Every finding on record at Allure of Mt Carroll

Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for 1 (R1) of 3 resident reviewed for call lights in the sample of 6.The findings include:R1's face sheet documents he was admitted to the facility on [DATE] with a primary diagnosis of Parkinson's Disease. The 7/17/26 admission resident assessment and care screening documents R1 to be cognitively intact. The same assessment shows he requires substantial/maximal assistance to transfer to and from the toilet. R1's care plan of 7/11/26, revised on 7/13/26, shows he requires 1-2 staff for toileting.On 8/1/26 at 10:00 AM, R1 was sitting in a recliner in his room. He had mild tremors, and his left side appeared to have some flaccidity. He appeared clean and well groomed with his call light in the chair within reach. R1 said he had been in the facility for 3 weeks and is going home on Monday. R1 stated he requires assistance to get up and use the bathroom, and he was left there for over an hour on (7/30/26) by V6 (Certified Nursing Assistant/CNA). She left and eventually came back to help me. R1 said he was banging on the wall trying to get someone to help him get out of the bathroom.On 8/1/26 at 11:50 AM, V6 (CNA) said on 7/30/26 she was working as a float. As a float aide she passes snacks and answers call lights on the wings while the other aides assist residents to bed. She stated on that night after supper, R1 requested to use the bathroom, so she used her gait belt and assisted him into the bathroom. She began to help R1's roommate get ready for bed, and when she was done R1 was not done and requested to sit a little longer. V6 said she went down another hallway and ended up in another room for a long time. When she was done and went back to R1's room she could hear him banging on the wall. V6 said R1 was in the bathroom for about 40 minutes.On 8/1/26 at 9:30 AM, V9 (CNA) said when call lights go off, the bathroom lights are a priority and we need to get those residents first before they try to get up on their own, and fall.The facility device activity report for 7/30/26 shows R1's call light was on for 51 minutes from 7:16 PM to 8:07 PM.On 8/1/26 at 12:36 PM, V3 (Assistant Director of Nursing) said she would expect call lights to be answered in a timely manner or as soon as possible. If the staff member cannot get back right away, they should radio someone and let them know. V3 said when a light call takes too long to get answered the resident is at risk for getting sores on their buttocks and legs. Their legs can get tired and weak from sitting that long and fall when standing. She said 51 minutes is too long for someone to be left on the toilet.

Based on observation, interview, and record review the facility to store controlled substances in a separately locked, permanently affixed storage container. This applies to 7 of 7 residents (R3, R6, R8, R40, R11, R53, and R57) reviewed for controlled substances in the sample of 33. The findings include:On 7/8/26 at 1:03 PM, the facility's medication room was reviewed with V3 (Assistant Director of Nursing). The door to the room was locked and within the room was a medication refrigerator. In the refrigerator (refrigerator was not locked and had no lock) was a lockbox, which V3 was able to remove from the refrigerator without a key (it was not affixed to the refrigerator). V3 stated the lock box contained lorazepam (an antianxiety mediation) and the refrigerator did not have a lock. On 07/8/2026 at 2:53 PM, V2 (Director of Nursing) stated narcotics as well as lorazepam need to be locked due to the increased risk of drug diversion. V2 stated controlled substances need to be double locked; however, V2 stated it was her understanding the door to the medication room was the permanently affixed lock. On 7/8/26 at 2:53 PM, V5 (Corporate Nurse) stated typically the refrigerator is also locked and would be considered the separately locked and permanently affixed storage for controlled substances. V5 stated V3 should not have been able to remove the lorazepam from the refrigerator without unlocking the refrigerator or having the lorazepam box secured to the refrigerator. On 7/9/26 at 10:40 AM, V2 provided a list of residents in the facility on lorazepam. The list included R3, R6, R8, R40, R11, R53, and R57. The facility's Controlled Substance Administration and Accountability policy (Copyright 2026) showed .The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure.Areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use.

Based on observation, interview, and record review the facility failed to protect a resident's rights by ensuring his private space was protected/honored for 1 of 1 resident (R41) reviewed for resident rights in the sample of 33.The findings include:On 7/7/26 at 1:36 PM, R41 was sitting in the recliner in his room. R41 stated R5 wanders the halls in her wheelchair, comes into his room and has gone through his dresser and closet. R41 stated the last time R5 did this was 4 days ago. R41 stated R5 has done this before, and he has reported it. R41 stated he has fallen asleep, gets the feeling someone is looking at him and R5 is in his room. R41 stated when he was younger, he was jumped, mugged and lost his eyesight in one eye from the incident. R41 stated since then when someone gets close to him it puts him in a defensive mood. R41 stated it is upsetting. R41 stated a lot of people have dementia, can't help what they do but he feels the facility should watch R5 closer.R41's current Care Plan dated 5/14/26 showed, Resident Concerns of peers entering room. Resident requests a stop plastic strip to deter other peers from entering room. Educate resident on safety and use of stop sign. Nurse to identify area of concern. Nurse to notify appropriate department leader(s) of concern per facility protocol. Nurse to notify Social Services of concern and possible need for care conference. The resident has impaired visual function related to blindness in left eye.On 7/9/26 at 9:39 AM, V8 (Social Service Director/SSD) stated R41 was on YYY hall and so was R5. R41 was moved to the XXX hall and doesn't have the stop sign across his doorway anymore; that was when he was in his old room because R5 would go into his room. V8 stated R5 doesn't go down the XXX halls to the end where R41's room is located. On 7/9/26 at 9:46 AM, V11 (Certified Nursing Assistant/CNA) stated she has worked at the facility for two months. V11 stated that R5 does wander down XXX hall all the way to the end. R5 wanders and goes into other resident rooms.On 7/9/26 at 9:51 AM, R41 stated R5 comes into his room whenever she comes down this hallway. R41 stated he had told the CNAs. R41 stated when he is asleep, she gets in his face, he wakes up, and is startled. R41 did not want to get startled and accidentally hit R5. On 7/9/26 at10:00 AM, V8 (SSD) confirmed it is R41's right and choice not to have R5 in his room.The Face Sheet dated 7/9/26 showed diagnoses including left eye blindness, obesity, hypothyroidism, urinary tract infection, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, aneurysm of thoracic aorta, obstructive and reflux uropathy, and necrotizing fasciitis.The Minimum Data Set, dated [DATE] for R41 showed no cognitive impairment.The facility's Resident Rights policy (May 2025) showed the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay at the facility. The policy did not show what the residents' rights and responsibilities were.

Based on interview and record review the facility failed to document a resident's discharge to the hospital and failed to issue a bed hold for 1 of 2 residents (R17) reviewed for discharge in the sample of 33. The findings include: R17's admission record documents she was admitted on [DATE] following a cerebral infarction with left side paralysis.R17's census record shows she was discharged to the hospital on 4/28/26 and returned to the facility on 5/6/26. A review of R17's progress notes for 4/28/26 shows no documentation of her transfer out of the facility, and no progress notes regarding her discharge to the hospital. On 7/08/2026 at 1:00 PM, V6 (Registered Nurse) said she believed R17 was going back to the hospital to have something done and was found to have a urinary infection, so she was admitted to the hospital for IV (intravenous) antibiotics. V6 said R17 was in the hospital for awhile to have the infection cleared up before her procedure. She said the notes should show how she left, where she went to and a bed hold should be issued. V6 reviewed R17's record and said none of the information was documented.On 7/09/2026 at 9:35 AM, V2 (Director of Nursing) said R17 had left on 4/28/26 for an appointment in the facility van. She was scheduled for an outpatient procedure and was found to have a urinary infection. The surgeon admitted her to the hospital for treatment before he would do the procedure. V2 said all the information should have been documented, and a bed hold issued once she was admitted to the hospital.The facility's undated policy for discharge/transfer documents for non-emergency transfer: g. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand.

Based on observation, interview, and record review the facility failed to ensure a resident's facial hair was shaved for 1 of 1 resident (R10) reviewed for activities of daily living in the sample of 33. The findings include: On 7/7/26 at 1:05 PM, R10 was sitting in his wheelchair in his room. R10 had prosthesis with a hook end to his left arm. R10 had thick facial stubble to his face. R10 stated he would like to be shaved. R10 stated at home he would shave himself everyday but he can't do it any longer due to his eyesight. R10 stated it had been a few days since he had been shaved by staff. On 7/9/26 at 9:24 AM, V9 (Certified Nursing Assistant) stated residents are shaved as needed. Most of the men are shaved daily and should be. V9 stated they all get shaved on shower days. V9 stated she has not had any residents refuse to be shaved. V9 confirmed they honor the resident's preferences. On 7/9/26 at 12:48 PM, V3 (Assistant Director of Nursing) stated male residents are usually shaved first thing in the morning. V3 stated shaving should be done based on the resident's preference. R10's Care Plan dated 2/14/26 showed he has an activity of daily living - ADL self-care performance deficit, related to shortness of breath and weakness. Personal hygiene/oral care: The resident requires 1 staff to maximize independence. The Minimum Data Set, dated [DATE] for R10 showed he was dependent for personal hygiene.The Face Sheet dated 7/9/26 for R10 showed diagnoses including acute respiratory failure with hypoxia, nonthrombocytopenic purpura, disorder of muscle, congestive heart failure, chronic obstructive pulmonary disease, macular degeneration, wheezing, shortness of breath, hypoxemia, orthopnea, kyphosis, weakness, and acquired absence of left upper limb below elbow.The facility's Activities of Daily Living policy (2025) showed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure a resident had oxygen for 1 of 1 resident (R6) reviewed for oxygen in the sample of 33.The findings include:On 7/8/2026 at 11:20 AM, R6 was sitting in a wheelchair in her room with oxygen on via nasal canula. R6 appeared short of breath and her respiratory rate was 30 breaths per minute. The nasal cannula was attached to a portable tank on the back of her wheelchair and the meter on the tank showed it was empty. R6 had an oxygen concentrator in her room. R6 stated they tell her to breathe in through her nose and out through her mouth when she is short of breath, but she can't breathe though her nose if there is no oxygen. Staff were alerted that R6 needed help. On 7/8/26 at 11:31 AM, V10 (Registered Nurse/RN) checked the portable tank on the back of R6's wheelchair and confirmed the oxygen tank was empty. V10 switched R6's nasal cannula over to the concentrator in her room and turned it on so she received oxygen at 2 liters per nasal cannula. V10 stated she did not realize R6 had returned from an appointment yet. V10 stated R6 should have been changed from the portable tank to the concentrator when she returned. V10 stated it was important for R6 to have her oxygen because she becomes short of breath. R6's respiratory rate improved after the oxygen was applied. The Physician Orders dated July 2026 for R6 showed oxygen at 2 liters per nasal cannula continuous every day and evening shift for oxygen levels regulated. The Care Plan dated 6/8/26 for R6 showed risk for ineffective breathing pattern related to nodular density infiltrate of right lung and glass opacity of the left lung. Administer oxygen as prescribed or per standing order. The Face Sheet dated 7/9/26 for R6 showed diagnoses including cellulitis of right and left lower limb, congestive heart failure, sepsis, non-pressure chronic ulcer of left lower leg, pseudomonas, severe sepsis, non-pressure chronic ulcer of right lower leg, anxiety disorder, restlessness and agitation, edema, atherosclerosis, hypothyroidism, hypertension, hyperlipidemia, chronic kidney disease, acute kidney failure, cardiomegaly, obesity, other disorders of the lung, and depression.The Oxygen Administration policy (7/8/26) showed, oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

Based on observation, interview and record review the facility failed to follow the posted menu for residents with a puree diet for 3 of 3 residents (R46, R53, R57) reviewed for diets in the sample of 33. The findings include:On 7/7/26 at 9:45 AM, V7 (Cook) said the facility had 3 puree diets to prepare for the noon meal. She said the kitchen purees 2 items for the meal. She said the lunch meal for today was Swiss steak, peas, garlic mashed potatoes, bread and butter.The facility list of residents on pureed diets included R46, R53, and R57.The facility menu for the noon meal shows creamy Swiss steak, garlic mashed potatoes, buttered peas, bread/margarine and an iced oatmeal cookie bar.On 7/7/26, V7 was observed pureeing the Swiss steak and peas in the robot coupe and placed them into the steamer. V7 did not puree the iced oatmeal cookie bar. During the lunch service, R57 was observed to have applesauce in place of the oatmeal cookie bar. V7 said the kitchen does not puree the desserts. The staff will replace it with applesauce, pudding or ice cream. V7 said she was always told there were always just 2 things to puree, she did not know why, it had always been that way.On 7/9/26 at 8:22 AM, V4 (Dietary Manager) said all the items on the menu should be pureed, including the desserts. She said once in awhile the kitchen will puree the dessert that is listed on the menu, but it is not done on a regular basis. She said there is a recipe in the binder for the puree dessert. 07/09/2026 11:33 AM, R57 said she is on a puree diet because she cannot chew too well. For dessert she always has applesauce, pudding or ice cream. She would certainly try another dessert if they were able to puree it, and make it so she could swallow it.

Based on observation, interview and record review the facility failed to prepare puree diets according to the recipe for 3 of 3 residents (R46, R53, R57) reviewed for puree diets in the sample of 33. The findings include: On 7/7/26 at 9:45 AM, V7 (Cook) said the facility had 3 puree diets to prepare for the noon meal. She said the kitchen purees 2 items for the meal. She said the lunch meal for today was Swiss steak, peas, garlic mashed potatoes, bread and butter.The facility list of residents on pureed diets included R46, R53, and R57.The facility menu for the noon meal shows creamy Swiss steak, garlic mashed potatoes, buttered peas, bread/margarine and an iced oatmeal cookie bar.On 7/7/26, V7 was observed placing the Swiss steak into the robot coupe. Once the steak was pureeing, V7 added cold milk to the mixture. Once she finished, she placed the puree steak back into the steamer. At 10:30 AM, V7 checked the reheating temperature of the steak, and it was 148 degrees. She said the temperature should be 165 degrees to be served. The puree recipe for creamy Swiss steak shows after adding the food to the food processor and getting it to a fine consistency, a beef broth is prepared by dissolving soup base in boiling water. Combine hot broth and thickener and gradually add to the meat. V7 reviewed the recipe and said she should have used the broth instead of milk.On 7/9/26 at 8:22 AM, V4 (Dietary Manager) said she would expect the cook to follow the recipe for the puree foods. She said using milk in the steak would decrease the temperature due to being a cold liquid.

Based on observation, interview, and record review the facility failed to have proper signage for residents on Enhanced Barrier Precautions (EBP). This applies to 3 of 3 residents (R6, R9, R52) reviewed for EBP in the sample of 33. The findings include: 1. R9's Face Sheet showed R9 was admitted to the facility on [DATE]. R9's Face Sheet showed she had a tracheostomy (opening in the throat to by pass the nose and mouth). On 7/8/26 at 11:10 AM, 7/9/26 at 11:03 AM, and 7/10/26 at 9:07 AM, R9's door had no visible signage for enhanced barrier precaution. On R9's door was a yellow cubby rack containing personal protective equipment (PPE). R9's Care Plan (dated 4/24/26) showed, The resident required Enhanced Barrier Precautions r/t (related to) tracheostomy.place signage s on doors of isolation precaution rooms. R9's physician orders showed an active order, May use EBP per policy as needed for indwelling medical devices. On 7/9/26 at 8:17 AM, V3 (Assistant Director of Nursing/Infection preventionist) stated residents with tracheostomies should be in EBP. V3 said there should be signage on the door indicating EBP is required so staff and visitors are aware of the precautions required. V3 said the purpose of EBP is to prevent cross-contamination. V3 said R9 should be in EBP due to her tracheostomy. V3 approached R9's door and stated there was no EBP posting, then V3 lifted the PPE bin on the door revealing the EBP signage. V3 said the signage was not visible. The facility's Enhanced Barrier Precautions policy (revised 4/26) showed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy showed residents with tracheostomies should be in EBP. 2. R52's Face Sheet showed R52 was admitted to the facility on [DATE] and R52 is on dialysis. On 7/8/26 at 11:10 AM, 7/9/26 at 11:03 AM, and 7/10/26 at 9:07 AM, R52's door had no visible signage for enhanced barrier precaution. On R52's door was a yellow cubby rack containing personal protective equipment (PPE). R2's Care Plan (dated 5/22/26) showed, The resident requires enhanced barrier precaution r/t dialysis. place signage s on doors of isolation precaution rooms. R52's physician orders showed an active order, May use EBP per policy as needed for indwelling medical devices. On 7/9/26 at 8:17 AM, V3 (Assistant Director of Nursing/Infection preventionist) stated residents dialysis residents should be in EBP. V3 said there should be signage on the door indicating EBP is required so staff and visitors are aware of the precautions required. V3 said the purpose of EBP is to prevent cross-contamination. V3 said R52 should be in EBP due to his dialysis ports. V3 approached R52's door and stated there was no EBP posting. R52's door had not signage under the PPE rack. 3. On 7/7/26 R6 was laying in bed with her bilateral lower extremities on a disposable pad. R6 had wounds to both of her lower legs. No enhanced barrier precaution - EBP signage was up for her. On 7/7/26 at 10:15 AM, V3 (Assistant Director of Nursing/Infection preventionist) stated R6's legs were unwrapped and had a numbing cream applied to them in preparation for care. V3 stated the skin was sloughing on the backside of R6's legs. V3 stated R6 developed necrotic wounds to her legs when she was at home, and they were working on debridement and healing of the wounds. On 7/7/26 at 10:35 AM, V3 and the wound physician were at R6's bedside. R6's legs were resting on the disposable pad. The wound physician debrided necrotic tissue from R6's left lower leg. When the wound physician was done with his procedure, he left the room and V3 stayed to apply dressings to R6's legs. V3 placed a tube of prescription enzymatic ointment, tube of topical antibiotic ointment, and two smooth wooden tools for application of the ointment on the soiled disposable pad. V3 opened packages containing petroleum dressing and gauze dressing and sat them on the bed next to the resident. V3 picked up one of the wooden tools applied the enzymatic ointment to it and applied the ointment to the necrotic areas on R6's left lower leg and heel. V3 picked up the other wooden tool and used it to apply antibiotic ointment to the wound area on R6's left lower leg that was not necrotic. R6 applied petroleum gauze and clean dressings to R6's bilateral lower legs. R6 removed the soiled disposable pad from under the residents' legs. 7/8/26 at 12:58 PM, there wasn't an EBP sign up for R6. On 7/8/26 at 2:24 PM, V3 stated she usually has an extra disposable pad that she places her wound care supplies on and she didn't do that yesterday with R6's dressing change . V3 confirmed it was a problem that she put the supplies on the soiled disposable pad due to infection control. V3 stated R6 did not have and EBP sign up because she thought EBP was for chronic wounds. V3 stated she was going to put a sign up because R6 has dressings. On 7/8/26 at 2:50 PM, V9 (Certified Nursing Assistant/CNA) was working in the hall that R6 resided on. V9 stated if someone has EBP then they should have a sign up. V9 stated she was not sure if R6 was on EBP or not. V9 stated for a resident on EBP, anytime they touch the resident they would wear a gown and gloves. The Care Plan dated 6/8/26 for R6 showed the resident requires enhanced barrier precaution related to wounds. Place signage on doors of isolation precaution rooms. The Face Sheet dated 7/9/26 for R6 showed diagnoses including cellulitis of right and left lower limb, congestive heart failure, sepsis, non-pressure chronic ulcer of left lower leg, pseudomonas, severe sepsis, non-pressure chronic ulcer of right lower leg, anxiety disorder, restlessness and agitation, edema, atherosclerosis, hypothyroidism, hypertension, hyperlipidemia, chronic kidney disease, acute kidney failure, cardiomegaly, obesity, other disorders of the lung, and depression. The facility's Clean Dressing Change policy (2025) showed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. The facility's Enhanced Barrier Precautions policy (2025) showed the facility will have discretion on how to communicate to staff which residents require the use of enhanced barrier precautions, as long as staff are aware of which residents require the use of EBP prior to providing high contact care activities. An order for enhanced barrier precautions will be obtained for residents with the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .

Based on interview and record review the facility failed to implement weight loss prevention interventions prior to a resident (R32) experiencing a significant weight loss. This failure resulted in R32 experiencing a significant weight loss of 9.6% in three months. This failure applies to 1 of 5 residents (R32) reviewed for weight loss in the sample of 14. The findings include: R32's admission care plan dated 12/29/23 showed R32 was at risk for malnutrition and weight loss related to her diagnoses of dementia, dysphagia (trouble swallowing), depression, and a history of pneumonia. R32's Weights and Vitals Summary showed R32's weights as 156 pounds (lbs.) on 2/6/24, 151 lbs. on 3/4/24, 147 lbs. on 4/17/24, and 141 lbs. on 5/3/24. The record showed R32 experienced a significant weight loss of 9.6% in three months, from 2/6/24 - 5/3/24. R32's Mini Nutritional assessment dated [DATE] showed R32 was deemed at risk for malnutrition and weight loss by V3 (Registered Dietician/RD). The assessment showed V3 RD documented R32's weight as 147 lbs., which showed R32 had experienced a nine-pound weight loss since 2/6/24, but no weight loss preventions, such as supplements and/or supervised dining, were initiated at that time. R32's dietary note dated 5/8/24 showed R32 had sustained a significant weight loss in three months (2/2024-5/2024). The note showed R32 would benefit from ONS/tray additions (supplements added to food tray) to aid in weight management/caloric intakes. The note showed supervised dining, nutritional juice, nutritional shakes, and house supplements were to be initiated at that time. R32's May 2024 physician orders showed a house supplement, nutritional juice, and nutritional shakes were started on 5/9/24. R32's current care plan showed supervised dining for R32 was started on 5/21/24. On 5/21/24 at 11:05 AM, V3 (Registered Dietician) stated prior to 5/21/24, she had last assessed R32, in-person, in January 2024. V3 stated the Mini Nutritional Assessment she completed on R32 in April 2024, was completed remotely. V3 stated, I completed her assessment by reviewing (R32's) information via the computer. I didn't see her in-person. V3 stated the facility monitors residents weight loss, weekly, to intervene before any weight loss becomes significant. V3 stated, I did document she was at risk for weight loss in April (2024). She had also been recently hospitalized which could potentially put her more at risk. When V3 was asked why R32 was not started on weight loss supplements and supervised dining until after R32 had sustained significant weight loss, V3 stated, I don't have a wonderful answer for you. I should have started her on supplements sooner . The facility's Nutrition at Risk policy dated 9/16/23 showed, Weight loss, poor nutritional status, or dehydration should be considered avoidable unless the facility can prove it has assessed/reassessed the resident's needs, consistently implemented related care planned interventions, monitored for effectiveness, and ensured coordination of care among the disciplinary team. Early identification of risk factors, regardless of the presence of any associated weight changes, can help the facility choose appropriate interventions to minimize any subsequent complications . The facility's Weight Monitoring policy dated 2/22/23 showed, A significant change in weight is defined as: 5% change in weight in 1 month, 7.5% change in weight in 3 months, 10% change in weight in 6 months.

Based on observation, interview, and record review the facility failed to provide residents receiving puree diets with smooth consistency to 5 of 5 residents (R15, R6, R18, R20, R25) receiving pureed diets in the sample of 14. The findings include: The Facility provided a document entitled Diet Type Report, dated 5/20/24 show R15, R6, R18, R20, and R25 were receiving pureed textured diet. On 5/20/24 at 11:50 AM, the facility provided a test tray of puree diets that included pureed lasagna, pureed garlic bread, and pureed mixed vegetables. The pureed garlic bread was thick, chunky, and clumpy, and the pureed mixed vegetables was watery, and required chewing. V15 (Dietary Manager) who was with the surveyor during the test tray process also tasted the pureed test tray. After tasting, V15 pointed to the pureed garlic bread and stated, this is so thick, it needs more liquid to get the texture of a mashed potato. V15 said the pureed mixed vegetables can be thickened and needed to be smoother. Pureed foods should be smooth in consistency. On 5/20/2024 at 11:00 AM, V16 (Cook) said a puree texture should be similar to the mashed potato consistency. The facility policy entitled Puree Food Preparation dated 2/22/23 show It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive in appearance. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth thick paste similar to a thick pudding. 2. Puree foods should be prepared in such a manner to prevent lumps or chunks, the goal is soft, smooth similar to a soft mashed potato.

Based on observation, interview, and record review, the facility failed to obtain a physician's order, failed to obtain consent, and failed to perform an assessment for a resident using a seat belt in a motorized wheelchair for one of one resident (R44) reviewed for restraints in the sample of 14. The findings include: R44's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including muscle weakness, contractures to both knees, tracheostomy status, hemiplegia, malnutrition, anxiety disorder, and contracture to her left hand. On May 21, 2024 at 10:10 AM, R44 was in her room in her motorized wheel chair. R44 had a seat belt in place to her lower abdomen. R44 said she uses the seat belt because she slides out of the chair. The Self-Releasing Seat Belt Informed Consent for Use was signed by R44 on May 21, 2024. R44's Restraint Enabler was entered on May 21, 2024 at 3:41 PM. R44's Order Summary Report does not show any orders for a self-releasing seat belt prior to May 21, 2024. R44's Care Plan that showed R44 uses a seat belt was not initiated until May 21, 2024. R44's Care Plan shows document self-releasing seat belt and release and ensure valid consent is on the chart prior to use of the self-releasing seat belt. R44's Care Plan also shows the resident is able to release the seat belt by herself, assess at quarterly and as need, which was initiated on May 21, 2024. On May 22, 2024 at 9:50 AM, V2 (Director of Nursing) said R44 has used a seat belt since she came to the facility. V2 said that there should be a doctor's order, consent by the residents, and assessments should be done quarterly and as needed. The facility's Restraint Free Environment policy implemented on May 2, 2023 shows, Residents may use devices per request for positioning and safety purposes that they are able to freely remove on their own with a signed consent. The resident/resident's representative may request the use of a physical restraint; however the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident's representative, the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use.

Based on observation, interview, and record review the facility failed to reassess a resident for safe swallowing after the resident had a choking episode in the facility. The facility failed to supervise a resident, with a history of falls, while the resident was seated on the toilet. The facility failed to ensure residents were transferred by staff in a safe manner. These failures apply to 3 of 14 residents (R14, R23, R42) reviewed for safety and supervision in the sample of 14. The findings include: 1. R14's Admission Record showed R14 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and cognitive impairment. R14's Progress Note dated 5/19/24 showed, Resident found to be purple in color with airway obstruction. Performed Heimlich maneuver, after a few thrusts resident gasped for air. Resident sat in wheelchair and was tearful. The note showed R14 choked on her evening medications. R14 was not sent to the hospital for an evaluation after the incident. R14's physician was notified on 5/19/24. On 5/20/24 at 12:24 PM, R14 propelled herself in her wheelchair into her room. On R14's bedside table was a box of chocolates. R14 was asked about her choking incident. R14 stated, My nurse gave me my evening meds (medications). I take them whole, one by one. She watched me take them. The nurse walked out of my room. I took a sip of water and suddenly I couldn't breathe. I guess I let out a gasp or a noise. The nurse came in and hit me on my back. I am not sure what I coughed up. R14 stated, since her choking incident, R14 still takes her medications whole and there have been no changes in the type of diet she receives. R14 denied having any previous choking episodes in the facility. R14's physician orders dated 5/20/24 were reviewed. These orders showed no orders to crush R14's medications, no orders for R14 to be evaluated by speech therapy, and no changes in diet orders for R14. On 5/21/24 at 9:10 AM, V5 (Registered Nurse) stated, (R14) doesn't get her meds crushed. She just got her medications this morning. She takes them whole, one by one. On 5/21/24 at 10:27 AM, V6 (Speech Therapist/ST) stated, Parkinson's disease can put a resident at increased risk for swallowing problems. If a resident has a choking episode, on foods or meds, staff must notify the physician and refer the resident to me for an evaluation. Staff should immediately downgrade the resident's diet. Residents, that have swallowing problems or choke, are to be referred to me because I am the one that assesses the resident for safe swallowing or any swallowing problems. V6 stated she had never seen R14 and had not received an order to evaluate R14 as of 5/21/24 at 10:27 AM. On 5/21/24 at 10:39 AM, V2 (Director of Nursing/DON) stated, If a resident chokes in the facility, we notify the doctor, downgrade the resident's diet, and refer the resident to speech therapy for an evaluation. V2 stated, The night (R14) choked. The nurse has just given (R14) her pills. The nurse watched her take the pills. I am not sure how many pills (R14) took. The nurse walked out of (R14's) room and heard a strange noise coming from (R14). The nurse ran back into the room. She saw that (R14) was choking so she did the Heimlich on (R14). After a couple of thrusts, the nurse was able to get pill products out of (R14's) mouth. (R14) was upset but she could breathe. She was able to drink water. V2 stated, (R14) is still getting her meds whole. She hasn't been seen by or referred to speech therapy yet. She should have been. We got busy and didn't get these things done (crushing meds and referral to speech therapy). When V2 was asked how the facility could ensure that R14 could still safely swallow medications and foods since her choking incident, V2 stated, We don't know that she can. The facility's Foreign Body Airway Obstruction Management (Choking) policy dated 5/30/23 showed, Residents with impaired swallowing, neurological disorders or dental issues are at an increased risk for foreign body airway obstruction . Residents should be assessed to determine if they are at a higher risk for foreign body obstruction/choking episodes and care planned accordingly. Consult the speech language pathologist as needed . 2. R42's care plan current care plan showed R42 was at risk for falls due to his diagnoses of impaired cognition related to dementia, weakness, hypotension (low blood pressure), and anxiety. The care plan showed R42 had three unwitnessed falls in the facility, from 2/9/24-5/20/24, because of R42 trying to self-transfer. R42's resident assessment dated [DATE] showed R42 required partial to moderate assistance of staff for toileting and transfers. On 5/20/24 at 8:55 AM, R42 was seated on the toilet in his bathroom with no staff present in R42's room or bathroom. At 9:00 AM, V7 (Certified Nursing Assistant/CNA) entered R42's room to check on R42. From 9:00 AM-9:15 AM, V7 CNA stood outside the bathroom door as R42 remained on the toilet. At 9:20 AM, V7 transferred R42 from the toilet to his wheelchair by holding onto R42's arms. No gait belt was used. On 5/21/24 at 8:49 AM, V8 (CNA) stated R42 should not be left alone on the toilet because he is at risk for falls. V8 stated staff are use a gait belt on any resident that needs assistance from staff to transfer or ambulate. On 5/21/24 at 8:56 AM, V4 (Licensed Practical Nurse) stated, (R42) should not be left alone in the bathroom. He tends to wander and get up on his own. 37232 3. R23's Face Sheet showed R23 had the diagnosis of weakness. A facility assessment done on 3/26/24 showed R23's cognition was intact. The same assessment showed R23 needed partial/moderate assistance to go from sitting to standing and to walk. R23's Witnessed Fall report dated 4/19/24 showed R23 was oriented to person, situation, time, and place. The same document showed R23 fell in her room during a transfer and a predisposing factor was gait imbalance. On 5/21/24 at 1:26 PM, R23 said she had a fall in her room while staff were assisting her to transfer to a scale. R23 said she stood up from her bed and had to take several steps to get to the scale. R23 said the scale was about 4 to 5 feet away. According to R23, her shoe caught the edge of the scale causing her to fall. R23 said staff were present during the fall and staff did not use a gait belt. R23 said staff did not lower her to the floor during the fall. R23 added sometimes staff used a gait belt to assist her to transfer. On 05/21/24 at 9:21 AM, V12 (CNA) said she was with R23 on 4/19/23 when R23 fell in her room. V12 said the day R23 fell she assessed R23 to stand up from bed by supporting R23 under her arm. V12 said when R23 stood and walked she needed help balancing. V12 said she helped R23 balance by holding onto R23's arm. According to V12, R23 took several steps and attempted to step onto the scale. V12 said as R23 stepped onto the scale V12 was not holding onto R23 and R23 fell . V12 said she did not use a gait belt while assisting R23 to transfer onto the scale. V12 said she only used a gait belt with R23 when walking outside of R23's room. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said a gait belt should be used when staff provide balance assistance during a transfer. On 05/21/24 at 12:43 PM, V13 (CNA) said gait belts are used to safely transfer residents. On 5/21/24 at 10:46 AM, V14 (R23's Physician) said given R23's comorbidities, she has weak bones putting her at risk for fractures. R23's Care Plan with an initiated date of 1/15/24 showed R23 had limited physical mobility related to weakness and at risk for falls related to noncompliance with assistance with transfers. The facility's Use of Gait Belt policy with a revised date of 5/21/24 showed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.

Based on observation, interview, and record review the facility failed to perform peri care in a manner to prevent urinary tract infections for one of six residents (R1) reviewed for peri care in the sample of 14. The findings include: R1's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. V10 CNA wiped a large amount of stool from R1's buttocks with a thin wet wipe. R1's stool was visible through the wet wipe. V10 folded the wet wipe in half and wiped R1's stool from her buttocks again. V10 folded the wet wipe a second time and wiped the stool from R1's buttocks with the same wipe a third time. R1 was turned onto her back. V9 wiped stool from R1's front peri area. V9 folded the wet wipe three times and wiped R1 four times with the same wet wipe prior to disposing of the wet wipe. On May 22, 2024 at 8:30 AM, V11 (CNA) said if stool is noted on a wet wipe, then it should be disposed of and a new wet wipe should be used. On May 21, 2024 at 10:17 AM, V2 (Director of Nursing) said wet wipes can be folded during incontinence care unless there is a large amount of stool. V2 said if there is a large amount of stool, then one wipe should be used and then thrown away and use a new wipe in order to prevent the spread of infection. The facility's Perineal Care policy reviewed May 20, 2024 shows, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes.

Based on observation, interview, and record review the facility failed to measure the external length of a peripherally inserted central catheter (PICC) for 1 of 2 residents (R52) reviewed for intravenous (IV) access in the sample of 14. The findings include: R52's Hospital Discharge Instructions dated 4/26/24 showed R52 had a PICC line placed to receive antibiotics for osteomyelitis (bone infection). On 05/20/24 at 12:30 PM, R52 had a PICC line to her right upper arm. R52 said she had a bone infection in her back and was getting IV antibiotics. R52 said the facility had been doing weekly dressing changes to her PICC line. However, R52 said she did not believe the facility was measuring the external length of the PICC. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said PICC measurements are done to see if the PICC has migrated. V2 added the measurements are documented in the Treatment Administration Record (TAR). R52's TAR showed the PICC dressing was changed 5/2/24, 5/9/24, and 5/16/24. There was no documented PICC measurements on the TAR. The facility's PICC/Midline/CVAD Dressing Change policy with a reviewed date of 5/20/24 showed measuring the external length of the PICC is done to ensure that it has not migrated and should be done with the weekly dressing changes.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change their gloves in a manner to prevent cross contamination for one of 14 residents (R1) reviewed for infection control in the sample of 14. The findings include: R1's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. R1 was laying on her back when V10 folded R1's incontinence brief in between her legs. There was stool noted to R1's front peri area. V10 then touched R1's body to help her to turn onto her right side. V10 did not change her gloves or perform hand hygiene prior to touching R1 body to help her turn. V10 then wiped the large amount of stool from R1's buttocks. V10 then helped R1 to turn onto her left side by touching her body. V10 did not change her gloves or perform hand hygiene prior to assisting R1 to turn. On May 22, 2024 at 8:30 AM, V11 (CNA) said glove should be changed after touching bodily fluids to prevent cross contamination. The facility's Hand Hygiene policy reviewed May 20, 2024 shows, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The facility's Hand Hygiene Table shows either soap and water or alcohol-based hand rub should be used after handling contaminated objects.

Based on interview and record review the failed facility failed to ensure residents' money were not taken from their rooms which apples to 2 or 9 residents (R1, R2) reviewed for Misappropriation in a sample of 9. The findings include: The facility's Final Incident Report dated 4/30/24 showed the facility was able to verify R1 had at least $160 and R2 had at $33 missing from their rooms. This report showed the money was not recovered during the investigation. On 5/1/24 at 10:00 AM, V1 (Administrator) stated on 4/23/24 it was reported to her R1 made an allegation of missing money in her room. After talking with R1 and R1's family who was present, it was determined R1 had at least $160 dollars missing from her nightstand. The next morning while the investigation was ongoing R2 made the allegation she was also missing money from a bag kept in her room. R2's family was able to confirm R2 had $33 dollars which was last seen in R2's bag. The conclusion of the investigation was R1 and R2 had money removed from their rooms. V1 stated they had suspected a staff member (V11 Certified Nursing Assistant) who was terminated on an unrelated topic on 4/23/24. On 5/1/24 at 10:25 AM, R1 stated she knew she had at least $160 dollars in the top drawer of the nightstand. R1 stated she took $200 out of her bank account and spent roughly $40 dollars on toiletries just before being admitted to the facility. R1 stated she kept the money in the bank envelope, rubber banded, and in the top drawer of the nightstand. R1 stated she went to get some money out for her family member. When R1 opened the drawer, the envelope was empty. R1 stated it was the first time she had attempted to get money out of the envelope since she was in the facility. On 5/1/24 at 10:50 am, R2 stated on Wednesday (4/24/24) the staff had been talking about missing money. R2 stated she looked in the bag R2 kept money in. R2 found the resealable bag used to keep her money in was not organized the same way she had left it. R2 stated she kept the money she had in the middle of some paper notes, an identification, and personal notes so it could not be seen on the outside. When she looked in the resealable bag the money was missing, and the papers were jumbled up. R2 stated V1 was notified that morning about the missing money. The facility's Abuse Policy dated 2/1/24 showed the definition of Misappropriation to be the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent.

Based on interview and record review the facility failed to contact law enforcement timely when an allegation of misappropriation occurred in the facility which applies to 2 of 9 residents (R1, R2) reviewed for misappropriation reporting is a sample of 9. The findings include: The facility's Final Incident Report showed on 4/23/24 R1 reported approximately $160 was missing. This report showed on 4/24/24 R2 reported missing $33 dollars. This report did not indicate the local police were contacted. On 5/1/24 at 10:00 AM, V1 (Administrator) stated she did not contact the local police for the missing money at the time of R1 and R2's allegations. V1 stated she had contacted the local police today (5/1/24). On 5/1/24 at 1:35 PM, V9 (local police officer) stated they had not been contacted by the facility prior to today (5/1/24) for an allegation of missing resident money. V9 stated it was reported to V9, R1's money was found to be missing on 4/23/24 and R2's money was reported missing on 4/24/24. The facility's Abuse Policy dated 2/1/24 showed reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes which include immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview, and record review the facility failed to ensure a physician was notified of a change in condition for 1 of 3 residents (R25) reviewed for hospitalization s in the sample of 15. The findings include: R25's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include systolic congestive heart failure, acute eosinophilic pneumonia, personal history of COVID-19, paroxysmal atrial fibrillation, and hypertension. R25's facility assessment dated [DATE] showed she has severe cognitive impairment and extensive assist for most cares. On 7/13/23 at 9:59 AM, R25 was in common area sitting in her wheelchair, covered with a blanket, and resting with her head down. R25's acute care hospital documents dated 6/15/23 showed she was admitted to the hospital on 6/7/23 and discharged back to the facility on [DATE]. The same documents showed, . presented to the hospital on 6/7 from nursing home with cough, chills, shortness of breath . Patient was subsequently admitted to the hospital for pneumonia . R25's 5/30/23 eMAR (electronic medication administration record) entered at 9:34 AM showed, Acetaminophen 500 mg given for complaint of lower back pain. R25's 5/30/23 eMAR note entered at 4:41 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/3/23 eMAR note entered at 5:00 PM showed, Acetaminophen 500 mg . complains of headache and all over aches. R25's 6/4/23 eMAR note entered at 3:22 AM showed, Acetaminophen 500 mg . complains of aches all over. R25's 6/4/23 eMAR note entered at 10:30 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has a nonproductive cough . R25's 6/4/23 eMAR note entered at 10:30 AM showed, Acetaminophen 500 mg . Resident requested for overall feeling of general discomfort . R25's 6/4/23 Health Status Note entered at 7:20 PM showed, Resident complains of overall general feeling of discomfort today. Overall general appearance lethargic, poor appetite. Has nonproductive cough . PRN (as needed) APAP (acetaminophen) given, and cough syrup given . will continue to monitor. R25's 6/5/23 eMAR note entered at 10:02 AM showed, Acetaminophen 500 mg Resident complains of overall general discomfort. 'I just don't feel good today.' R25's 6/5/23 eMAR note entered at 10:03 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has nonproductive cough. R25's 6/6/23 eMAR note entered at 9:39 AM showed, Acetaminophen 500 mg . Resident requested for join pain. R25's 6/6/23 eMAR note entered at 9:55 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . nonproductive cough. R25's 6/6/23 eMAR note entered at 5:20 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/7/23 Health Status Note entered at 11:07 AM, Resident requesting to go to the ER (emergency room ) as she is feeling weak, cough and SOB (shortness of breath). Resident requests I call daughter in law and ask what she thinks . ambulance called for transport to [acute care hospital] . R25's 6/7/23 progress note showed, Situation: . Shortness of breath . Nursing observations, evaluation, and recommendations are Resident is talking slowly due to her feeling SOB . nonproductive cough and sitting with eyes closed . On 7/13/23 at 10:01 AM, V3 (Registered Nurse/RN) said the nurses should notify the provider if there is a change in the resident's treatment. V3 said they notify the physician through their electronic medical record unless they are notifying the physician of something urgent which they would call to the physician. On 7/13/23 at 10:10 AM, V6 (RN) said she sent R25 to the hospital when assessed her and heard fluid on her lungs. V6 said R25's general overall appearance was poor; she was pale and withdrawn. V6 said they call the physician if there is a significant change in a resident but for non-urgent notifications, they use the electronic record to notify. V6 said there was no documentation of notification to R25's physician between 5/11/23 and 6/7/23. On 7/13/23 at 10:49 AM, V2 (Director of Nursing) said if the nurse notes a change of condition, it is determined on a case-by-case situation if the physician is notified. If a resident starts to not feel well the nurse should do an assessment which would include vitals, lung sounds, all of it and then if they are depending upon the assessment, you will notify the physician or monitor the resident. V2 said if the resident's condition continues to get worse the nurse would notify the physician. V2 said the nurse should have started a notification to the physician to say the resident is using the Tylenol and cough syrup when she started taking them regularly. V2 said the 6/4/23 Health Status Note should have been a notification to the physician so the physician would be aware of the resident's complaints, the medications given, and the nurse's assessment. The facility's policy implemented 2/1/22 titled Notification of Changes showed, . the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's facility member or legal representative when there is a change requiring notification. Circumstances requiring notification include . 2. Significant change in the resident's physical, mental or psychosocial condition such as a deterioration in health . 3. Circumstances that require a need to alter treatment. This may include. new treatment .

Based on observation, interview, and record review, the facility failed to assess an area of pressure after one was identified for 2 of 4 residents (R20, R48) reviewed for pressure in the sample of 15. The findings include: The facility's 2/1/22 Pressure Injury Prevention and Management Policy showed the facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment. Assessments of pressure injuries will be performed by a licensed nurse and documented. 1. R48's face sheet showed an [AGE] year-old female with diagnosis of psychotic disorder, dementia, osteoarthritis, and muscle weakness. On 7/12/23 at 9:43 AM, V3 (Wound Nurse) performed wound care to R48's left heel wound. R48 complained of severe pain when the wound was cleaned and general pain aside from the wound itself. There was an oval shaped open area to the left lateral heel. The wound edges were very pale and well defined. Moderate serous drainage was noted from the wound. There was no odor and the wound measured approximately 1.5 centimeters X 1 centimeter with some depth. On 7/13/23 at 9:56 AM, V2 (Director of Nursing/DON) said R48's wound was found on 3/10/23 and a full wound assessment was not done. An initial wound assessment should include the location, color, shape, size, a description of the area around the wound, any odor, drainage, and if the skin is intact. A wound assessment should be done when it's found to establish a baseline to measure progression or improvement by. V2 said an assessment could be done by briefly visualizing the wound and noting any odor. The facility's 7/10/23 weekly wound report showed R48 had a Stage 3 (previous DTI-deep tissue injury) to the left outer heel that was facility acquired on 3/10/23. R48's 3/10/23 weekly skin assessment showed a small painful discolored area to the left outer heel. R48's first wound assessment dated [DATE] showed the wound was acquired 5/22/23 and was initially a suspected deep tissue injury and currently a Stage 2 pressure injury. This assessment showed it was the initial assessment and there was no previous assessment for reference. R48's 7/10/23 weekly wound assessment showed the left heel wound progressed to a Stage 4 pressure injury. R48's 6/6/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfers, toilet use, personal hygiene, and bathing. R48's care plan showed an alteration in skin integrity related to fragile skin as evidenced by a Stage 2 pressure injury to the coccyx on admission, a healed deep tissue injury to the sacrum that healed 5/29/23, and a Stage 3 pressure injury to the left outer heel (current). The National Institutes of Health website showed a wound assessment standard includes evaluation of the depth, length, and width of the wound. Evaluation of the wound bed for exposed bone, vessels, hardware, or subcutaneous fat. Survey for presence, type, and amount of exudate (drainage). Assess surrounding skin tissue for signs of injury. Check the wound margins. Evaluate for warmth, pain, odor, purulence, delayed healing, or other signs of infection. 2. R20's face sheet showed a [AGE] year-old female with diagnosis of dementia, acquired absence of left toe, osteomyelitis of the left foot and ankle, heart attack, dementia, and chronic kidney disease Stage 3. On 7/12/23 at 9:17 AM, V3 (Wound Nurse) performed a dressing change to R20's left medial ankle. The open area was circular, pale, and approximately 1 centimeter in diameter with some depth. There was a moderate amount of serous drainage which caused the dressing to come off in her stocking. There was no foul odor, and the wound edges were well defined. R20 tolerated the procedure without complaints of pain. On 7/13/23 at 9:56 AM, V2 (DON) said R20's pressure injury started out as a teeny tiny scab. I found it on 6/16/23 at 4:00 PM. It was on her left inner ankle. I had the wound nurse do full wound assessment on Monday morning (6/19/23). A full wound assessment should be done when a wound is identified. R20's 5/12/22 admission assessment does not show any impairment of skin integrity. R20's 5/20/22 pressure injury risk assessment showed she was at risk for developing pressure injuries. The facility's 7/10/23 weekly wound report showed R20 had a Stage 2 pressure injury to the left medial ankle that was facility acquired on 6/19/23 (wound was identified 6/16/23). R20's 6/16/23 weekly skin assessment authored by V2 (DON) showed an old scab to the left inner ankle. There was no wound assessment documented. R20's 6/19/23 weekly wound assessment showed a left medial ankle wound assessment was not completed until 3 days after identification. This assessment showed the pressure injury was a Stage 2. R20's 7/10/23 weekly wound observation showed the left medial ankle wound had progressed to a Stage 3. R20's care plan showed she was at risk for impaired skin integrity and had a Stage 2 pressure injury to the left ankle and a healed Stage 3 pressure injury to the left heel. R20's 5/21/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfer, toilet use, and personal hygiene. This assessment showed R20 was at risk for developing pressure injuries and did not have any unhealed pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident with dementia exhibiting exit seeking behaviors by not increasing supervision to prevent elopement. This resulted in R1 exiting the facility unknown to staff on (MONTH) 29, (YEAR). R1 was unable to be located for approximately two hours and fifteen minutes before emergency responders and the canine unit located him approximately a quarter of a mile from the facility in a farmer's field and was transported to the hospital for treatment. This applies to 1 resident (R1) in the sample of 4 reviewed for elopement risk. The Immediate Jeopardy began on (MONTH) 29, (YEAR) at 5:58 AM. V1 was notified of the Immediate Jeopardy on (MONTH) 6, (YEAR) at 8:38 AM related to R1's risk for his safety while he was gone. While Immediate Jeopardy was removed on (MONTH) 6, (YEAR), the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. The findings include: On (MONTH) 29, (YEAR), R1's electronic medical record showed R1 was an [AGE] year old male that was admitted to the facility on (MONTH) 20, (YEAR) from another long term care facility with [DIAGNOSES REDACTED]. R1's nursing notes from the previous facility that were provided to the current facility upon admission showed a note dated (MONTH) 19, (YEAR) at 7:30 AM, Resident up independently wandering facility with coat on. Exit seeking tendencies noted . R1's nursing admission assessment dated (MONTH) 20, (YEAR) showed R1 to be alert and oriented to person and place, required no assistive devices for mobility, had a history of [REDACTED]. R1's admission MDS (Minimum Data Set) dated (MONTH) 26, (YEAR) showed R1 had severe cognitive impairment and had wandering behavior. R1's current nursing progress notes showed two entries on (MONTH) 22 regarding R1 wandering. The 3:15PM note showed R1 insisting on walking up and down the halls while pushing his wife in a wheelchair. The 3:27 PM note showed R1 was found in between 2 outside doors in the break room, wander guard alarm sounding. Earlier in shift, resident was following a group of visitors toward the front door with wife in wheelchair. A nursing note dated (MONTH) 24 at 10:40 AM showed, Front door alarm sounding. (R1) had followed a guest out the front door with wife in wheelchair. R1's nursing note dated (MONTH) 25, (YEAR) at 5:21 AM showed, during the evening hours (R1) asked a visitor if they would give him and his wife a ride to (a neighboring town). Another staff member overheard it and reported it to nursing staff; resident walked up and down the halls for several hours tonight pushing his wife in her wheelchair walking mostly to the door at the end of 100 hall . An MDS note dated (MONTH) 26, (YEAR) at 2:24 PM showed, Cognition score of 3 indicates severe impairment .He does pace the halls while pushing wife in wheelchair and has exhibited exit seeking behaviors On (MONTH) 29, (YEAR), at 2:30 PM, V14 (R1's son) said R1 had a history of [REDACTED]. V14 said R1 has dementia and just does not know or understand what he is doing. On (MONTH) 29, (YEAR), at 12:45 PM, V4 RN (Registered Nurse) said the staff keep an eye on R1 because he wanders. V4 said R1 has dementia and has tried to go out of the doors before. V4 said R1 has told others he wanted to leave and he wanders down the halls looking out the windows. V4 said when she was working on Thanksgiving day she found R1 to be between two exit doors near the employee break room attempting to leave the facility. V4 said a couple of days later R1 was pushing his wife in her wheelchair when he attempted to follow a visitor out of the front exit. On (MONTH) 29, (YEAR), at 1:33 PM, V9 CNA (Certified Nursing Assistant) said R1 is someone who she would keep an eye on. V9 said R1 would talk to the staff about wanting to look for his brothers and thought they were in the parking lot. V9 said she caught R1 trying to go out the door with a visitor before. On (MONTH) 29, (YEAR), at 1:50 PM, V5 CNA said R1 was an elopement risk. On (MONTH) 29, (YEAR), at 10:09 AM, V1 Administrator stated, This morning at approximately 6:10 AM it was noticed that (R1) was not in the building. The staff called me right away and after a thorough search of the building staff called 911. He was seen 15 minutes prior to them noticing he was gone walking the halls. I was able to get on my computer at home and view the security cameras. I was able to track him on the security camera and narrowed it down to him going into room [ROOM NUMBER] (an unoccupied resident room) and he did not come out of that room. I called and let them know and they checked the room and the window was open, the screen was able to be pushed away, and they saw footprints outside of the window in the snow. The staff immediately let the fire and police department know which window it was and they found him at 8:16 AM. He was about a quarter mile away out in the field. He was a little scratched up and he had one shoe in his hand. He was wearing his coat which he always has on, pants, shirt, socks and a shoe. The temperature outside this morning was about 30 degrees. V1 said R1 was wearing a wander guard device that alarms if he attempts to go out of an exit door as a precaution because he would talk about wanting to leave. V1 said the facility did not think he would attempt to leave without his wife but V1 said well this morning he did. On (MONTH) 30, (YEAR), at 8:45 AM, V16 (R1's granddaughter/caretaker) said R1 has a history of being confused and delusional at home. V16 said R1 has been getting progressively more confused. V16 said when she spoke with R1 at the acute care hospital on (MONTH) 29, (YEAR) after the emergency services found him R1 told her he pushed the screen out from the window and once he got out of the window he just started running. The facility provided a time line of the events surrounding R1's elopement on (MONTH) 29, (YEAR) which showed Resident was last seen walking down the 300 hall wing at 5:54 AM and he was found at 8:16 AM and being transported to the local hospital for evaluation. The document titled Pre-hospital Care Report provided by the transporting ambulance service dated (MONTH) 29, (YEAR) showed they were dispatched to the facility at 6:30 AM. The report showed, after a two hour and fifteen minute search the patient was spotted near a fence line one quarter mile north northeast of the nursing home by a deputy and canine unit. He was brought to the road by a utility vehicle. Patient presents in no acute distress with no primary deficits noted. He is wearing a fall weight jacket, a heavy sweatshirt underneath, slacks and socks. He has one shoe on and is carrying the other. Unsure how long he had been walking without the one shoe on. Patient placed on cot . removed jacket and covered patient with several blankets after turning heat up inside cabin. Left scene, temperature 94.1 degrees. Hands and feet are both extremely cold. Hands wrapped in blankets. Shoe and socks removed. Feet dried then placed on blankets with warm packs, then wrapped in aluminum foil followed by more blankets The Assessment and Plan history and physical from R1's admission to the acute care hospital dated (MONTH) 29, (YEAR) showed acute cold exposure, acute hypothermia, and acute [MEDICAL CONDITION] infarction. On (MONTH) 30, (YEAR), at 11:47 AM, V3 CNA stated she last saw R1 at around 6:00 AM on the morning of (MONTH) 29, (YEAR). V3 said R1 was close to the sitting area near the 300 wing and it looked like he was getting ready to walk down the 300 hallway. V3 said, (R1) walks around all the time pushing his wife in her wheelchair from hall to hall. It caught me off guard because I'm not used to seeing him up that early and dressed so it stuck out 'like a sore thumb.' (R1) would normally be in his room in bed or at least in the recliner. I had never seen him out of his room and dressed at that hour. It was out of the ordinary for (R1) to be out and (R1's spouse) still in their room. I had never seen him walk the halls by himself before; he was always with his wife. On (MONTH) 29, (YEAR), at 12:50 PM, V8 CNA said they have to keep an eye on R1 because of his exit seeking behaviors which he has had since admission to the facility. V8 said R1 has been having exit seeking behaviors, wandering, pushing on all the doors, and asking visitors for a ride. V8 said she triggered the search for R1 when she went into R1's room to assist his wife with getting dressed and noticed R1 was not in the room. V8 said R1 does not usually go anywhere without his wife so she knew something was not right. On (MONTH) 29, (YEAR) at 2:05 PM, V7 CNA said when she reported for her shift starting at 6:00 AM during report one of the other CNAs was asking if anyone knew where R1 was. V7 said everyone started looking for R1 and she looked down the 300 hall. V7 said the door to room [ROOM NUMBER] was closed and when she opened it the room felt very cold. V7 said she noticed the window was open and thought someone had probably just left it open. V7 said she closed the door and continued searching for R1. On (MONTH) 30, (YEAR), at 8:58 AM, R1 was observed at the acute care hospital. R1 had numerous significant scratches to bilateral hands, wrists, and arms, top of his head and bilateral lower extremities. On (MONTH) 30, (YEAR), at 8:58 AM, R1 stated he remembered being out in the cold but he did not remember what he was doing. R1 said, I think I stepped out a window. I thought my wife was outside and crying .I wanted to be with her. I wanted to go home. On (MONTH) 30, (YEAR), at 8:34 AM, V13 (emergency room Physician) said R1 was brought into the emergency roiagnom on (MONTH) 29, (YEAR). V13 said the ambulance staff had already started warming R1 during the transfer to the emergency room but he was still cold. V13 said R1 had scrapes on his head, hands, and feet. V13 said the blood tests done in the emergency indicated R1 had a cardiac event. V13 said it is difficult to say if being exposed to the cold environment caused the cardiac event but he went on to say R1 was attempting to climb over a fence when was found by emergency responders and the physical exertion of walking through the field and climbing the fence is more likely to have caused the [MEDICAL CONDITION] infarction than the cold environment. V13 said R1 is confused and requires supervision. V13 stated it is not safe for R1 to be in the cold or unsupervised. The national weather service website showed on (MONTH) 29, (YEAR) from 5:55 AM to 8:15 AM during the hours R1 was outside of the facility the temperature was 27 degrees Fahrenheit in Mt. Carroll. The facility's policy and procedure for elopement with revision date of (MONTH) (YEAR) showed the purpose of the policy to assess and identify residents at risk for elopement .to minimize risk for elopement through individualized interventions .to provide protection for residents at risk for elopement. The policy showed, all residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. The policy defines elopement as, When a resident who needs supervision leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. R1's electronic care plan initiated on (MONTH) 20, (YEAR) for potential for elopement related to history from prior facility and last revised on (MONTH) 26, (YEAR) showed a goal of resident will not leave facility unattended with interventions to include: attempt non-pharmacological interventions, offer hot chocolate, watch TV in fireplace area and personal alarm (wander guard) used to alert staff to resident's movement and to assist staff in monitoring movement. Through observation, interview, and record review the surveyor confirmed on (MONTH) 7, (YEAR), the facility took the following actions to remove the immediacy: 1. All staff In-Service completed on (MONTH) 29, (YEAR) addressing the following: a. Reviewed the incident that occurred early that morning b. Discussed details of emergency plan c. Discussed what we learned and what we could do better d. Reminders and debriefing with staff on the risk of elopement and discussion of any tweaking of our processes based on this incident. 2. On (MONTH) 29, (YEAR) window clamps were ordered to ensure windows do not open more than four inches. These were sent overnight by mail. 3. On (MONTH) 30, (YEAR) a meeting was held with R1's family to reevaluate and discuss care needs for the safety of R1. 4. R1's family hired a 24 hour per day sitter to keep eyes on R1 - 24 hours per day when he returns from the hospital until future care plans are determined. Resident returned from the hospital on (MONTH) 5, (YEAR). 5. On (MONTH) 30, (YEAR) the window clamps were received and maintanence immediately installed in all resident rooms that are at risk for elopement. After those were complete the facility began installing the clamps in all remaining resident rooms. Also installed device on all other windows that are accessible to resident that open far enough for a person to fit through (dining room, staff lounge). 6. On (MONTH) 4, (YEAR) the behavior committee reviewed residents at risk for elopement, reassessed all resident and reviewed care plans to determine that all interventions are appropriate.

Based on interview and record review the facility staff failed to respond to a stat emergency request for help when R1 was found unresponsive on 11/7/12. The facility staff failed to monitor R1's blood sugar level when he was unresponsive. This contributed to a 2 hour delay of treatment for [REDACTED]. The resident was hospitalized for [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for diabetes care and emergency care and treatment in the sample of 3. The findings include: The resident transfer sheet dated 11/7/12 shows R1 is an [AGE] year old man with [DIAGNOSES REDACTED]. On 11/9/12 at 10:10 AM, E4 CNA (Certified Nursing Assistant) stated she checked on R1 at 7:00 AM on 11/7/12 and he appeared to be snoring and in no apparent distress. E4 stated while E6 (CNA) was shaving and giving morning care to R1 on 11/7/12 at 9:00 AM, he was making noises but failed to wake up or respond. E6 called on a hand held radio for a nurse to respond "stat" to R1's room. E4 stated there was no immediate response from any nurse. E6 went down the hallway to locate a nurse. E6 found E5, (LPN-licensed practical nurse), in hallway "with an armful of pills and said she would come down as soon as she got rid of the pills." On 11/16/12 at 1:15 PM, Z2 POA ( power of attorney) stated it is R1's routine to be up by 8:00 AM. Z2 stated that R1 is always putting on his call light in the morning and can be somewhat demanding. On 11/9/12 at 9:50 AM , E6 stated she had walked by R1's room between 7:00 and 9:00 AM on 11/7/12 and he appeared to be sleeping. E6 states "lately R1 has been getting up later at 8:00 AM and 8:30 AM." E6 said by 9:00 AM she thought it was odd that he had not been up or had not put on his call light, so she went to see if he wanted breakfast. E6 stated at that time she found R1 to be unresponsive to verbal or tactile stimuli. E8, RN (Registered Nurse), was on duty at the time of the "stat" call for assistance. E8 stated she did not hear the call because her radio was in her pocket with the volume turned down. E8 stated she did not assess R1 at any time because R1 was not down the hallway she was assigned to work. E8 stated she had passed medications for E5 that morning, after E5 requested help. E5 said the care levels of the residents in the facility has increased, but the teamwork and communication amongst the staff has not. On 11/9/12 at 12:45 PM, E2 DON (Director of Nurses) stated anytime a "stat" request is made, all available nurses are expected to respond. E2 also stated the nurses should keep radio volume at a level it can be heard. E10, RN and E11, LPN were also on duty 11/7/12 at the time of the incident and each had a radio. At no time did E10 or E11 respond to the emergency call. On 11/16/12 at 2:10 PM, E3 ADON (Assistant Director of Nurses) stated that all nurses should respond to emergency calls for help, but it is not a policy of the facility that a resident be assessed by an RN during an emergency event. During an interview with E5 on 11/9/12 at 9:30 AM, she states at the time of the stat call, she was working on a discharge for R2 and was trying to deal with family members. E5 stated she wanted to get her paperwork done. E5 stated " I was trying to finish the discharge." The time noted on R2's discharge paperwork was 8:56 AM. E5 stated the CNA's had reported R1's condition to her during the discharge. E5 stated it was approximately 5 to 10 minutes prior to her going into R1's room. The nursing notes by E5 dated 11/7/12 at 9:05 AM, document R1 appeared to be asleep but unresponsive to tactile stimuli per the CNA assessment. E5 documented vital signs as Temperature 93.4 (hypothermic), Pulse 80, and Respirations at 20. The blood pressure was 118/60 and pulse oximetry reading of 96% oxygenation on room air. On 11/9/12 at 9:30 AM, E5 stated she did not personally assess R1 and did not check his blood sugar. E5 stated she should have done a blood sugar on R1 knowing he is diabetic. The nursing note of 11/7/12 at 9:15 AM, E5 documents a call to the physician was placed and he was given a condition report. The physician ordered R1 to be sent to the emergency room . E5 states the CNA's were checking on R1 and were reporting back to her, and she would "peek" in on him. At 9:30 AM the ambulance was called. On 11/16/12 at 1:15 PM Z2, POA (Power of Attorney) stated she arrived at the facility on 11/7/12 at 9:30 AM. Z2 states when she arrived, the CNA told her R1 "did not look good." Z2 stated when she saw R1 he looked grey and felt cold, like he was dead. Z2 stated no staff were with him at that time. Z2 stated the nurse came in and looked at him but did not do anything with him. Z2 said she would have expected " a blood sugar to be done because he is diabetic and he has had low blood sugar before." She said she waited about 20 minutes for the ambulance to arrive. The ambulance documentation sheet shows an arrival time of 9:42 AM and departing the facility at 9:50 AM. The ambulance service sheet of 11/7/12 documents: "upon arrival, EMT's found patient (R1) lying supine in bed, not responsive to verbal or painful stimulation. NH (nursing home)staff state patient (R1) had been in this condition for approximately 1 hour. When questioned whether a blood sugar had been checked on this known diabetic, the nurse stated she "had not gotten around to it yet". A blood sugar was checked per ambulance staff with a result of 39 mg/dL. The Appleton and Lange Handbook of Laboratory and Diagnostic Tests dated 1994 on page 115, cites a normal elderly blood sugar to range 70-120 mg/dL. The ambulance service sheet documented R1 was immediately given " [MEDICATION NAME] 1mg intramuscularly left deltoid at 10:00 AM. Tympanic temp 94.1.... R1 had snoring respirations and nasal airway inserted right nare on second attempt without difficulty and oxygen applied. Had teeth clenched tightly and lips rolled into dentition, with swelling of lips noted. Small amount of pinkish drainage noted at right nare and corner of mouth and suctioned gently....Unable to determine oximetry despite multiple attempts including pediatric probe to left ear lobe. A repeat glucose test performed 10 min after [MEDICATION NAME] was 41. One D50 amp injected IV...Bags of warmed IV fluids placed to groin and side of neck....Heart rate irregularly irregular with rate of 40's to 70's. Recheck of blood sugar after D50 was 202. Patient (R1)beginning to open eyes to verbal stimuli but not reliably responding to commands. On 11/19/12 at 9:20 AM, Z1 (physician) stated the nurse should have checked a blood sugar. Z1 stated that a blood sugar in the 30's is a concern and if a sugar that low remains untreated it may result in death. The ER discharge summary dated 11/7/12 documented "chief complaint of : Low blood sugar, unresponsive. admitted to hospital." On 11/9/12 at 12:45 PM, E2 stated there is no specific policy on emergency response. E2 stated she does not carry a radio, but the office manager has a radio and should have notified her of the emergency.