessions on SilverChair,- the computerized learning educational system used in the facility .Theses session related to observation of resident, resident safety, and other related topics. DON, ADON Asst. Administer, Administer of their designee thru randomly assigned pre and post test and other appropriate monitoring Daily QA/QA tool will follow resident outcomes and monitor staff compliance Completion Date: [DATE] and on going.

Inspection of October 18, 2010

1 finding

F314G · Actual harm, isolated

Based on observation, interview and record review, the facility failed to implement pressure relieving measures to prevent the development of and worsening of pressure sores in three residents (R6, R12 and R13) in the sample of 10 residents. This failure has the potential to affect all 113 residents on the skilled and the dementia care units. Findings include: R6 was an [AGE] year old resident who was admitted to the facility on [DATE] following the amputation of his left leg below the knee. R6 had a history of [REDACTED]. In addition, R6 was documented to have a history of pressure ulcers, [MEDICAL CONDITION], poor skin turgor, inability to reposition self and below usual body weight. R6 received his nutrition through a gastrostomy tube. Upon admission, R6's Comprehensive Pressure Ulcer Assessment rated him as " high risk " for developing pressure ulcers. The assessment was performed by E11 (Wound Care Nurse) who noted some excoriation at the gastrostomy tube site, but otherwise, intact skin. Some general preventive measures were noted on the care plan of 6/12/10 to be implemented. On 6/17/10, E11 assessed R6 to have a stage one area to the coccyx. At that time, R6 was care planned with extensive preventive measures in place. The POS (Physician order [REDACTED].. R6 was discharged home on[DATE]. On 9/03/10 at 8:50 AM, surveyor observed E11 administer wound care to R13. R13 is a [AGE] year old with [DIAGNOSES REDACTED]. R13 is alert and confused. R13 is fed by gastrostomy tube and is frail. R13 was admitted to the facility on [DATE] without pressure ulcers. R13 was sent to the hospital shortly after admission and returned to the facility on [DATE]. When he returned, it was noted that he had stage 2 wounds to the right hip and the right knee. At that time, the care plan for skin integrity noted interventions to be implemented. However, on 8/28/10 ,the right knee wound was healed but the right hip wound had declined to unstagable and the left hip had developed a stage 2 wound. When asked about the wounds, E11 verified the status of the wounds. R12 is [AGE] years old with [DIAGNOSES REDACTED]. R12 has resided at the facility for five years. R12 had a short stay in the hospital and returned on 7/07/10 with a stage 2 to the right inner heel. Between 7/07/10 and 9/03/10, R12 did not have any other hospitalization s. However, chart review showed that R12 developed a stage 2 pressure ulcer to the left hip on 8/23/10 which was debrided and noted as unstagable on 8/28/10.

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