Every finding on record at Avantara Libertyville

Based on interview and record review the facility failed to provide a resident with the Physician prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. This failure resulted in R1 choking on her food and expiring at the hospital. This applied to one of three residents (R1) reviewed for diets in the sample of three.The Immediate Jeopardy began on 5/17/26 when R1 received physician orders for a downgrade in diet to pureed and the next morning was served a mechanical soft diet rather than the Physician prescribed puree diet. R1 choked and expired at the hospital. V1 (Administrator) was notified of the Immediate Jeopardy on 5/22/26 at 9:58 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 5/18/26, prior to the start of the survey and was therefore Past Noncompliance. This past noncompliance occurred from 5/17/2026 to 5/18/2026. Findings include:The facility face sheet for R1 shows she was admitted to the facility with diagnoses to include metabolic encephalopathy, osteoarthritis, and dysphagia. The facility assessment dated [DATE] shows R1 had moderate cognitive impairment and required a set up for meals. A nursing note dated 5/17/26 shows that R1 was observed eating her physician ordered diet of mechanical soft in her room. R1 was observed coughing and gagging while eating her breakfast. R1 then appeared not to be able to cough to clear her airway. The nurse documented that she performed the Heimlich maneuver, and an expulsion of food was achieved. The same note shows the nurse contacted the on-call provider and was given orders to downgrade the diet for R1 to puree. The Physician Order Sheet for R1 shows a new order dated 5/17/26 for a pureed texture diet. A nursing noted dated 5/18/26 for R1 shows at approximately 7:30 AM, staff became aware of R1 coughing while eating her breakfast in bed. The nurse was called to the room and encouraged the resident to cough up the food but R1 was unable to do this. The staff assisted her to a standing position and began performing abdominal thrusts. The nurse documented a mouth sweep was performed and no food was observed. The note goes on to show that at approximately 7:40 AM 911 was called and the crash cart was brought to the resident's room. A pulse was unobtainable and R1 was lowered to the floor and Cardiopulmonary Resuscitation (CPR) was initiated. At approximately 7:45 AM, the paramedics arrived and took over the situation. R1 was transported to the local emergency room.On 5/21/26 at 10:09 AM, V3 LPN (Licensed Practical Nurse) said she was the nurse that responded to R1 choking on 5/18/26. V3 said she was called to the room by the CNA (V7) and found R1 coughing on her breakfast. V3 said R1 then required abdominal thrusts which was attempted numerous times, R1 then went limp and was lowered to the floor where abdominal thrusts were attempted. R1 lost her pulse and CPR was started. R1 was transferred to the hospital by EMS but later died at the hospital. V3 said she noticed cut up pancakes on R1's breakfast tray. V3 said she was aware that R1 had choked the day before and her diet was to be downgraded. On 5/21/26 at 10:25 AM, V4 CNA (Certified Nursing Assistant) said he had served R1 her breakfast on the morning of 5/18/26. V4 said her diet slip on the breakfast tray said for a mechanical soft diet and the tray contained a mechanical soft diet which included regular pancakes. V4 said he set up R1 with her tray and continued with passing trays. V4 said he was not aware that R1 had choked the day before and that her diet had been downgraded to a pureed diet. On 5/21/26 at 10:52 AM, V7 CNA said she was monitoring the residents who were eating in their rooms on 5/18/26 and she noticed R1 coughing and holding her neck. V7 said she yelled for the nurse who was near R1's room. On 5/21/26 at 12:34 PM, V15 [NAME] said he was the cook on 5/18/26 and was the staff plating the food for breakfast. V15 said he was not aware that R1 had choked the day before and that her diet was downgraded to pureed foods. V15 said R1's diet slip showed she was on a mechanical soft diet and that was the diet he served to R1. On 5/21/26 at 11:44 AM, V10 LPN said she was working with R1 on Sunday 5/17/26. V10 said R1 was eating her breakfast in bed as she usually does. V10 said she heard a noise from R1's room and saw R1 holding her throat and could not speak. V10 said she stood R1 up and began abdominal thrusts and was able to help R1 expel food from her airway. V10 said she called V11 Nurse Practitioner on call and explained what had happened and a chest x-ray was ordered and R1's diet was downgraded to puree. V10 said she called the kitchen before lunch and told the person who answered the phone (V16 Dietary Aide) that R1 would need a puree diet due to a choking incident. V10 said at lunch, R1 was served a puree diet so she assumed the kitchen was aware of the new diet order downgrade and did not feel she needed to do anything else. V10 said she had never had to change a resident diet order and felt what she had done was enough. On 5/21/26 at 10:40 AM, V5 [NAME] said he was the cook on 5/17/26 and was the person plating the food for the residents. V5 said at lunch a nurse (V10), called the kitchen and spoke with one of the dietary aides (V16) and requested a puree tray for lunch, so that is what I served R1 that day. V5 said no written diet slip showing a change in diet was ever sent to the kitchen that day, so her diet slip we use in the kitchen was not changed. On 5/21/26 at 10:41 AM, V6 Dietary Manager said no diet change slip was ever given to the kitchen to show us that R1's diet was downgraded to puree on 5/17/26. V6 said a diet change slip was to be filled out by nursing and brought to the kitchen. On 5/22/26 at 12:30 PM, V16 Dietary Aide said she was the staff that took the call from the nurse (V10 LPN) on Sunday 5/17/26 stating that R1 needed a puree tray for lunch. V16 said she told V5 the cook this information. V16 said that night she was assisting with the supper trays and R1's diet slip showed mechanical soft, so a mechanical soft tray was sent to the unit for R1. V16 later said a staff member (she could not remember who) called and stated they needed puree for R1, so a new tray was sent to the unit for R1 containing puree foods. V16 said she never received any paper diet order changes, and she never communicated the information given to her from the nurse (V10) other than a puree tray for lunch on 5/17/26. On 5/21/26 at 12:18 PM, V11 NP (Nurse Practitioner) said he was called when R1 had a choking incident on 5/17/26. V11 said he gave orders for a chest x-ray and to change R1's diet to puree. V11 said he expects the staff to follow that order to avoid R1 choking again. On 5/21/26 at 1:17 PM, V13 Speech Therapist said he had been seeing R1 for her diagnosis of dysphagia and she was doing well on a mechanical soft diet. V13 said he was surprised R1 had choked on 5/17/26 on her mechanical soft diet, and that a new diet order of puree foods was appropriate and should have been provided to R1 to avoid a second choking incident. The hospital emergency room notes dated 5/18/26 for R1 shows she arrived to their facility by paramedics doing CPR. The note shows the paramedics reported large amounts of pancakes were observed in R1's airway and they were unable to intubate in the field. R1 was intubated in the emergency room and CPR continued until her time of death at 8:30 AM. The menu for breakfast on 5/18/26 showed residents on puree diet were to receive puree pancakes, puree oatmeal and puree sausage links. The facility was asked for a policy regarding diet orders, and a Physician Orders policy was provided. The policy does not provide any guidance for diet orders or changes to a diet order. The Immediate jeopardy that began on 5/17/26 was removed and the deficient practice corrected on 5/18/26 after the facility implemented the following actions: 1.) The facility completed an audit of residents' diet orders to ensure that diet orders match the residents' dietary tickets. This audit was completed by DON and Food Service Director on 5/18/2026 prior to lunch meal being served. All residents diet orders and dietary tickets matched correctly. 2.) An education was conducted by DON/Admin on 5/18/2026 to Nurse (who received the physician order for change in diet from regular mechanical soft to puree diet) to ensure that any new diet orders are entered in PCC, printed, and hand delivered to the kitchen. Upon receipt, the Diet Change Order Communication Log is completed, notating the date, time, resident initials and room number, nurse's name, name of dietary staff receiving, and name/date of dietary staff creating the new meal ticket, ensuring the correct diet is served to the resident per physician order. A 1:1 education was also completed with Dietary Aide to ensure that any new diet orders received from nursing are communicated appropriately and follow the process of the Diet Change Order Communication Log. 3.) This new Diet Change /Order Communication Protocol was implemented to ensure the new printed diet order will be hand delivered & signed to the kitchen and have dietary supervisor /cook received and signed the new diet order in the Diet Change Order Communication Log to ensure a new meal ticket is generated and a correct diet is served to the resident per physician order. 4.) All Nursing staff and all dietary staff were educated on the new communication protocol on 5/18/2026 by DON/Food Service Director/Designee. All nursing and dietary staff scheduled to work and in the facility on 5/18/2026 signed this Inservice. All nursing and dietary staff who were not scheduled to work were in- serviced via phone by the DON/Food Service Director and or Designee on 5/18/2026. The staff who were in- serviced via phone were/will sign the Inservice sheet on their next scheduled shift in person.5.) A QA audit tool was developed on 5/18/2026 to monitor and ensure that residents'dietary order matches what is written on the resident dietary ticket, and what isserved to residents during meals. This audit will be conducted to 10 residents 3xweek x12 weeks by Food Service Director and or Designee. (Exhibit E) 6.) A QA audit tool was developed on 5/18/2026 to ensure that the Diet Change /OrderCommunication is completed, and a correct diet is served to the resident perphysician order. The QA audit tool is utilized to monitor and ensure that the dietaryteam receive a printed order for any change in diet order by nursing staff, and thatthis new order is hand delivered to the kitchen by nursing, with a new meal ticketgenerated and logged in the Diet Change Order Communication. This audit will becompleted to 10 residents 3x/week x12 weeks by Director of Nursing and orDesignee. (Exhibit F) 7.) A QAPI meeting was held on 5/18/2026 with the facility medical director to discussthe abatement plan. The facility medical director approved the abatement plan.(Exhibit G) 8.) All trends and results from the audit will be discussed in the monthly QualityAssurance Performance Improvement meeting until resolution.

Based on observation, interview, and record review the facility failed to ensure kitchen staff were performing hand hygiene and utilizing gloves in a food safe manner. This has the potential to affect all residents receiving food from the facility. The findings include:On 12/15/25 at 10:10 AM, V5 (Cook) grabbed the lid of the garbage can, placed garbage into the garbage can, then proceeded to walk over to the steamer and grabbed a pan from the steamer and removed it. V5 was not wearing gloves and did not perform hand hygiene before grabbing the pan from the steamer. On 12/15/25 at 11:11 AM, V5 threw a disposable spoon into the garbage can by lifting the garbage can lid. V5 then started to rinse the food processor pitcher and parts in the two-compartment sink by the main door into the kitchen. V5 then took a soiled plate and placed it by the dish machine prior to performing hand hygiene. On 12/15/25 at 11:59 AM, V5 donned gloves. On 12/15/25 at 12:29 PM, V5 left the service line, wearing the same gloves he started service with, reached into the reach-in cooler and grabbed a slice of deli ham. V5 took the deli ham slice and placed it onto the flat top to cook with the grilled cheese, also on the flat top. Without changing gloves or washing hands, V5 returned to the service line and resumed serving food. At 12:30 PM, V5 went back to the flat top, placed the slice of deli ham onto the grilled cheese, combined the two slices of bread, and took the sandwich to the cutting board. V5 then cut the sandwich and placed it on a plate and handed the plate to another kitchen employee. V5 did not remove V5's gloves. On 12/15/25 at 12:32 PM, V5, while still wearing the same gloves, walked to the walk-in cooler and returned with an unopened package of cheese slices. V5 opened the cheese package and removed slices of cheese using the same gloves. On 12/15/25 at 12:42 PM, V5 reached into the reach-in cooler behind the service line and grabbed a slice of deli ham. V5 put the ham slices onto bread for a sandwich and handed the plate to another food service employee. at 12:44 PM, V5 made another ham sandwich following the same procedure and using the same gloves. This surveyor did not observe V5 change gloves during the lunch service on 12/15/25 from 11:59 AM to 12:45 PM. On 12/15/25 at 11:12 AM, V4 (Food Service Director) said hands should be washed when entering the kitchen, when your hands are soiled, or before wearing gloves. V4 also said employees should wash hands after touching the garbage can, including the garbage can lid. Facility provided Kitchen policy dated 6/30/25 states, . 7. Staff . c. Staff will wash hands prior to handling food for 15-20 seconds. d. Staff will use gloves to prevent bare hand contact with ready to eat food. e. Staff will wash hands after handling soiled items, after using the toilet, after removing gloves, and after switching from working with raw food items to working with ready to eat food.Centers for Medicare and Medicaid Services form 671 dated 12/15/25 shows there are 100 residents residing in the facility. The facility provided a Diet Type Report showing there are two residents that have orders for enteral feedings. This report also shows those residents receive food from the kitchen.

Based on observation, interview, and record review the facility failed to ensure the pureed chicken alfredo was a smooth consistency. This applies to 4 of 4 residents (R74, R12, R19, R39) reviewed for pureed diets in the sample of 21. The findings include: On 12/15/25 at 11:01 AM, V5 (Cook) started the puree process for the chicken alfredo. V5 said the consistency should be similar to mashed potatoes or pudding and should not have any chunks. At 11:06 AM, V5 asked another food service employee for disposable spoons and tested the pureed chicken alfredo consistency. V5 agreed it was an acceptable consistency and transferred the pureed chicken alfredo to a food service pan. While transferring the pureed chicken alfredo to the food service pan, the consistency appeared chunky and not smooth. On 12/15/25 at 12:53 PM, the facility provided test tray of pureed chicken alfredo, pureed vegetables, and pureed noodles. The pureed chicken alfredo was fibrous and not smooth. V4 said the puree chicken should be a little smoother and be like a mashed potato consistency. Facility provided In-Service Training For Puree Diet Preparation document shows puree food texture should be smooth with no bits or lumps and does not require chewing. Per the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines, pureed food should be smooth with no lumps and minimal granulation. The altered diet list provided by the facility shows that R74, R12, R19, and R39 receive a pureed textured diet.

Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 21 residents (R87) reviewed for activities of daily living in the sample of 21. The findings include: On 12/16/25 at 9:43 AM, R87 was in his room sitting in his wheelchair. On 12/16/25 at 1:10 PM, R87 was in the dining room during the noon meal. R87 said she has been up since breakfast and would like to lay down. On 12/16/25 at 1:16 PM, this surveyor asked V8 (CNA) if R87 lays down after lunch. V8 said he normally stays up in his wheelchair until PM shift. V8 said she will ask R87 if he'd like to lay down. R87 told V8 he would like to lay down. At 1:20 PM, V8 wheeled R87 into his room and transferred him using the mechanical stand lift with V9's (CNA) assistance. A strong smell of urine was noted as R87 was in a standing position. V8 and V9 lowered R87 on top of the clean incontinent pad, removed his pants, his incontinent brief was heavily saturated with urine. V8 and V9 removed his pants, and his incontinent brief soiled thru the incontinent pad. V9 said it's wet and removed the soiled pad. V8 said R87 was last changed in the morning after breakfast and stated, I think he drank a lot of liquids. Residents should be checked and changed every two hours for incontinence care. R87's current care plan shows he has frequent bladder incontinence and should be checked for incontinence episodes. The facility's Incontinence and Perineal Care Policy states, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation.do rounds at least every two hours to check for incontinence during the shift.

Based on observation, interview and record review the facility failed to ensure hand splints were applied for a resident with limited mobility. This applies to 1 of 2 residents (R70) reviewed for restorative services in the sample of 21. The findings include: On 12/15/25 at 10:54 AM, R70 was lying in her bed with a low air loss mattress, a hand splint was in place to her right hand. Her left thumb was hyperextended and fingers contracted. She said she is supposed to have hand splints on both hands, but the left-hand splint they can't find. She said she thinks her hand splint was thrown away, it's been a couple of weeks since she has not had her left-hand splint and her splints are placed in the morning for four hours. On 12/16/25 at 9:41 AM, R70 was lying in bed with her bilateral fingers clenched to her palms, without her hand splints in place. At 12:35 PM, R70 remained in bed with her fingers clenched without her hand splints in place. R70 said the staff usually apply her hand splints about 8:00 AM, but they have not placed her splints on today. On 12/16/25 at 12:46 PM, V6 (Licensed Practical Nurse) said R70 is total dependent on staff for all cares, she has no mobility to her hands and stated, I thought she had splints. On 12/16/25 at 12:57 PM, V7 (Restorative Nurse) said restorative assessments should be done on admission, quarterly and when a resident is discharged from therapy. R70 has limited mobility and is on a range of motion program with hand splints. If splints are missing staff should notify me and she can get the splints replaced. She was not aware of R70's left hand splint missing and her splints should be applied as ordered. R70's Physician Order Sheets dated December 2025 shows to apply bilateral (splints) on for four to six hours or as tolerated. R70's Restorative assessment dated [DATE] shows she has limitation range of motion in the following area, right wrist and hand, left wrist and hand and is on the following programs; range of motion, splint or brace assistance and is tolerating the splint/brace program well. The same assessment shows R70 is oriented to self, time, situation, able to use call light and makes needs known. The facility's Restorative Nursing Program Policy revised July 2025 states, It is the policy of this facility to assess for comprehensive nursing and restorative upon admission.appropriate nursing and restorative services consistent to the resident's functional needs must be provided.nursing and restorative may include the following.splint/orthotic management, contracture prevention and management/PROM/AROM exercises.

Based on observation, interview and record review the facility failed to ensure staff wore Personal Protective Equipment (PPE) while providing direct care to a resident on Enhanced Barrier Precautions (EBP) to prevent the spread of cross contamination. This applies to 1 of 21 residents (R119) reviewed for infections control in the sample of 21. The findings include: R119's current care plan dated through January 2026 shows she is on EBP related to presence of gastrostomy (G-tube) and staff should wear gown and gloves during cares. On 12/15.25 at 11:18 AM, an EBP sign was posted outside of R119's room with an isolation cart located outside of the room. The sign shows to wear gloves and gown. V10 (Rehab Aide) entered R119's room without a gown and transferred R119 from her bed to her wheelchair, removed her incontinent brief and toileted her. On 12/16/25 at 12;46 PM, V6 (Licensed Practical Nurse-LPN) said R119 has a g-tube and is on EBP precautions. Staff should wear a gown and gloves when providing care to protect the resident from getting an infection. The facilities Enhanced Barrier Precautions Policy dated September 2025 states, The facility will use EBP precautions to reduce transmission of multi-drug resistant organisms in the nursing homes. EBP involves the use of gown and gloves to reduce the transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wound and/or indwelling medical devices EBP will be used for any resident in the facility: with open wounds has indwelling medical devices (e.g feeding tube) .examples of high-contact resident care activities requiring gown and glove use among residents that trigger for EBP use include: dressing .transferring, providing hygiene, changing linens, changing briefs or assisting with toileting

Based on observation, interview, and record review the facility failed to provide bed mobility in a safe manner for 1of 7 residents (R1) reviewed for safety/falls in the sample of 7. This failure resulted in R1 falling from R1's bed and sustaining left and right femur fractures requiring hospitalization.Findings include:R1's Care Plan initiated 04/10/2024 shows, R1 is diagnosed with morbid obesity and generalized osteoarthritis. R1 has an activity of daily living self-care performance deficit related to general weakness, immobility, and decreased activity endurance.R1 Minimum Data Set, dated [DATE] shows, R1 is dependent on staff to roll left and right. R1's Progress Notes dated 8/12/2025 at 10:36PM, shows, Radiology Note, Results: FRACTURE OF THE PROXIMAL LEFT FEMUR.R1's Progress Notes dated 8/12/2025 at 11:50PM, resident transported to emergency room per non-emergency ambulance via stretcher.R1's Final Incident report of 08/12/2025 at 11:00AM, shows, R1 needs the assistance of staff for bed mobility . R1 requested assistance from staff to start her day. As V4 CNA assisted R1 to roll to her side R1's leg fell off the bed. V4 CNA attempted to lift R1's legs back on to the bed, due to R1's large size and V4's small size, R1 and V4 CNA fell approximately 4 feet from the bed to the floor. R1's legs crossed during the fall. Due to R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, R1 sustained a left and a right femur fracture.R1's Progress Notes dated 8/13/2025 at 6:30AM, shows, called emergency room for an update on resident status . Resident is admitted with a diagnosis of Closed fracture of proximal end of left femur; closed fracture of distal end of right femur; left urethral stone.On 08/20/2025 at 10:27AM, R7 said, my roommate (R1) is in the hospital. R1 fell when the CNA-Certified Nursing Assist was providing incontinent care. It was a hard fall. R1 weighs over 300 pounds and the CNA is small. The CNA was not able to catch her. On 08/20/2025 at 12:15PM, V3 LPN-Licensed Practical Nurse said, R1's X-ray showed she broke her left and right femur bones. The CNA that was taking care of R1 rolled her leg too close to the side of the bed. The CNA tried to lift R1's leg back into the bed, but R1 had to be lowered to the ground. V3 stated when V3 went in the room R1 was sitting by the bed on the floor. R1 said, there was a POP to the right knee and later complained of left thigh pain.On 08/20/25 at 12:30PM, V4 CNA said, I was preparing R1 to get out of bed into the wheelchair. I rolled R1 from one side to the other during morning care. R1's leg fell off the side of the bed, I was not able to do anything, I tried to put her back into bed. I grabbed her waist and lowered her to floor. R1's legs crossed as we went to the floor. R1 ended up sitting on the floor with her legs crossed in a sitting position. I uncrossed them and called the nurse. We placed a sling under her and used a mechanical lift to put her back into the bed. On 08/20/2025 at 1:43PM, V2 DON-Director of Nursing said, R1's legs swung over the side of the bed. The CNA is very small. With R1's weight, combined with R1's legs being crossed as R1 went to the ground, the left and right hip fractures happened.On 08/21/2025 at 2:05PM, V5 NP-Nurse Practitioner said, R1 started slipping off the bed. R1 is morbidly obese; the CNA is small. I was notified of an audible POP to the right knee during the fall. Later R1 started complaining of left hip pain. I ordered X-rays.

Based on interview, and record review, the facility failed to notify the physician on a resident experiencing a change in condition for 1 of 7 residents (R1) reviewed for dependent care in the sample of 7. Findings include:R1's Final Incident report of 08/12/2025 at 11:00AM, shows, R1 needs the assistance of staff for bed mobility . R1 requested assistance from staff to start her day. As V4 CNA assisted R1 to roll to her side R1's leg fell off the bed. V4 CNA attempted to lift R1's legs back on to the bed, due to R1's large size and V4's small size, R1 and V4 CNA fell approximately 4 feet from the bed to the floor. R1's legs crossed during the fall. Due to R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, R1 sustained a left and a right femur fracture.R1's Vital Sign record dated 08/12/2025 at 5:00PM, shows, Pain at 12:35PM, 2/10, Pain at 5:00PM, 8/10.R1's Progress Note dated 8/12/2025 at 5:46PM, shows, patient resting in bed during X-ray wait time. Continues to report left leg pain rated 8/10 on pain scale.R1's Progress Note dated 8/12/2025 at 10:21PM, shows, X-ray results received at 10:05PM, indicating left femur fracture. Medical Doctor.Nurse Practitioner.resident informed of results; continues to report left leg pain rated 8/10. Order received from Medical Doctor to transfer patient to hospital for further evaluation and management.On 08/20/2025 at 12:15PM, V3 LPN-Licensed Practical Nurse said, when I initially assessed R1 after the fall, R1 denied pain. I went back and re-assessed R1 and she complained of a low-level pain to the thigh. I provided acetaminophen and updated V5 Nurse Practitioner of the left thigh pain; an X-ray for the hip was ordered. X-ray did not arrive during my shift. I gave report to the evening shift.On 08/25/25 at 1:30PM, V5 Nurse Practitioner said, she was not notified of R1's increase in pain. The staff should have notified (V5) of R1's 8/10 pain.

Based on observation, interview and record review the facility failed to ensure nursing assistants were certified after completing the training program. This applies to all 114 residents residing in the facility. Findings include: The facility Data Sheet dated 01/14/25 shows 114 residents residing in the facility. On 01/14/25 at 10:43 AM, V7 (Certified Nursing Assistant-in training) was observed working on the 2nd floor. She was leaving a resident's room. Her name tag stated CNA. V7 said she's been working at the facility for about 1.5 years and floats throughout the facility. She said she went to school for her CNA training and she's is a CNA. She said she completed the training a 2nd time about three months ago. V7 said she has her own resident assignment. On 01/14/25 at 11:52 AM, V2 (Director of Nursing) said we do not employ staff that are not licensed, there is window once a CNA has completed the training and have 120 days to take their test and pass. If they don't, they are removed from the schedule. V2 said there is one male staff who has completed the training and is schedule to take his test. She is not aware of any other staff who have not tested and who are not certified. On 01/14/24 at 11:58 AM, V6 (Human Resources) said staff who are in the CNA program have 120 days to pass their test after their class is completed. They can do all the duties as a CNA under the supervision of the nurse and have their own patient assignment. V7 did not pass her test and is taking the test again, V8 (CNA) just passed her test and is certified. On 01/14/25 at 2:00 PM, V1 (Administrator) and V2 (DON) confirmed V8's start date of 8/14/23 and V9's start date of 8/15/23. V2 said she was not aware of V8 not passing her test and confirmed she was aware of V9 not passing her test and was placed as activity aide until she passed her test. V8's Basic Nursing Assistant Training Program certificate dated October 7, 2024, to November 9, 2024. V8's undated Health Care Worker Registry showed Certification Program Information: Date training successfully completed 8/12/23 and 11/9/24. Date of Competency Evaluation: 12/11/23 (F-Fail), 01/06/25- F2. The registry shows V8 as unlicensed Health Care-Certified Nurse Aide. V9's Basic Nursing Assistant Training Program certificate dated October 7, 2024, to November 9, 2024. V9's undated Health Care Worker Registry showed Certification Program Information: Date training successfully completed. 05/6/23 and 11/9/24. Date of Competency Evaluation: 7/05/23 (F1), 12/10/23 (NS) and 12/16/24 (P). There was no evidence provided of V9's schedule regarding the timeframe when she was pulled from direct care. The facility's schedule from 01/01/25 to 01/14/25 showed V8 worked as a CNA 11 out of 14 days. The facility did not provide a policy on Health Care Worker Registry Check.

Based on observation, interview, and record review, the facility failed to store and prepare food in a sanitary manner. This has the potential to affect all 122 residents residing in the facility. The findings include: The CMS 671 form, dated 9/23/24, list the resident census as 122. On 9/23/2024 at 10:10AM, small white circular containers were seen unlabeled in the freezer. Frozen pizza was observed in the corner of the freezer in an open box, uncovered, and open to air. On 9/24/2024 at 10:55AM, V6, Cook, was observed using a spatula to scoop taco meat into the blender to puree. V6 set the spatula down in a strainer pan over the sink that was visibly soiled with yellow, white, and brown food debris. V6 then removed the spatula in the strainer and used it to scoop rice out of a pan into the blender. On 9/23/2024 at 11:40AM, V7, Dietary Director, said, Foods should be prepared and labeled with the date. This way staff know when it was made and when to toss it out. Foods should be covered in the freezer. On 9/24/2024 at 12:29PM, V7 said a spatula that has touched a dirty surface shouldn't be placed back into food for residents. V7 said residents are placed at risk for food borne illnesses from being contaminated with bacteria. The facility's Kitchen policy, revised 7/23/2023, states, refrigerated food should be covered, dated, labeled and shelved to allow air circulation. The facility's Food Handling policy, revised 7/26/2024, states, This facility recognizes that the critical factors implicated in foodborne illness are contaminated equipment.

Based on observation, interview, and record review, the facility failed to obtain weights as ordered for residents with congestive heart failure (CHF) for 4 of 24 residents (R38, R66, R244, and R11) reviewed for quality of care in the sample of 24. The findings include: 1. R38's Face Sheet showed R38 had the diagnosis of CHF. R38's Order Summary Report showed an order for weekly weights to be done on Friday mornings, starting on 8/9/24 R38's Weights and Vitals Summary showed there were no weekly weights for the week of 8/9/24, 8/23/24, 8/30/24, and 9/20/24. R38's Medication Administration Record and Treatment Administration Record did not have any recorded weights. On 09/24/24 at 12:07 PM, R38 said she gets weighed once every few weeks. 2. R66's Face Sheet showed R66 had the diagnosis of CHF. R66's Orders showed an order for daily weights. R66's Weight and Vitals Summary and Treatment Administration Record for 9/1/24-9/23/24 showed missing daily weights for 9/4/24, 9/6/24, 9/7/24, 9/9/24, 9/10/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/21/24and 9/23/24. On 09/24/24 at 12:09 PM, V13 (Licensed Practical Nurse) said, For residents with CHF, weights are typically done weekly or daily depending on the orders, and weights are done to monitor for fluid gain. V13 added, Weights should be done as ordered. 34506 3. R224's Admission Record shows she was admitted to the facility on [DATE], with diagnoses including acute on chronic diastolic congestive heart failure, malnutrition, acute pulmonary edema, acute respiratory failure with hypoxia, and dyspnea. R244's After Visit Summary from the local hospital, dated 9/9/24 shows, Daily weight. R224 was admitted to the local hospital prior to admission to the facility with a diagnosis of acute on chronic congestive heart failure. R244's Order Summary Report, dated September 9/24/24 shows an order entered on 9/15/24 for weight upon admission/readmission, weekly x 4 then monthly. R244's Weights and Vitals Summary shows R244 was weighed on 9/15/24 and 9/23/24. There were no daily weights noted in R244's electronic medical record. R244's Care Plan, initiated 9/18/24, shows R244 is at risk for altered cardiovascular functioning related to congestive heart failure.Obtain labs and weights as ordered. 4. R11's Admission Record shows she was admitted to the facility on [DATE], with diagnoses including chronic diastolic congestive heart failure, acute kidney failure, and presence of prosthetic heart valve. R11's Order Summary Report, dated 9/24/24 shows an order was entered on 9/3/24 to monitor weight daily before breakfast. Notify MD of a two pound weight gain in one day or five pound weight gain in one week. R11's Weights and Vitals Summary shows R11 has only been weighed on 9/3/24. On 9/25/24 at 9:47 AM, V9, RN (Registered Nurse), said residents that have congestive heart failure should be weighed everyday so the staff know if the residents are retaining fluid. A weight gain could signify a congestive heart failure exacerbation. V9 said the doctor is notified if a resident has a weight gain.

Based on observation, interview, and record review, the facility failed to wear PPE (Personal Protective Equipment) for residents with Enhanced Barrier Precautions (EBP), failed to place a resident on Enhanced Barrier Precautions, and failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for four of 24 residents (R233, R232, R113, R66) reviewed for infection control in the sample of 24. The findings include: 1. R233's Admission Record shows he was admitted to the facility on [DATE], with diagnoses including Gout, malignant melanoma of skin, heart failure, pneumonia, end stage renal disease, bacteremia, and gastrostomy status. On 9/24/24 at 9:37 AM, R233 had a sign on his door that showed Enhanced Barrier Precautions. V5, RN (Registered Nurse), went into R233's room to administer medications via R233's PEG (Percutaneous Endoscopy Gastrostomy) tube. V5 did not wear a gown. On 9/25/24 at 9:47 AM, V9, RN, said gown and gloves should be worn in a residents room with Enhanced Barrier Precautions when administering medications via PEG tube. V9 said the gown and gloves are worn to protect the resident from infections. 2. R232's Order Summary Report, dated 9/24/24, shows he was admitted to the facility on [DATE], with diagnoses including cellulitis of right lower limb, acute kidney failure, emphysema, local infection of the skin, and specified soft tissue disorder. R232's Care Plan, initiated 9/17/24,shows R232 is on Enhanced Barrier Precautions due to the presence of bilateral lower extremity wounds. On 9/23/24 at 9:53 AM, V3 and V4, CNAs (Certified Nursing Assistants), provided peri care for R232. There was urine and stool in R232's incontinence brief. V4, CNA, wiped R232's front peri area, then touched R232's body to help him to turn onto his right side. V4 then wiped R232's buttocks, removed R232's dirty sheets, placed clean sheets onto R232's bed, placed R232's clean brief on him, and touched R232's bed controls. V4 did not change her gloves or perform hand hygiene. On 9/25/24 at 9:46 AM, V8, CNA, said, Gloves should be changed after you touched a dirty incontinence brief and before you touch clean items so that the dirty is not transferred onto clean items. The facility's Hand Hygiene Policy, revised 7/30/24, shows, Hand hygiene is important in controlling infections. Hand Hygiene using alcohol based hand rub is recommended during the following situations: Before moving from work on soiled body site to a clean body site on the same resident. 33760 3. R113's careplan, dated 6/1/24, shows, (R113) is on EBP due to presence of indwelling catheter with interventions that include: ensure that gown and gloves are used during high-contact resident care activities like .changing briefs, or assisting in toileting, .device care-urinary catheter. R113's door had a sign posted that show, STOP, Enhance Barrier Precaution (EBP) . Everyone must: .Wear gloves and gown for the following High Contact Resident Care Activities: Changing brief, device care use .urinary catheter. On 9/23/24 at 10:05 AM, V14 (CNA) entered R113's room with just gloves on, and emptied R113's catheter bag. Then V14 proceeded to provide incontinence care and catheter care to R113, again just wearing gloves. When it was time to transfer R113 to his wheelchair, V15 (CNA Supervisor), wearing gloves and gown, handed a gown to V14. V14 stated, What is this for? I thought (R113) was just an a regular isolation. 37232 4. On 09/25/24 at 09:35 AM, R66 was in bed. R66 had an intravenous access in his right upper arm. R66 also had dressings to his feet. There was no Enhanced Barrier Precautions sign outside of R66's room. On 09/23/24 at 12:59 PM, V19 (Certified Nursing Assistant) repositioned R66 in bed by placing her hands on R66's shoulders and moved him to the center of the bed. V19 did not have on any personal protective equipment (no gloves or gown) while repositioning R66. There was still no Enhanced Barrier Precaution signs outside of R66's room. On 09/24/24 at 11:00 AM, V11 (Infection Control Nurse) said, Any resident with an implanted medical device or wounds should be on enhanced barrier precautions. Staff were to wear gloves and gowns when providing high contact care. Repositioning a resident is considered high contact care. Staff know what residents are on Enhanced Barrier Precautions by a sign outside of the resident's room. R66's orders showed R66 had an implanted medical device of an intravenous access. On 09/24/24 at 11:04 AM, V12 (Wound Care Nurse) said R66 had wounds to his legs. The facility's Enhanced Barrier Precaution policy showed enhanced barrier precautions involves the use of gowns and gloves to reduce the transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with multidrug-resistant organism as well as residents with wounds and/or indwelling medical devices. Enhanced barrier precautions require the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of extensively drug resistant organisms to staff hands and clothing. The same policy showed providing device care/use is considered a high-contact care activities.

Based observation, interview, and record review, the facility failed to ensure pressure relieving interventions were in place for 2 of 5 residents (R106 and R30) reviewed for pressure injury in the sample 24. The findings include: 1. On 09/23/24 at 09:35 AM, R106 was in bed. Hanging on the foot board of the bed was an air mattress pump. The orange standby light was lit up on the air mattress pump. The light next to On was not lit up. R106's Care Plan showed she was at risk for developing a pressure injury. Listed under interventions was to check air mattress for proper functioning. 2. On 09/23/24 at 10:25 AM, R30 was in bed. Hanging on the foot of the bed was an air mattress pump. The lights on the pump were not lit up. The air mattress pump's power cord was not plugged into an outlet. R30's care plan showed R30 had cerebral palsy, paraplegia, limited mobility, and was at risk for skin alterations. Listed under interventions was to check air mattress for proper functioning. On 09/24/24 at 11:04 AM, V12 (Wound Care Nurse) said R106 and R30 are at risk for pressure injuries. V12 said air mattresses are a pressure relieving intervention, and R106 and R30 should have working air mattresses.

Based on observation, interview, and record review, the facility failed to provide catheter care to prevent urinary tract infection to 1 of 6 residents (R113) reviewed for catheter care in the sample of 24. The findings include: On 9/23/24 at 10:05 AM, V14 (Certified Nursing Assistant-CNA) provided catheter care to R113. V14 (CNA) removed R113's incontinent pad, then took disposable wipes and wiped R113's perineal area, then applied a new incontinent brief. V14 did not provide any cleansing to R113's catheter tubing, and did not provide any cleansing to R113's frontal area/genitals area. On 9/24/24 at 9:40 AM, V2 (Director of Nursing) said staff should provide thorough incontinence care, including the catheter tubing when providing pericare to prevent infection. R113 has history of UTIs (urinary tract infections). The facility policy entitled Urinary Catheter. 16. For male residents Use wash cloth with warm waster and soap to cleanse around the meatus .17. Use clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review, the facility failed to provide individualized activities for a resident with dementia for 1 of 3 residents (R76) reviewed for dementia care in the sample of 24. The findings include: R76's facility assessment, dated 7/19/24, show R76 is severely cognitively impaired. R76's electronic medical record shows R76 has diagnosis of dementia. R76's care plan, dated 2/18/24, shows, (R76) demonstrate movement behavior of wandering, pacing or roaming. Intervention include: remain safely engaged in activity focused care, a meaningful intervention or social interaction. Engage (R76) with walking movement/keeping busy/exercise program. On 9/23/24 during the initial tour on 2nd floor, R76 was noted to be walking and pacing aimlessly from her room towards the nurses station, then by the elevator, then back to the nurses station then hallways. R76 was being repeatedly told to go back to her room. There was no activity being provided to R76. On 9/23/24 at 10 AM, R76 was coming out form her room. V15 (Certified Nursing Assistant-CNA Supervisor) went to R76 and said, You need to go back to your room. At 11 AM, R76 was coming out of her room. V11 (Infection Control Nurse) hurriedly went to R76, provided her a walker and redirected R76 to her room. R76 continued to walk around the nurses station, then near the elevator, then to her room. R76 would sit down in her bed for a short time then wander again. At 12:15PM, R76 was coming out of her room. V14 (CNA) said to R76, Stay in your room. The facility presented this surveyor the Activity Calendar for September 2024 that shows (All ) Activities on 3rd floor. There were no staff noted to bring R76 to 3rd floor on 9/23/24 (Monday) On 9/24/24 at 9:20 AM, R76 was walking towards an office on 2nd floor. V15 again told R76 to go back to her room. R76 continued to wander from her room to the nurses station. At 10 AM, R76 was in her room sitting in her bed watching TV. R76 said, Hi, hello, and thank you, then got up and took her walker and walked towards the nurses station. At 12:50 PM, V16 (Licence Practical Nurse/LPN) said, This is (R76's) routine, being redirected all day. (R76) paces and wanders back and forth. Due to dementia, (R76) rarely speaks in English, and now speaks in Russian. Both V16, LPN, and V15 (CNA Supervisor) confirmed all the facility activities were done on 3rd floor. There was no activity being provided to R76 at this time. At 1:40 PM, V16 (LPN), V17 and V10 (both CNAs) were all trying to redirect R76 from the elavator to go to her room. On 9/24/24 at 2PM, V20 (R76's husband) said he tries to come everyday, weather permitting, to visit R76. V20 said R76 used to work in the beauty department that provided facial and skin treatments. (R76) loves to talk about those things. R76's Activity Assessment, dated 7/26/2,4 under behaviors of wandering, leaves area -NO The same Activity Assessment under past and present interests listed family contact and watching TV (did not include R76's interests with beauty treatments per husband.) On 9/24/24 at 9:45 AM, V1 (Administrator) V2 (Director of Nursing) and V18 (Activity Director) said they are in the process of working together to provide activities to R76, who has dementia. The Facility Policy entitled Dementia Care undated shows, 3.Therapeutic diversional activities are provided consistent to the residents level of functioning, individualized activity preferences consistent to interests and costumary routines. Activities are provided either in a small groups or 1:1 setting in accordance to the level of functioning and level of activity performance.

Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered for a resident with pressure injuries for 1 of 3 residents (R2) reviewed for pressure in the sample of 3. The findings include: R2's Physician Orders (POS), dated 12/1/23, shows sacrum wound: cleanse with normal saline, pat dry, apply silver gel, cover with bordered foam dressing every day shift and as needed. The same POS shows an order dated 12/14/23 for sacrum wound: cleanse with normal saline, pat dry, apply santyl ointment to wound bed, cover wound bed with calcium alginate, cover with bordered foam dressing every day shift and as needed. R2's Wound Nurse Practitioner Noted, dated 12/11/23, shows sacrum pressure treatment recommendations: 1. cleanse with normal saline 2. apply santyl and calcium alginate to base of the wound. 3. secure with bordered foam. 4. change daily and as needed. R2' Progress Note, dated 12/14/23, at 8:15 AM, shows patient urinary catheter was removed in the morning at 5:30 AM because it was leaking and tried to reinsert it, but it failed, no urine retained. On 12/14/23 at 9:34 AM, R2 was in bed finishing breakfast. R2 said she had a wound on her bottom that she got in the hospital. R2 said she was not sure if there was a dressing on her wound or not, because she had a big mess overnight. R2 said her catheter was leaking everywhere and they had to clean her up. R2 said everything was saturated including her gown and the bedding under her, so they cleaned her up and got new bedding. R2 said the Certified Nursing Assistant (CNA) cleaned her up and the nurse took out the catheter and was having trouble putting in a new catheter, so they just put a brief on her. R2 said the nurse told her the wound nurse would change the dressing later that morning. R2 said this was around 5:00 AM that all this happened. At 9:45 AM, V5, CNA, assisted R2 to roll to her side and lowered R2's incontinence brief. R2's dressing was so saturated it was unattached and fell off into the incontinence brief, which contained urine and stool. R2's dressing was completely saturated with bloody brownish material. R2's wound had stool in it. V5 cleaned R2, and V3, Registered Nurse, changed R2's dressing. V3 said the nurse should have changed the dressing this morning when they cleaned R2 up from her catheter leaking. V3 cleaned the wound with normal saline and applied silver gel, and then a bordered foam dressing. On 12/14/23 at 11:37 AM, V5, Wound Care Director, said R2 has an unstageable sacral wound. V5 said if a dressing is saturated or falling off, the dressing needs to be changed as soon as possible. V5 said there is a risk for infection in the wound if a dressing is saturated with urine and or stool and not changed right away. V5 said the nurse should have changed the dressing herself, and not waited for the wound care nurse to do it later. V5 said R2's treatment order changed when the wound doctor saw her on 12/11/23 to santyl and calcium alginate to wound and cover with dressing. V5 said R2's previous treatment was the silver gel, and she had forgot to put the new treatment order in the computer. The facility's Pressure Ulcer Policy, dated 3/23 shows, to provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present.

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food safety. This has the potential to affect all 100 residents residing in the facility. The findings include: The Facility Data Sheet dated 11/6/23 shows an in-house census of 100. On 11/6/23 at 12:02PM, V11, Cook, was observed moving his glasses around on the countertop, cleaning up scraps of paper on the counter, and putting them in the trash while plating residents' food for lunch. V11 did not change his gloves or wash his hands between touching his glasses and scraps of paper, before returning to plating food. On 11/6/23 at 12:02PM, V12, Dietary Aide, was observed putting silverware on trays for residents. V12 dropped a fork on the ground. V12 picked up the fork and placed it back on top of the silverware cart near the clean silverware and creamer packets. V12 did not wash his hands after picking up the fork off of the ground before returning to placing silverware on residents trays. On 11/6/23 at 12:57PM, V10, Food Service Director, said items that touch the floor should be discarded or sanitized, and are considered contaminated. V10 said contaminated items should not be placed near clean items. V10 said after touching contaminated items, gloves must be changed, and hands must be washed before returning to food prep. The facility's Kitchen policy, revised on 7/23/23, states, The facility will comply with state and federal regulations in operating facility's kitchen.

Based on observation, interview, and record review, the facility failed to ensure resident rooms and environment were clean and home like for 6 of 23 residents (R69, R54, R84, R16, R59 and R17) reviewed for homelike environment in the sample of 23. The findings include: On 11/6/23 at 9:32 AM, R84's room was noted to have a strong foul smelling odor. On the floor and in his bed were multiple Styrofoam cups, straws, and wrappers. His bedside table base had a thick substance caked onto it with hair stuck to it. The floor was very dirty with pieces of dried food and wrappers on it. On 11/7/23 at 8:59 AM, R84's room was in the same condition a foul odor, dirty floor and sticky bedside table and his bottom sheet was also noted to be stained with what appeared to be spilled liquid. On 11/6/23 at 10:00AM and 11/7/23 at 9:05AM, the floor of R16's and R59's room was covered with trash, used tissues, used food containers, food wrappers, a clean brief, plastic wrappers and an empty box of gloves. On 11/7/23 at 9:05AM, R16 stated she thought housekeeping had been in already. On 11/6/23 the floor around the bed in R17's room was covered with used, dirty tissues. Again on 11/7/23, the R17's floor was covered with used, dirty tissues. On 11/6/23 at 10:14 AM, R54's room had lots of spots on the floor where dried food was caked on it, and areas on the floor that were very sticky with what appeared to be spilled liquids. On 11/6/23 at 10:28 AM, the garbage can inside R69's room was completely full with garbage spilling out onto the floor. In reference to the garbage can R69 said, I don't know what they do around here. On 11/7/23, the carpet in the third floor hallway was covered with small pieces of white debris and on the tile floor around the nurse's station and in front of the elevator there were several spots of orange, sticky- looking fluid. On 11/7/23 at 8:45 AM, V4 (Registered Nurse/RN) stated, Housekeeping is here every day but when they leave at 3:00-4:00 PM it is hard for them to catch up in the morning. Nursing tries to help but we can only do so much. On 11/7/23 at 8:35 AM, V5 (Housekeeping) said the facility is short of housekeeping staff, and as a result, they cannot keep up with all the duties. She said the housekeepers are supposed to mop and empty garbage in resident rooms daily, but that is not always done. V5 said she tries to at minimum spot mop resident rooms. The facility provided General Housekeeping policy, revised on 9/29/23, said the facility will ensure the resident rooms will be kept clean, orderly, sanitized and mopped.

Based on observation, interview, and record review, the facility failed to provide R79 with a PASRR (Preadmission Screening and Resident Review) thirty days after admission for one of seven residents (R79) reviewed for Preadmission Screening for individuals with a mental disorder in the sample of twenty. The findings include: R79's Admission Record on 11/08/23 at 1:01PM, shows R79 was admitted to the facility on [DATE]. R79's Physician's Orders on 11/08/23 at 1:02PM, shows, Diagnoses: schizoaffective disorder, bipolar type. Sertraline hydrochloride for depression related to schizoaffective disorder. R79's PASRR level One performed 07/07/2023 shows, Exempted Hospital Discharge, physician documented that he requires 30 days or less of nursing facility care. Mental Health Medications: olanzapine 15 milligrams daily, Diagnosis: schizoaffective disorder. Exempt Hospital Discharge 30-day approval- A 30 day or less stay in the nursing facility is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the nursing facility beyond the authorization timeframe. On 11/08/23 at 12:03PM, R79 was lying in bed watching television. On 11/08/23 at 11:00AM, V13, Admission Director, said, (R79) was admitted for shortness of breath, there was no mention from the hospital that he needed psychiatric care. (R79) did not trigger for psychiatric care. On 11/08/23 at 12:03PM, R79 said, I was diagnosed with schizoaffective disorder a couple of years ago. I was seeing things that were not there. I have not seen a psychiatrist while I have been in the facility. I see the Nurse Practitioner for my leg pain. On 11/08/23, R79's Medical Record did not show R79 received specialized psychiatric care between 07/07/23 to 11/08/23. There was no level one PASRR re-screen with-in 30 days after admission, or a referral for a level two PASRR screen between 30-40 days after admission. The facility did not provide documentation for a PASRR Level One re-screen or a PASRR Level Two for R79 upon request. The facility's PASRR policy, revised 07/24/23, shows, .residents with mental disorder .will receive PASRR Screening within the timeframe allowed.

Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for a resident which applies to 1 of 8 residents (R78) reviewed for pressure wounds in a sample of 23. The findings include: R78's Facility Assessment, dated 10/18/23, showed R78 is a [AGE] year old female, whom is dependent on staff for mobility care concerns, and at risk for developing pressure injuries. R78's Braden Assessment, dated 10/24/23, showed R78 to be at high risk for developing pressure injuries. On 11/6/23 at 9:55 AM, R78 was in bed watching television. R78's heels were resting on the mattress with her feet pressed against the footboard. R78 had no offloading devices in place (pillows or boots), and the pump to R78's air mattress was in standby mode. On 11/7/23 at 9:30 AM, V8, Certified Nursing Assistant, stated, When you push the standby button turns the pump on/off without turning the power off. When the yellow light is on the air pump is not on. The pump should be on when the residents are in bed. On 11/8/23 at 11:00 AM, V7, Wound Nurse, stated, (R78) had skin issues when she was admitted . (R78) has a non-open area on her leg and dry skin on her heels we need to keep an eye on. R78's Careplan, dated 10/25/23, showed an intervention for skin integrity included: off-loading bilateral heels when in bed as tolerated every shift and PRN (as needed).

Based on interview and record review, the facility failed to identify a resident's significant change in condition; failed to assess a resident with a significant change in condition; and failed to notify a resident's provider of a change in condition; resulting in delay of potential lifesaving care to 1 of 3 (R2) residents reviewed for death in the sample of 12. The Immediate Jeopardy began on [DATE] at 3:00 PM when R2 was unresponsive. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 10:50 AM. They surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's Admission Record (Face Sheet) showed an admitted [DATE]. R2's Face Sheet showed diagnoses to include but not limited to: achalasia (Achalasia is a rare disease in which food passage from the mouth to the stomach is disturbed.), gastric reflux disease, protein-calorie malnutrition, and diabetes. On [DATE] at 10:45 AM, V13, R2's Daughter and facility employee, stated R2 was admitted to the facility following a hospital stay. V13 stated R2 was vomiting and not eating at home, which lead to her subsequent hospital admission and having a feeding tube placed. V13 stated her mother was a Full Code (If R2's breathing or heart stopped, lifesaving interventions should be initiated.) R2's History and Physical (H&P), dated [DATE], (dictated [DATE] at 9:29 AM by V16, Medical Director/R2's physician) showed R2 .for 5 weeks prior to her admission was experiencing bouts of vomiting, which was worsening. She was experiencing frequent bouts of emesis (vomiting) despite taking [nausea medication]. The H&P showed She is feeling poorly and that she is nauseated .She is breathing well. The H&P showed, this is a middle-aged elderly female, currently in no acute distress. R2's Skilled Note from [DATE] at 7:25 AM showed, Resident has been nauseous and vomiting through shift. Resident on continuous feeding .resident also refused the TB (Tuberculosis) test, stating 'She got the shot .' R2's Social Service Note from [DATE] at 2:34 PM showed, .patient was alert and oriented . R2's Social Service Note from [DATE] at 2:06 PM showed, .patient cooperated in the evaluation even though she was feeling nauseated . R2's [DATE] Physician Note (time of visit not indicated. Note was dictated [DATE] at 11:40 AM.) The patient is awake and alert, but continues to have emesis. We changed her feeding to now 18 hours a day to see if that will help better tolerate the feedings. The note stated the emesis was foul smelling. R2's Skilled Noted from [DATE] at 3:03 PM, showed, pt (patient) extremely lethargic and not responding to external stimuli. [V16,Medical Director/Doctor of Osteopathy/R2's physician] notified. Ordered to hold morphine [for] 6 hours and changed the morphine order to q6h prn (every 6 hours as needed). Orders carried out. Patient stable at this time. (Note authored by V23, Registered Nurse.) R2's Order Summary Report (Physician Order Sheet, POS) showed an order for Morphine (narcotic pain medication) 10 milligrams per 0.5 milliliters solution and to administer 0.75 milliliters via her feeding tube every 4 hours for pain for 7 days. This order was started on [DATE]. The POS showed the order was changed to as needed on [DATE]. R2's Diagnostic Note from [DATE] at 6:59 PM showed, cxr & kub (chest X-ray and kidney, ureter, bladder X-ray) results relayed to [V16.] R2's Skilled note from [DATE] at 8:24 AM (this note followed R2's [DATE] 6:59 PM note; no other notes between), showed, The writer took a report from the night shift nurse saying that pt (patient) wasn't responding, and pt is gurgling. RN (Registered Nurse) check on the pt O2 71 (oxygen saturation 71 percent), put on non-rebreather (mask used to supply high concentrations of oxygen) went up to 76, BP (Blood-pressure) ,d+[DATE], T (temperature) 97.5, R 30 (Respiratory Rate 30 breaths per minute) Pt is non-responsive, not reactive to chest rub. Spoke to pt's daughter, explained the situation, pt's condition, okay to send her out. It was explained they take the pt to the closest ED (Emergency Department) at [local area hospital.] (Note authored by V22, Registered Nurse/RN) R2's Skilled Note from [DATE] at 8:34 AM showed, Per staff the last time they saw pt responding was last night. (Authored by V22, Registered Nurse/RN) R2's Skilled note from [DATE] at 1:58 PM showed, Call to [local area hospital] to get updates on pt, pt coded (heart and breathing stopped) at the hospital. R2's local area hospital records showed, [R2] is a [AGE] year old female who presents to the ED from [the facility] for being unresponsive when staff went to wake her up from sleep at 8 am. Last known well 11 pm when she went to bed. Per EMS (Emergency Medical Services) she was GCS 3 (Glasgow Coma Scale - A test to indicate consciousness. A score of 3 indicates she did not open her eyes to pain of verbal stimuli; she was non-verbal; and her motor function did not respond to painful stimulus.) They attempted intubation (oral airway) but she vomited and aspirated (went into her lungs.) The hospital records showed, Patient had CT (CAT scan) brain no bleed. After return she became bradycardic (slow heart rate) and pulseless. CPR (Cardio Pulmonary Resuscitation, chest compressions and breathing assistance) .CPR continued for [greater than] 30 minutes. No ROSC (return of spontaneous circulation) .Patient expired at 10:43 AM. R2's vital signs were documented as follows: * [DATE] (Admission) Blood pressure ,d+[DATE]; O2 saturation 96 percent (only documentation of O2 saturation) *[DATE] at 3:50 PM Blood pressure ,d+[DATE] *[DATE] at 6:42 PM Blood pressure ,d+[DATE] *R2's physician note on [DATE] show vital signs that reflect blood pressure, pulse, and respiratory rate that was taken by the facility staff and documented on [DATE] at 6:43 PM *[DATE] at 1:39 PM Blood pressure ,d+[DATE] (a change of more than 45 points from her previous systolic pressure and the lowest documented blood pressure during her admission at that time.) *[DATE] at 8:24 AM (per progress note) Blood-pressure ,d+[DATE]; Temperature 97.5 Fahrenheit; Respiratory rate 30; O2 saturation 71 percent; after non-rebreather mask applied (mask used to supply high concentrations of oxygen) O2 saturation went up to 76 percent On [DATE] at 10:45 AM, V13, R2's daughter and facility employee, stated she saw her mother every day of R2's stay, except [DATE]. V13 stated her mother started to decline on [DATE]. V13 said R2 started to become lethargic and out of it on [DATE]. V13 said on [DATE] sometime shortly after 10:30 AM, she went to see her mother. V13 stated her mother had a bowel movement so she, herself, changed R2. V13 said when she provided the care, She couldn't move, she couldn't talk, she couldn't do anything, and it was like there was nothing there .When I cleaned her up there was no response from her at all, no acknowledgement at all from her that I was doing anything to her. I asked the nurses what was her vitals and no one could tell me that, and I believe they couldn't tell me that because no one was doing them. The nursing staff didn't seem concerned about her declining state. [V23] thought it was maybe the morphine, but other than that they had no idea why (she was declining). I thought my mom needed to be sent out and maybe I should have made them send her out, but they were nurses so I thought they would do that if they thought it was necessary. There was no change in my Mom's condition through the day of the 17th. The last time I saw her was around 7:30 PM. I saw the CNA (Certified Nursing Assistant) once or twice the first day, and the second day to do vitals but that was all. V13 said, I think the nurses should have recognized she was declining and sent her out. I assumed that the nurses were tracking her decline and they would make the appropriate decisions. V13 said, Every single day it was a different nurse, there was no continuity between the nursing staff. On [DATE] at 11:35 AM, V14, R2's Daughter, stated the first time she saw her mother at the facility was on [DATE], between the hours of 3:00 PM to 6:00 PM. V14 said, I went to see her and I was wondering what the foul smell in the room was. Then the nurse came in and I was also asking her what was that funny sound in her room, and the nurse said she is okay. I kept saying what is that noise? It sounded like there was mucous in her throat and the nurse was in her room and the nurse kept acting like everything was normal. My mom was slumped over in bed and we had to pick her up. I opened my mom's eyelid and there was nothing there, she didn't wake up at all; she didn't respond. She was okay when she went in there ([DATE]), and then on Friday ([DATE]) she couldn't respond, then the next day ([DATE]) she was gone. I was like what happened through the night and why did they not check on her? They kept saying she was sleeping. The noise was when she was breathing. It sounded like there was something in her throat. The nurse said the noise when she was breathing was normal because she has a feeding tube. I said it didn't sound normal. It sounded like there was something in her throat. She didn't wake up at all that day when I saw her. When I brought up the sound to the nurse, she did not do any vital signs. The nurse would talk to her and give her insulin. She (the nurse) was talking to her like everything was normal, but she (R2) was not waking up at all or responding to her when she talked to my mom. The last time I saw her was on [DATE] on her birthday . V14 continued, The nurse said the noise was normal and it was the feeding tube, but I was like how is that the feeding tube, it's when she is breathing, it didn't sound right it sounded like she had so much mucous in her throat. V14 said, Mom did not respond the entire time I was there. I kept trying to talk to her and I touched her and there was no response. My sister and I lifted her up to reposition her and she was just dead weight; there was no response. I was wondering if she needed to be sent out, but I was going off of what the nurse said, which was she was okay and that my mom was sleeping, but that did not make sense. The next morning, they said they were rushing my mom to the hospital and they were doing CPR (Cardio Pulmonary Resussitation) at the hospital, and they said she was gone. All I kept thinking about was the night before and what happened in that short amount of time. I kept thinking something didn't feel right; that she was not waking up and that she was just sleeping didn't make sense. I knew something wasn't right and why didn't they check on her all night until the next morning. They just kept saying she was sleeping, but she wasn't. On [DATE] at 12:10 PM, V19, R2's Sister and Power of Attorney (POA), stated, I didn't get to go and see her I was going to go and see her (R2) on Saturday. That is usually when I do my traveling. I talked to her on the phone on Wednesday ([DATE]); it would have been around 1:00 PM. She was concerned about some bills that needed to be paid, and I told her I was going to take care of her personal business. She sounded her normal self; she was cracking jokes and she was doing well at that time. She said she was feeling fine at that time. She didn't say anything about nausea at that time. I tried to call her Thursday ([DATE]) and she didn't answer, so I called [V13] and asked her why [R2] wasn't answering the phone. [V13] said she wasn't doing well. [V13] said it was like she was going backwards and not doing well. Then the following day she [V13] called me and said her levels had dropped and they were trying to get her levels back up. (Levels) I think she was talking about her blood pressure and stuff like that; like her vital signs. I talked to [V13] on Thursday and Friday. She said on Friday her color did not look good; she looked sick. She said she wasn't alert; she was sleeping. She said she was going to ask the nursing staff to lower that drug she was on for the pain, the morphine, and that they were giving her too much and only give it to her when she asked for that. The facility's staffing schedule for R2's floor on [DATE] showed V23, RN, was scheduled to work from 7:00 AM to 7:00 PM, then V18, Agency RN, was scheduled for from 7:00 PM to 7:00 AM the following morning. The schedule for R2's floor on [DATE] showed V22 was scheduled to be R2's day nurse. On [DATE] at 9:54 AM, V23 stated she believed [DATE] was the only time she had provided care for R2. V23 stated she had received report that R2 was lethargic. V23 stated when she began her shift on [DATE], R2 was drowsy, not opening her eyes, and she was not responding to questions. V23 stated she documents all physician communication regarding resident status changes. V23 stated if there was an order to hold morphine for lethargy she would notify the doctor if the lethargy did not improve. V23 stated she would expect a person's lethargy to improve in a couple of hours if morphine was the cause. (R2's record showed no assessment or vital signs following V23's progress note on [DATE] at 3:03 PM until the following morning.) On [DATE] at 2:23 PM, V18, Agency Registered Nurse, stated she does recall R2, and, to the best of her knowledge, [DATE] was her only shift providing care for R2. V18 stated, She was not responsive to anything around her. As far as I knew, she was not responsive. I was told by the previous nurse that when she came to the facility she had her eyes open .I was not told that she was ever alert and oriented .The nurse prior did not tell me she had called the doctor regarding this patient. I don't recall any indication that I should be doing any sort of assessment on this resident. As agency, I did have access to PCC (Point Click Care/ electronic documentation system) and that is where I would do all of my documentation for her. The day nurse was just saying she had her eyes open and if I recall that was just a few days prior. If I had been aware that she was alert and oriented and the doctor was called regarding her condition that day, I would have been more concerned regarding her condition that night. I, personally, if had known that information, I would have been monitoring her . V18 said during the night I would check on her and talk to her but she did not respond. I tried talking with her, and she would not look at me, turn her head, open her eyes or respond in anyway what-so-ever. I didn't notice anything in particular about her breathing .If I or the CNA's did any vitals or assessments it would be in [R2's electronic health record] in the vitals tab, or the progress notes, or the MAR/TAR. (medication/treatment administration record. R2's electronic health record showed no documented vital signs or progress notes during V18's shift.) V18 stated, I was not told any of that information; that she was suspected lethargic due to morphine and that she was alert and oriented a couple of days prior. If I had been told that information, I would have definitely called the doctor; if I didn't get ahold of the doctor I would have called 911 and had her sent out. I don't need a doctor's order to call 911 for a full code resident. On [DATE] at 1:50 PM, V22 stated she cared for R2 when she was admitted ([DATE]), and she was the nurse that had her sent out ([DATE].) V22 said R2 was alert and oriented on her admission. V22 said, I came at 7:00 AM and got report from the agency nurse and she said [R2] seemed to be sleeping and unresponsive, so I saw [R2] first. She was unresponsive so I sent her out. V22 said the previous nurse was not concerned because, the order was to stop her morphine and she was still coming down from the morphine. Morphine can affect your breathing; I don't remember if she was on oxygen. V22 stated when a resident is experiencing a change in condition the physician and family are notified and if the physician is not available she would send the resident to the ED. On [DATE] at 2:00 PM, V2, Director of Nursing (DON), stated all assessments and vital signs should be documented. V2 stated when a nurse recognizes a change in condition they should do a head-to-toe assessment, vital signs, and then contact the provider. V2 said if a nurse is monitoring a resident for lethargy related to morphine, the nurse should be doing on-going assessments as appropriate to include vital signs. V2 stated morphine affects the respiratory system, which is monitored through respiratory rate assessment and oxygen saturation measurements. V2 stated this monitoring would be passed to the next nurse and should continue. V2 stated nurse-to-nurse hand-off should include physician calls as well as changes in mental status over the previous days. V2 stated this information is important for the nurse to be able to determine if a change in condition has occurred. V2 said gurgling is not a normal sound for a resident on a feeding tube, and it can signify pneumonia or aspiration. On [DATE] at 1:15 PM, V16, Medical Director/Doctor of Osteopathy/R2's physician, stated he remembers R2 well. V16 stated he recalled seeing R2 2 or 3 times, but he could not recall the time of day he saw her on those visits. V16 stated he does not recall a phone call on [DATE] regarding R2's morphine. V16 said if he was called and told she was not responding, he would have ordered her to be sent out. (R2's Skilled Noted from [DATE] at 3:03 PM was recited to V16) V16 replied, Lethargy and not responding to external stimuli is a contradiction. V16 stated if he gave an order to hold morphine because the nurse believed the patient was narcotized (under the influence of a narcotic) I think frequent assessment would be appropriate during that time, and if the nurse told me several hours later they were not improving, they (nurses) are my eyes and ears; I depend on them to give me an accurate description of the patient, if they told me not responsive; I would ask them to send her out. V16 stated he is not always available, and the nurses should be capable to make the decision to send a resident with a significant change in condition to the ED (Emergency Department). V16 said a resident being unresponsive is a significant change in condition and they should be sent out in a timely manner. V16 said the purpose of sending a resident to the ED is the hospital has more medical services available compared to the facility and the services can be provided more quickly. V16 said, It's possible [R2's] outcome would have been different, if she was sent out sooner; however, it is difficult to say in hind sight. R2's Care Plan for her feeding tube showed report signs of aspiration or intolerance of feeding. R2's Certificate of Death Worksheet showed she passed on [DATE]. The death certificate showed the immediate cause (Final disease or condition resulting in death) was Myocardial Infarction (MI, Heart attack) with R2's achalasia condition leading the MI and the aspiration being the event which initiated the MI. The facility's Notification for Change in Condition policy (revised [DATE]) showed, The facility must immediately inform the resident; consult with the resident's physician .a significant change in the resident's physical, mental, or psychosocial status . The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy: 1. One on one training was provided to nursing staff providing care for R2 on [DATE] and [DATE] by V2, regarding change in condition policies and procedures as well as assessments and documentation. 2. On [DATE] through [DATE], in person in-service was conducted by administration regarding physician notification for change in condition; assessment for change in condition; general change in condition policies and procedures; documentation; nurse-to-nurse handoff; and hospital transfer. 3. All agency and new hire staff who did not receive training described in #2 above will be in serviced prior to the start of their shift. 4. On [DATE], a facility wide assessment for residents experiencing change in condition was conducted by administration; MD or NP notified as appropriate. 5. Quality Assurance audit tool was initiated by V3 to ensure physician is notified for any resident with significant change in condition. Audit to be conducted three times per week for 12 weeks. 6. V16, Medical Director, was notified of the Immediate Jeopardy and approved the abatement plan.

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for Covid-19 resident room, and failed to have the required PPE for airborne/droplet isolation available outside the resident room to prevent possible exposure to Covid-19, for 12 of 12 residents ((R299, R300, R301, R146, R297, R18, R302, R303, R59, R34, R305, and R304) reviewed for transmission based precautions in the sample of 22. This failure has the potential to infect high risk residents with Covid-19 and spread the disease of Covid-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/26/2021 at 12:05 PM when it was determined there was lack of proper PPE in the isolation carts for staff to wear into the rooms of residents considered to be PUI and on airborne/droplet precautions to rule out Covid-19. The Immediate Jeopardy was identified on 7/26/2021 at 12:05 PM. V1 (Administrator) was informed of the Immediate Jeopardy on 7/27/2021 at 11:30 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 7/27/2021. However, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility provided list on 7/26/2021, shows the following 12 residents are on airborne/droplet transmission-based precautions and considered to be PUI, to rule out Covid-19. (R299, R300, R301, R146, R297, R18, R302, R303, R59, R34, R305, and R304). Outside the rooms of the identified residents there were isolation carts and a sign posted on the doors. The sign shows anyone entering the room is required to wear a gown, N95 face mask, gloves, and a face shield when entering their rooms. The list provided by the facility on 7/26/2021 shows that 83.06% of residents and 92.4% of staff have been fully vaccinated against Covid-19. The facility provided immunization report shows the following residents (R299, R300, R301, R146, R297, R18, R302, R303, R59, R34, R304 and R305) have either refused the Covid-19 vaccine or are considered not fully vaccinated against Covid-19 per CDC criteria. On 7/26/2021 at 12:05 PM, the 2nd floor isolation carts outside the resident's rooms were checked by the surveyor. The carts contained, gowns, surgical masks, cleansing wipes for face shields, and some carts had gloves inside them but not in all of the carts. There were no face shields or N95's in the carts. Staff on the floor were observed to be wearing surgical masks and not N95's or face shields. On 7/26/2021 at 12:13 PM, V3 (Registered Nurse/RN) was asked by the surveyor what PPE she has been wearing into the resident's rooms that are on transmission based precautions and considered to be PUI. V3 said she had not been wearing a N95 because they don't have any in the isolation carts. V3 verified she has been wearing a gown, gloves, and surgical mask all day when entering the rooms of the residents considered to be PUI and on isolation. V4 (Nurse Supervisor) was present during the conversation with V3 and said she had also worn only a surgical mask, no N95 to enter the room of a resident considered PUI and on isolation. V7 (Certified Nursing Assistant/CNA) also present at the same time said she has been also wearing only her surgical mask because they have not had any N95 masks in the isolation carts. On 7/26/2021 at 12:25 PM, V12 (CNA) said that she has her own face shield and N95 mask that she brought to the facility and has been wearing. V12 said that for the most part everyone is wearing N95's when we have them. We have brought up that we need more N95's in the carts on the 2nd floor. On 7/26/2021 at 12:25 PM, V2 (Infection Control Nurse) was observed putting masks and face shields in the isolation carts on the 2nd floor. On 7/26/2021 at 12:31 PM, V7 applied a mask (later identified as a KN90), gown, and gloves from the isolation cart outside of R59's room and entered the room. V7 did not apply a face shield before entering the room. R59 is on airborne/droplet precautions as a person under investigation (PUI) for COVID-19. On 7/26/2021 at 12:32 PM, V8 (CNA) was answering R146's call light. R146 is on airborne/droplet precautions as a person under investigation (PUI) for COVID-19. V8 had a surgical mask on with an N95 mask over it. He put on a gown and walked into R146's room. He did not have his N95 mask on correctly (he had a surgical mask under the N95 mask) and was not wearing a face shield or gloves. There is a sign on R146's door that shows what PPE staff should wear when entering her room. At 12:38 PM, V8 went back into R146's room with her lunch tray. He was wearing the same PPE. His surgical mask was still under the N95 and he only put on a gown. He was not wearing gloves or a face shield. When V8 came out of R146's room, he took his isolation gown off in the hallway (and not before leaving the room). On 7/26/2021 at 12:34 PM, V2 said that the facility has plenty of PPE in stock and that there is a procedure in place for staff to obtain the needed PPE for the isolation carts. V2 said if supplies in the cart are low the staff are supposed to let a supervisor or V10 (Environmental Service Director) know and they will be re stocked immediately. V2 also said the reception desk has a key for storage room where the PPE is located and can unlock the door whenever needed. On 7/26/2021 at 12:54 PM, V8 said when staff enter the isolation rooms of residents who are considered to be PUI they should wear a face shield, gown, gloves and a N95 mask. V8 said he was trained by computer how to wear a N95 mask correctly and had no explanation for why he put his N95 over a surgical mask when he entered 146's isolation room. V8 said he told the maintenance director earlier in the day (but did not know her name) that there were no more N95 masks in some of the isolation's carts. Through further conversation it was determined V8 was referring to V10 having been the person he told that the floor need more PPE. On 7/26/2021 at 1:05 PM, V2 took the surveyor into the storage room to look at the PPE supplies. The masks that were identified as having been put in the PPE carts on the 1st and 2nd floor of the facility at approximately 12:25 PM, were identified as 3M brand masks model numbers 9001 and 9002. The 9001 and 9002 model masks are labeled to be KN90/KN95 masks not N95 masks. On 7/26/2021 at 1:11 PM, V10 said that no one let her know that there were no masks or face shields in the carts, or she would have got them right away. V10 also said the facility has a new ancillary staff person and they are also responsible to check the isolation carts for the PPE. V10 said the isolation cart supplies were probably low from the weekend. On 7/26/2021 at 1:15 PM, V2 said that staff have been educated on what to do if the supplies are low in the isolation carts. V2 said someone always has a key to open the supply room and can get the supplies any time. V2 also said after she heard the conversation between the surveyor and staff on the 2nd floor she went into the medication room on the 2nd floor which should also have extra N95 masks and face shields but there were none. V2 said that staff absolutely have to wear a N95 mask, face shield, gown and gloves when entering the room of residents considered PUI. V2 said a KN90 /KN95 mask is not acceptable. V2 also said staff should not wear a surgical mask under a N95 mask because it disrupts the seal of the N95. V2 said all staff were fit tested and educated about wearing N95 masks. On 7/26/2021 at 1:25 PM, the 1st floor PUI resident room isolation carts were checked and contained either KN90 or KN95 masks. V9 (CNA) working on the 1st floor was asked to see which mask she was wearing, and she had on a KN90. V6 (RN) was also wearing the same model 9001 a KN90 mask. V9 said she had been wearing those masks when entering the rooms of the PUI residents because that is what was provided to her. V6 said she was not aware there was a difference in masks but that she had been wearing the one she had because that is what the facility gave her. Both V6 and V9 had been assigned to the 1st floor and taking care of PUI residents. On 7/26/2021 at 2:00 PM, V11 (Physical Therapy Assistant) was observed in the resident dining area of the 1st floor wearing a KN90 mask with a surgical mask under it. The mask was stretched out, loose and not fitting her face correctly. V11 said that her supervisor had told her she should not wear a surgical mask under this mask {a N95 mask} but she thought it would help protect her because the mask was too loose for her face. On 7/26/2021 at 2:24 PM, R146 stated, the staff have not been wearing PPE in her room. They have only been wearing a surgical mask. R146's Minimum Data Set, dated dated dated [DATE] shows, she is cognitively intact. On 7/27/2021 at 9:14 AM, V13 (CNA) was going into R18's room. R18 is on airborne/droplet precautions. V13 had a surgical mask under her N95 face mask. She was not wearing her N95 face mask correctly. On 7/27/2021 at 9:20 AM, V2 said the facility follows the CDC recommended guidance on Covid-19 for all residents who are new admissions and not fully vaccinated. V2 confirmed that R299, R300, R301, R146, R297, R18, R302, R303, R59, R34, R305 and R304 are not vaccinated due to having either refused to be vaccinated, having received only a partial dose of the vaccine, or having received the last dose of the vaccine within the last 14 days since admission. On 7/27/2021 at 10:00 AM, V14 (CNA) was inside R301's room standing next to her bed holding a garbage bag, she was not wearing a face shield or a gown. R301 is on airborne droplet precautions. At 10:03 AM, V14 said she has been working at the facility for a couple months and had taken online courses for PPE usage. V14 said I didn't think I needed to wear a gown because I just walked into the room to grab garbage. V14 also said staff are supposed to wear the full PPE when entering the isolation rooms, and this was on her. 07/27/21 at 12:24 PM, The Illinois Department of Public Health website was reviewed and showed the Lake County Covid-19 positivity rate for the period of 7/11/2021 to 7/17/2021 (which was the most recent posting) to be 1.5% On 7/27/2021 at 12:15 PM, V1 (Administrator) said the most recent guidance she has from the Lake County Health Department and the CMS (Center for Medicare and Medicaid Services) website shows that the Lake County Covid-19 positivity rate on 7/7/2021 was 1.7%. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The Centers for Disease Control Preparing for COVID-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory mask, eye protection, gloves, and gown when caring for new admissions and readmissions. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, Appendix: Additional Information about Airborne Infection Isolation Rooms, Respirators and Facemasks: Filtering Face piece Respirators (FFR) including N95 Respirators: A commonly used respirator in healthcare settings is a filtering face piece respirator (commonly referred to as an N95). FFRs are disposable half face piece respirators that filter out particles. To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. Three key factors for an N95 respirator to be effective: 1. The respirator must be put on correctly and worn during the exposure. 2. The respirator must fit snugly against the user's face to ensure that there are no gaps between the user's skin and respirator seal. 3. The respirator filter must capture more than 95% of the particles from the air that passes through it. The facility Personal Protective Equipment guide dated 6/17/2021 states . N95 respirators are used when providing care or services within six (6) feet of patients with suspected or confirmed COVID-19 on transmission- based precaution including new admission for quarantine period . The same usage guide also says that face shields, gowns, and gloves should be worn when providing care or services within six feet of patients with suspected or confirmed Covid-19, in transmission-based precautions including new admissions for quarantine period. The Immediate Jeopardy that began on 7/26/2021 was removed on 7/27/2021, when the facility took the following actions to remove the immediacy: 1. Staff in-servicing on proper use of PPE including donning and doffing, began on 7/27/2021 and will continue prior to the start of each staff members scheduled shift. This will be completed by 8/4/2021. 2. Beginning 7/27/2021 all staff will be in-serviced as they start their shift on the location of PPE supplies. This will be completed by 8/4/2021. 3. Competencies of all staff will begin on 7/27/2021 for proper PPE and donning and doffing. This will be completed by 8/4/2021. 4. To ensure compliance audits to ensure all isolation carts have the proper PPE will be conducted by the administrator or designee daily for 7 days, and the weekly until reviewed by the QA committee. 5. Nursing management or designee will conduct audits on all shifts to ensure staff are donning and doffing according to guidelines. These audits will be done 5 times daily for 5 days and then weekly until reviewed by the QA committee. 6. An emergency QA meeting was held on 7/27/2021 to review the IJ abatement plan, and the facility Medical Director has been notified.

Based on observation, interview, and record review the facility failed to ensure a resident was not physically abused. This failure resulted in a resident sustaining an injury to her left arm. This applies to 1 of 3 residents (R3) reviewed for abuse in the sample of 5. The findings include: R3's Physician order [REDACTED]. R3's Minimum Data Set assessment dated [DATE] shows R3 is moderately impaired in her cognition. R3's Nurses Notes dated 5/7/19 shows that at 6:30 AM on 4/28/19, R3 was heard yelling from the hallway. R3 became combative during a blood draw. R3 refused to be touched. The lab technician continued to draw blood and R3 sustained a skin tear to her left lower arm. R3's skin tear measures 6.9 x1.9 x 0.1 centimeters with serosanguinous drainage. On 5/9/19 at 9:35 AM, R3 was in bed. R3 was guarding her left arm. R3 had a dressing from her wrist to her elbow. R3 had a large deep purple bruise on her left hand and left upper arm. On 5/8/19 at 4:30 PM, V12 (R3's family member) said that R3 is confused and can be resistive to care due to her dementia. V12 said, V9 (Laboratory Technician-lab tech) attempted to draw blood from R3 on 5/6/19 and R3 refused. R3's physician ordered that the blood draw be done the next day (5/7/19) at 5:30 PM in the afternoon when one of R3's daughter could be in the facility. V12 said V9 drew the blood in the morning of 5/7/19 (instead of the agreed time of 5:30 PM) R3 sustained a large injury in her left arm. V12 was very upset and felt R3 was abused and forced to have her blood drawn. On 5/13/19 at 10:27 AM, V10 (Registered Nurse) said she was R3's nurse on 5/7/19. V10 said she was passing the morning medication when she heard R3 screaming. V10 said she went to R3's room and found V9 (lab tech) in the room. V10 said she saw a gauze soaked with blood over R3's left arm. R3 was crying and screaming. V10 said she asked V9 what happened. V10 said V9 said R3 was fighting when V9 attempted to draw her blood and R3 sustained a skin tear. V10 said R3's laboratory requisition was marked for 5PM draw later in the afternoon. V10 said she cannot understand why V9 was doing the blood draw at that time. V10 said R3 had a huge skin tear to her left arm measuring approximately 3 inches. On 5/13/19 at 10:45 AM, V9 (Laboratory Technician) said she was in the facility on 5/7/19 at around 5:30- 6AM. V9 said she saw R3's laboratory requisition marked blood draw 5:30 PM. V9 said since she was already in the facility, she wanted to draw the blood that morning. V9 said she went to R3's room. V9 said she introduced herself to R3. V9 said while she was applying the tourniquet to R3's arm, R3 was resisting. V9 said as soon as the tourniquet was applied, R3 swung her left arm and was very combative. R3 was screaming, kicking, and grabbing at V9. V9 said R3 tore her lab coat and kicked her in the stomach. V9 said the tourniquet was at R3's left wrist impeding R3's circulation. V9 said she wanted to remove the tourniquet. V9 said she used her right arm and held down R3's left arm to remove the tourniquet, that's where R3's skin tear came from. V9 said R3's left arm was bleeding. V9 said she went to get the nurse. V9 said she should have waited for the time it was supposed to be drawn which was 5:30 PM, rather than forcing to do the blood draw in the morning. On 5/13/19 at 10:00 AM, V14 (Phlebotomist Manager) said he was informed by V9 of the incident on 5/7/19. V14 said V9 saw R3's requisition when V9 went to the facility in the morning. V14 said V9 saw it was marked 5:30 PM but V9 said the nurse said it was ok. V14 said V9 told her that R3 was combative when V9 was placing the tourniquet on R3. V14 said V9 tried to remove the tourniquet and that's when R3 received the skin tear. On 5/13/19 at 11:31 AM, V11 (Certified Nursing Assistant-CNA) said she was working as a CNA on 5/7/19. V11 (CNA) said V10 (RN) asked her help with R3. V11 said when she entered R3's room, R3 was crying. V11 said there was blood all over R3's sheets. V11 said she noticed R3's injury in her left arm. On 5/14/19 at 11: 30 AM, V2 (Director of Nursing) said V10 called her the morning of 5/7/19. V2 said V10 told her that V9 was insisting on going to R3's room to draw the blood. V2 said she instructed V10 to tell V9 to wait for the afternoon. V2 said V9 still went to R3's room to draw the blood in spite of R3 being combative. V2 said V9 was not allowed to go back to the facility. On 5/13/19 at 1:30 PM, V1 (Administrator) said he did the investigation regarding the incident on R3. V1 said that V9 went to draw blood on R3 even though it was not scheduled at that time. R3 was resistive and became belligerent. A skin tear was noted on R3's left lower arm. V1 said V9 was not allowed to go back to the facility for going against the instruction for an evening blood draw. On 5/14/19 at 1:30 PM, V15 (Nurse Practitioner) said R3's blood draws were routine and could have been drawn the evening of 5/7/19 when the daughter was present and agreed upon. V15 said V9 had no reason to force the blood draw in the morning. R3's latest care plan shows R3 is sensitive with treatment and care. With intervention that include if resist care, leave and return later. Allow flexibility to accommodate mood, preferences . The facility policy on Abuse dated (YEAR) shows The resident has the right to be free from abuse

Based on interview and record review the facility failed to follow their policy and procedure for admission and preventing Neglect of a resident's care. This failure contributed to a resident (R1) experiencing a 3 day delay in obtaining a [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) machine. R1 was sent out to a local hospital for exacerbation of [MEDICAL CONDITIONS] and Hypercapnia (Elevated CO2 levels). This applies to 1 of 3 residents (R1) reviewed for neglect. The findings include: The hospital records showed R1 was hospitalized from June 8, 2016 to June 17, 2016. R1's hospital progress notes showed acute hyperbaric [MEDICAL CONDITION] with R1 using a [MEDICAL CONDITION] with improvement of CO2 (Carbon [MEDICATION NAME]). Plan is for R1 to be released to a skilled nursing facility with improving respiratory status. The Physician order [REDACTED]. The POS showed R1 is to have a [MEDICAL CONDITION] (settings 22/12 at 30%) on when sleeping with oxygen bleeding in at 4LPM (Liters Per Minute). The Nurse's notes dated June 17, 2016 showed R1 was admitted from local hospital with a [DIAGNOSES REDACTED]. The Nurse's notes from June 17, 2016 to June 19, 2016 showed R1's [MEDICAL CONDITION] was not applied at night for 3 days ( [MEDICAL CONDITION] was not available). On July 5, 2016 at 11:00 AM E1 (Administrator) said, R1 was admitted on a Friday sometime after 5pm and prior to him coming to the facility they were not aware he needed a [MEDICAL CONDITION]. The nurse who took report and the order for the [MEDICAL CONDITION] did not go any further with the order. On Monday June 20, 2016 during a meeting we discovered R1 did not have his [MEDICAL CONDITION] machine and it was ordered and received that day. I talked to the on-call nurse manager that weekend and she said she was not notified of R1 needing a [MEDICAL CONDITION]. I would expect the nurse to call the clinical phone, call me or the nurse manager and notify us of the situation. Management was not notified of R1 not having his [MEDICAL CONDITION]. On July 5, 2016 at 2:35 PM, E6 (Registered Nurse) said she took R1's telephone report from the hospital on June 17, 2016 and helped admit R1 when he arrived at the facility then she gave report to the primary nurse. R1's admission orders [REDACTED] On July 5, 2016 at 2:40 PM, E7 (Licensed Practical Nurse-LPN) said I did not admit R1. I just knew his [MEDICAL CONDITION] machine was not here. I took care of him the first night (June 17, 2016). I've never had to order any equipment. I should have called the clinical line and let them know he needed a [MEDICAL CONDITION] machine. On July 5, 2016 at 2:00 PM, E5 (RN) said, I was told R1 needed a [MEDICAL CONDITION]; he did not come with one. I told the day RN to follow up with his [MEDICAL CONDITION] in the morning. I came back to work the next night and he did not have his [MEDICAL CONDITION] again. I asked about the [MEDICAL CONDITION], but it was not there. I passed it on and told the on-coming nurse to make sure R1 gets his [MEDICAL CONDITION]. We should notify the supervisor if we don't have the equipment or call the medical equipment provider. On July 6, 2016 at 4:10 PM, E10 (RN) said she works as needed at the facility. I was told R1 needs a [MEDICAL CONDITION], but that it was not available at the time. I was told they were working on it, but nothing specific. On July 5, 2016 at 2:20 PM, E8 (RN) said I have not been trained on ordering medical equipment. I passed the information on to the day nurse that R1 needed a [MEDICAL CONDITION]. The Treatment Administration Record showed five nurses from June 17, 2016 to June 19, 2016 cared for R1 during the second and third shift. The TAR showed R1 is to have a [MEDICAL CONDITION] on when sleeping and removed in the morning. None of the five nurses notified managment of R1 needing a [MEDICAL CONDITION] during their shift. The track order receipt for R1's [MEDICAL CONDITION] machine dated June 20, 2016 was ordered and received (3 days after his admission). The Nurse's note dated June 20, 2016 showed R1 refused to wear his [MEDICAL CONDITION] machine. On July 6, 2016, at 2:44 PM, E9 (RN) said, she took care of R1 the night he refused his [MEDICAL CONDITION] machine. E9 said the staff from the equipment company came to the facility at 8:30 PM to set up the [MEDICAL CONDITION] machine and showed E9 how to apply the O2 concentrator when R1 was ready to have the [MEDICAL CONDITION] machine applied. E9 said R1 told her I don't want a new nurse setting the machine on me and experimenting with me. E9 said she re-educated R1 on the importance of the [MEDICAL CONDITION] and explained to him she was not a new nurse and she knew how to apply the equipment. E9 said she tried for a second time to apply the [MEDICAL CONDITION], but R1 refused and she told the on-coming nurse R1 refused. E9 said she did not notify the physician or family member. E9 said R1 was not confused and did not have any problems breathing during her shift. On July 5, 2016 at 3:00 PM, E1 (Administrator) said they did not have a policy in place on how staff should obtain medical equipment. We now have a policy in place and started in-servicing our staff and the policy is now at all the nurse's stations. On July 5, 2016 at 9:38 AM, Z1 (Wife) said R1 was supposed to have a [MEDICAL CONDITION] machine on at night. R1 told Z1 he did not have his [MEDICAL CONDITION] machine. Z1 talked to two different staff members about the [MEDICAL CONDITION] machine. Z1 said the staff told her it was taken care of. The facility's Admission Policy dated 2009 states, Obtain baseline vital signs, height and weight and need for specialized equipment ( The policy does not state how to obtain specialized equipment). The facility's Abuse and Neglect Policy dated 2011 states, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

Based on interview and record review the facility failed to provide a [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) machine for 3 days for a resident who had a [DIAGNOSES REDACTED]. This failure contributed in R1 being rehospitalized on [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for specialty care. The findings include: The hospital records showed R1 was hospitalized from June 8, 2016 to June 17, 2016. R1's hospital progress notes showed acute hyperbaric [MEDICAL CONDITION] with R1 using [MEDICAL CONDITION] with improvement of CO2 (Carbon [MEDICATION NAME]). Plan is for R1 to be released to a skilled nursing facility with improving respiratory status. The Nurse's notes dated June 17, 2016, showed R1 was admitted from the hospital with the [DIAGNOSES REDACTED]. The Transition of Care report dated June 17, 2016 showed R1 was hospitalized related to shortness of breath at home, altered mental status, [MEDICAL CONDITION] exacerbation, and CO2 retention. The report showed R1 was being transferred to the facility and is alert and oriented and will need a [MEDICAL CONDITION] at bedtime. The Physician order [REDACTED]. The POS showed R1 is to have a [MEDICAL CONDITION] (settings 22/12 at 30%) on when sleeping with oxygen bleeding in at 4LPM (Liters Per Minute). The Nurse's notes from June 17, 2016 to June 19, 2016 showed R1's [MEDICAL CONDITION] was not applied at night (for 3 days [MEDICAL CONDITION] was not available). There is no documentation notifying the physician of the [MEDICAL CONDITION] machine not being available to R1. The track order receipt for R1's [MEDICAL CONDITION] machine dated June 20, 2016 was ordered and received (3 days after his admission). The Nurse's note dated June 20, 2016 showed R1 refused to wear his [MEDICAL CONDITION] machine. There is no documentation notifying the physician R1 refused his [MEDICAL CONDITION]. The Nurse's note dated June 21, 2016 at 1:17 PM, showed R1 had a condition change. R1 refused to eat lunch. R1 was short of breath and had difficulty breathing. His Oxygen level was at 78 percent then decreased to 74 percent. At 1:47 PM, R1's oxygen level dropped to 60 percent, 911 was called. The physician was notified at that time and R1 was sent to the hospital. The Nurse's note dated June 22, 2016 showed R1 was admitted to the hospital with [REDACTED]. The Medication Administration Record [REDACTED]. On July 6, 2016 at 9:38 AM, Z1( Wife) said, R1 was transferred from the hospital to facility of Libertyville on a Friday (June 17, 2016) and he was suppose to have a [MEDICAL CONDITION] machine at night. Z1 spoke with a nurse and was told we need to get the machine. R1 told Z1 on Sunday (June 19, 2016) that he did not have his [MEDICAL CONDITION] machine yet. Z1 said she talked to two different staff members about R1 not having his [MEDICAL CONDITION] machine and was told it was taken care of. On July 5, 2016 at 11:00 AM E1 (Administrator) said, R1 was admitted on a Friday sometime after 5pm and prior to him coming the facility was not aware he needed a [MEDICAL CONDITION]. The nurse who took report and the order for the [MEDICAL CONDITION] did not go any further with the order. On Monday June 20, 2016 during a meeting we discovered R1 did not have his [MEDICAL CONDITION] machine and it was ordered and received that day. I talked to the on-call nurse manager that weekend and she said she was not notified of R1 needing a [MEDICAL CONDITION]. I would expect the nurse to call the clinical phone, call me or the nurse manager and notify us the situation. Management was not notified of R1 not having his [MEDICAL CONDITION]. On July 5, 2016 at 11:17 AM, E4 (Registered Nurse-RN) said, usually admissions staff place the order for the [MEDICAL CONDITION]. Staff should notify the supervisor if the equipment is not available. E4 said she took care of R1 a couple of times (between 6/17/16-6/20/16). I remember we were waiting for the delivery of the [MEDICAL CONDITION] machine. I was told it was ordered. On July 5, 2016 at 11:27 AM, E3 (RN) said if resident needs equipment and we don ' t have it we can call the equipment company and order it. It's the nurse's responsibility to get the equipment. Staff has to call the company, follow up with the provider, and tell the manager in charge if the equipment is not available. On July 5, 2016 at 2:00 PM, E5 (RN) said, I was told R1 needed a [MEDICAL CONDITION]; he did not come with one. I told the day RN to follow up with his [MEDICAL CONDITION] in the morning. I came back to work the next night and he did not have his [MEDICAL CONDITION] again. I asked about the [MEDICAL CONDITION], but it was not there. I passed it on and told the on-coming nurse to make sure R1 gets his [MEDICAL CONDITION]. We should notify the supervisor if we don ' t have the equipment or call the medical equipment provider. R1 did not have any respiratory distress while I took care of him or any changes in his mental status. On July 5, 2016 at 2:35 PM, E6 (RN) said she took R1's telephone report from the hospital on June 17, 2016 and passed the report to the primary nurse. R1's admission orders [REDACTED]. I would follow up with a supervisor if the equipment was not available for the resident. On July 5, 2016 at 2:40 PM, E7 (Licensed Practical Nurse-LPN) said, usually any special equipment is already ordered. I've never had to order any equipment. I should have called the clinical line. I did not admit R1. I just knew his [MEDICAL CONDITION] machine was not here. R1 was alert and oriented; he did not have any respiratory distress while I took care of him. We should notify the physician if the resident refuses and re-educate the resident. On July 5, 2016 at 2:40 PM, E7 (Licensed Practical Nurse-LPN) said we should notify the physician if the resident refuses and re-educate the resident. On July 6, 2016, at 2:44 PM, E9 (RN) said, she took care of R1 the night he refused his [MEDICAL CONDITION] machine. E9 said the staff from the equipment company came to the facility at 8:30 PM to set up the [MEDICAL CONDITION] machine and showed E9 how to apply the O2 concentrator when R1 was ready to have the [MEDICAL CONDITION] machine applied. E9 said R1 told her I don't want a new nurse setting the machine on me and experimenting with me. E9 said she re-educated R1 the importance of the [MEDICAL CONDITION] and explained to him she was not a new nurse and she knew how to apply the equipment. E9 said she tried for a second time to apply the [MEDICAL CONDITION], but R1 refused and told the on-coming nurse R1 refused. E9 said she did not notify the physician or family member. E9 said R1 was not confused and did not have any problems breathing during her shift. On July 6, 2016 at 3:05 PM, Z2 (Physician) said the purpose of a [MEDICAL CONDITION] is to partially remove CO2 (Carbon [MEDICATION NAME]) for residents who have [MEDICAL CONDITION]. Residents with [MEDICAL CONDITION] can be high retainers of CO2. [MEDICAL CONDITION] ' s are used for residents with [MEDICAL CONDITION]. Hypercapnia is elevated CO2 levels; it is treated using a [MEDICAL CONDITION]. Z2 said it's possible if R1 had his [MEDICAL CONDITION] his second hospitalization (diagnosed with [REDACTED]. Z2 said if a [MEDICAL CONDITION] is prescribed for a resident it's because they need it . Z2 said I don ' t think R1 passed away from not having his [MEDICAL CONDITION]. Z2 said he was not notified of R1 not having a [MEDICAL CONDITION] machine for 3 days, and was not notified R1 refused his [MEDICAL CONDITION]. Z2 said he would want to be notified of these circumstances.

Based on observation, interview and record review, the facility failed to ensure three residents (R4, R16 and R20) of five reviewed (R2, R4, R8, R16, R20) for Hydration needs, had his fluid requirements met to prevent the development of severe dehydration and the associated complications that resulted from this. Failed to notify the doctor, assess and follow their hydration policy. As a result of this failure, R20 was admitted to the hospital with [REDACTED]. Findings include: R20 was admitted to the facility on [DATE] for rehab therapy after suffering [MEDICAL CONDITION](cardiovascular accident) earlier in the month. R20 had left sided weakness, [MEDICAL CONDITION], and dysphagia identified on admission. The initial nurse's note 6/28/12 at 3:36 am, documented R20 as alert and oriented with some facial drooping on the left...unable to help with moving in bed when turning to the right side. Skin intact, SO2 93% on room air, HR 63. The following note documents "slurred speech... .(but) makes needs known." The nutritional assessment of the same date (6/28/12) assessed R20 as a high nutritional risk. The assessment showed oral intake of food meets only 26-75% of estimated needs; oral intake of fluids 1000-1499 cc/day. The dietician's assessment identified needs of 2313-2775 cal/kg for oral intake with a total protein need of 93 grams. Fluid needs were 2775 cc/day. R20 was ordered a mechanical soft diet with nectar thickened liquids. The Respiratory assessment of 6/28/12 noted normal vital signs with diminished breath sounds in the left lower lung. A recommendation was made for an incentive spirometer to be placed at the bedside, to be used four times daily. There was no documentation to support this was ever used by the resident. The history and physical dated 6/28/12 by Z1 (primary physician) documented normal vitals, "[MEDICAL CONDITION] although speech is discernable." Z1s next note dated 7/3/12 again noted normal vitals and "doing reasonably well." R20 's status appears to have changed according to nurses' notes as early as 7/5/12 when the note timed 19:06 documented "...speech slurred, pocketing food...appetite poor." The notes dated 7/6 and 7/8 are brief and showed no followup of the concerns on 7/5. A review of the note of 7/9 at 13:08, by Speech Therapy, stated: " Video swallow canceled secondary to change in status." No further details are given in the note. At 15:43 another note read: "unable to verbalize needs, pockets meds, all AM meds held MD/NP (nurse practioner) notified. Asked NP to see pt. SBAR done. Vital signs 114/62, 99.2, 97-94% on RA. Tylenol suppository given, T 98.4 at 2:45pm. STAT CBC/CMP done. Endorsed to next shift re UA/CS. Given ice chips ." The results of the labs drawn were relayed to the physician according to note timed at 22:04 on 7/9/12. Telephone order 7/9/12 at 7pm gives an order for [REDACTED]. O2 at 2L/min via nasal cannula was started. The hospital medical records showed when R20 was admitted to the hospital on [DATE], he was dehydrated. The note dictated by Z2 (nephrologist) notes: "[MEDICAL CONDITION]. He does have an estimated fluid deficit of approximately 5 liters, with a sodium of 154. I suspect this [MEDICAL CONDITION] is due to a combination of decreased free water as well as insensible losses...elevated BUN (70mg/dL) and creatinine(1.80mg/dL)." Notes by Z3 (pulmonologist) confirm R20 was hypoxic and chest CT (Cat Scan) showed bibasilar infiltrates. Z3 attributed this to "hypoxic [MEDICAL CONDITION] due to pneumonia...at risk for aspiration." Z3 also referred to the "acute kidney injury, most likely due to dehydration." As part of his plan, R20 required placement of an NG (Nasal [MEDICAL CONDITION]) tube for 300ml of free water flushes every 4 hours and supplemental IVF (Intravenous fluid) of 80ml/hour of 0.45% normal saline" to achieve rehydration. R20 showed evidence of left leg [MEDICAL CONDITIONS] requiring placement of an IVF filter, aspiration that required placement of a PEG (Percutaneous Endoscopic Gastrostomy) tube. On admission R20 "had sinus [MEDICAL CONDITION](153 bpm) from dehydration" and was described as "He was extremely debilitated." This was per Z4's note. Z4 (cardiologist) listed R20's discharge [DIAGNOSES REDACTED]. The facility staff was asked to provide any monitoring of the intake of R20. E3 (director of nursing) stated that intake and outputs were not done routinely even though a resident has been identified as high risk for dehydration and had a significant change of condition. Any policy to this effect was requested but one was not provided. The nurse aides document percentages of meals consumed only. Review of R20's record shows an average consumption of 75% from 6/27 -7/3. Then the consumption starts to decline to 50% or less. On 7/7/12 documentation showed 25%, 0%, 100% for the three meals, on 7/8 it was 0%, and refused. Only two meals documented. Again on 7/9/12 only two meals are documented at 25% and 25%. R20's careplan for maintaining adequate hydration is the same as that of R2 and R8. Approaches included obtaining lab results as ordered and notifying physician, report changes related to signs of fluid deficit (tongue furrows, dry mouth, etc.), therapy eval and treat as ordered, thickened liquids as ordered. These approaches did not address preventive measures but only identifying dehydration once symptoms are present such as the dry mouth and furrowed tongue. Preventive interventions such as detailed monitoring of fluids consumed or encouraging fluid consumption were not considered in the plan. This lack of preventive measures contributed to R20 developing severe dehydration and subsequent organ system failures. Review of R16's medical record on 1/8/13, showed that E6 wrote a nutritional note on 11/29/12 that noted a 13.6% weight loss in a two month period. The last physician note was dated 10/20/12. On 12/18/12 R16's diet was changed to regular-enhanced with health shakes bid and magic cup everyday and multivitamin everyday. Nurses notes show R16 was lethargic and refusing breakfast and lunch. This was repeated several times in the next few weeks. on 1/3/13 the nurse's note documented lethargic, refused breakfast and lunch, unable to swallow some meds...dry cough. Labs were ordered and obtained on 1/4/13. Results of the labs showed an elevated H/H of 15.7/47.1 and a BUN of 76 and Creatinine of 2.5, both outside of the normal range of 8-28 for BUN and 0.4-1.6 for Creatinine. A critical level of 2.8 for potassium was also noted. The low potassium level was addressed but there was nothing acknowledging the elevated BUN and Creatinine. R16 was identified as at risk for dehydration on assessment and is also on multiple diuretics ([MEDICATION NAME] and [MEDICATION NAME]). When observed on 1/6/13, R16 was in bed, pale, with no fluids available at bedside. On 1/6/13 a new red area was identified on R16's buttock. There is no documentation that indicated that the facility hydration plan was being followed for this resident or the other abnormal labs were being evaluated based on R16's overall condition. R4's physician's orders [REDACTED]. On 01/06/13 at 10:20am R4 was lying in bed with her eyes closed. She did not verbally respond and her movements were slow. On 01/06/13 at 02:00pm E9, Certified Nursing Assistant ( CNA ) was interviewed regarding oral intake. E9 stated, "R4's appetite varied; however , she does better with her family. R4 had dry lips. We used Vaseline and swabbed R4's mouth. The Nurses were aware of these symptoms. R4 only ate about 25% of her noon tray today." E10, Nurse, was interviewed on 01/06/13 at 10:20am. E10 stated, "R4 was dehydrated. She had a poor appetite. The physician was faxed and phoned last night. There has been no response at this time. R4 had dry cracked lips and her mucous membranes were dry." At 12pm on 01/06/13 at 12:00pm E10 added, "I called and faxed the physician on 01/04/13. The message had not been responded to at this time. On 01/05/13 I learned that the physician was on vacation. I did not feel that it was an emergency to reach the physician." (It was brought to the facility's attention that the resident had a change in condition and there was a delay of two days without the physician being notified.) (The facility then contacted the physician and received orders for Intravenous Hydration.) On 04/21/12 R4 was evaluated as a high nutritional risk. R4's lab dated 11/02/12 had a blood urea nitrogen ( BUN ) level of 46. ( reference range was 8-28 ) R4's Nursing notes dated 11/03/12 documented Intravenous Hydration was ordered. On 12/26/12 R4's BUN level was 31. R4's Nursing Notes dated 01/04/06 at 10:56pm documented,"...Patient's family translated that patient feels too weak to open mouth to chew, eat or take in fluids. "Physician" faxed at this time for lab orders Follow up needed." There are no further assessments, monitoring prior to the note written on 01/06/13. R4's Hydration Care Plan initiated on 09/06/12 addressed hydration with an intervention of reporting changes in fluid deficit... The facility's care plan for dehydration included assessing mental status. If there was an acute mental status change notify the physician immediately. The resident is to be managed in the facility with options that included monitor vital signs and urine output every 4-8 hours. Offer small frequent fluids 2-4 ounces every 2 hours. The facility failed to document the assessments after dehydration was suspected.

Based on observation, record review and interview nursing staff failed to provide adequate supervision and assistance during a transfer activity of one of three sampled residents (R1). This failure resulted in R1 falling to the floor and sustaining multiple facial contusions, facial lacerations requiring suturing, contusion injuries to right hand and bilateral lower extremities and pain. Findings include; The facility incident report for R1 dated 6/10/12 is included: On 6/10/12 at 4:20PM R1 was assisted back to bed using a mechanical (sit to stand) lift and set on the edge of the bed by E3 and E4 (certified nurse assistants). R1's bed contained an air mattress. Immediately after R1 was seated onto the edge of bed and prior to removing the mechanical lift, E4 left E3 alone with R1. After E4 left the room, E3 removed the lift belt straps from R1, turned away from the resident, with her back to R1 while rolling the mechanical lift away from R1's bed. E3 witnessed R1 fall forward off the bed and onto the floor. E3 was unable to reach R1 in time to prevent the fall. R1 sustained facial contusions and lacerations that required suturing and a contused right hand. This incident report also documents: "Per investigation, it seems as if resident (R1), was not positioned securely in the center of mattress and was seated at the edge of the bed with her legs dangling. When CNA (E3), turned away, residents poor trunk stability caused her to lean forward and she (R1), slid off bed." E3's written statement included " Before the fall, patient (R1), was sitting on the left side of the bed with her knees together." " I was removing the lift in order to make room to swing the patients legs on to the bed." "(E4) was present during the actual transfer from wheelchair to bed using the lift. When we were done E4 left and R1 was sitting on the side of the bed in an up-right position, with her right hand holding onto the lift. I told her (R1), to take right hand off lift which she did, so I could move lift out of the way. She (R1), just went straight forward and landed on her head, telephone base ended on floor also, I saw her fall but I was too far away moving lift. I had already removed the sling." R1's medical record includes: R1 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R1's 5/10/2012 minimum data set assessment (MDS), includes needs extensive assistance by two or more people with bed mobility, transfers and toileting activities. This assessment also documents no behavioral problems, alert, communicative and with modified independent cognition. This MDS documents R1 weight as 167 pounds. R1's 3/03/2008 fall risk care plan includes at risk for falls due to impaired balance , generalized weakness and history of falls. Interventions document two person assistance with transfers using a mechanical lift. On 6/11/12 the care plans interventions were updated to include "make sure patient is securely positioned in center of mattress when / after transferring to bed. R1's Care plan also includes "Deficits in bed mobility and transfer skills, bed<-->chair, related to complaints of generalized pain and muscle weakness in bilateral upper and lower extremities and deficits in functional sitting and standing balance." R1's 6/11/12 Fall assessment includes : Difficulty maintaining sitting and standing balance, gait problem and muscular-skeletal problem. R1's 6/11/12 physical therapy includes: weakness and decreased coordination and left upper and lower extremity due to history of possible stroke in December 2011, as well as right lower extremity muscle weakness. Requires moderate assist with bed mobility and maximum assist with mechanical lift for transfers. During individual interviews the following information was obtained: On 6/28/12 at 11AM, E1 (Administrator), said On 6/10/12 E3 and E4 assisted R1 to bed using mechanical lift. Once R1 was put on the bed, E4 left the room. We think R1 slid off the bed because she was on an air mattress. On 6/28/12 at 3:00PM, E4 said that on 6/10/12 she assisted E3 to transfer R1 to bed using the mechanical sit to stand lift. After R1 was seated on the bed, E4 left the room to assist other residents. E4 said maybe E3 couldn't get to R1 in time due to the lift being in the way. R1's room is very crowded and E3 could not get to R1 to help her until the lift is moved out of the way. E4 also said maybe she should have stayed with R1 until she was laying in bed, but the nurse aides do not usually do that. On 6/29/12 at 9:35AM, during a telephone interview, E3 said On 6/10/12 E4 assisted E3 to transfer R1 to bed using the mechanical lift (sit to stand). E4 left the room right after R1 was seated on the bed. After E4 left, I was pulling the mechanical lift out of the way so I could lift R1's legs up on the bed. The space between residents bed and window was very crowded and a wheel chair was also in the way. There are always two nurse aides to transfer residents with mechanical lifts. Once the residents are transferred to bed or chair, the other nurse aide usually leaves the room. R1 has poor sitting balance and it would have definitely been better if E4 stayed with R1 while I moved the lift out of the way. On 6/29/12 at 12:12PM, E8 (3rd floor PM nurse supervisor), said R1's 6/10/12 fall incident was probably due to her being on an air mattress. E8 said she felt it was all right for E4 to leave R1's room before the lift was removed and R1 was laid down. E8 said she did not think about the possible need for E4 to stay with R1 while E3 was removing the lift until this conversation. On 6/12/12 facility inserviced all nursing staff on "Safety tips on lift transfers". This inservice included Be sure patient is securely positioned in bed/ chair/ toilet before removing lift and sling. Ensure the patient is not on the edge of the bed or chair during positioning. Never turn your back on a patient that has poor trunk control and stability. On 6/29/12 E8 also said prior to R1's 6/10/12 fall, the mechanical lift inservices did not include "safety tips on lift transfers" information . This information will now be included in all future orientation and annual lift inservices. On 6/28/12 R1 observed in bed with yellow colored bruising to right hand 4th finger, middle and left side of forehead and bilateral knees to mid shin area's. R1 complained of continued pain below right knee ever since her 6/10/12 fall. This area had a brownish colored swollen area. R1's mid forehead had a 1.5 - 2 inch lateral healing laceration and a 2 inch lateral healing laceration above the left eyebrow.

Based on observation, interview, and record review, the facility failed to follow Physician order [REDACTED]. The facility failed to assess pain, monitor pain, notify the resident's physician of a resident's increased pain, and did not evaluate the effectiveness of pain medication. The facility failed to have Policies and Procedures for Pain and additionally, did not follow their Pain Practice Guide. The facility also failed to provide comprehensive pain management. This is for 4 residents (R11, R1, R3 and R8) out of 9 reviewed for pain in the sample of 21. As a result of the facility failures R11, who has neoplastic, metastatic bone, bone marrow, and [MEDICAL CONDITION], suffered from unrelieved pain. Findings include: On 1-13-2011 at 10:15am. E1, (Administrator) stated, "We do not have a Policy and Procedure for Pain. We use the Pain Practice Guide to train our staff. Our Medical Director, (Z2) did not have input into it's development, nor has he reviewed the Pain Practice Guide. It was developed by corporate." The 1-2008 Pain Practice Guide is, "A focused patient evaluation to identify pain is completed using the Quality Assurance and Assessment Audit Tool. Obtain pain scale scores daily and before and after administration of as needed [MEDICATION NAME]. Scores are documented on the MAR, (Medication Administration Record). Patients with a score of 4 to 7 twice in a 7-day period or who had one score of 8, 9, or 10 are reported to the physician for possible treatment adjustment, noted on 24 hour report, reviewed during the Eagle Room process and monitored on the Quality Assurance and Assessment Pain Management Tool." Revised 6-2006 Pain Management Tool Heading is, "Quality Assurance and Assessment Audit Tool: Privileged Work Document." According to the Facility 1-2008 Pain Practice Guide, page 4, "Numeric Pain Rating. The Numeric Pain Rating Scale is used for alert and oriented patients. In using the numeric rating scale, the patient is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable)." 1. The 12-30-2010 Patient Admission Screen contains documentation that R11 was admitted to the facility on [DATE] at 4:00pm., with [DIAGNOSES REDACTED]. Section 2. Pain: "Patient is experiencing aching, left leg and thigh pain, at a five that is aggravated by walking and position changes, and negatively affects (R11's) activities of daily living." A). R11's admission orders [REDACTED]., (milligrams)/325mg., 1-2 tablets every four hours as needed for pain. Pain scale every morning with medication pass, goal 0 out of ten, (Numeric Pain Scale)." [MEDICATION NAME] is an opiod narcotic used to [MEDICAL CONDITION] pain. With chronic use for pain management tapering of dose is required to prevent withdrawal. Monitoring parameters include assessment of patient pain relief. [MEDICATION NAME] is a narcotic [MEDICATION NAME] combination used for moderate to severe pain relief. Monitoring parameters include assessment of patient pain relief). Pharmacologic Category, Use Information, and Monitoring Parameters obtained from Lexi-Comp's Drug Reference Handbooks, 12th Edition Geriatric Dosage Handbook The 12-30-2010 MAR, (Medication Administration Record) contains documentation that R11's [MEDICATION NAME] 25mcg. [MEDICATION NAME] is due on 1-2-2011. On 1-11-11 at 1:17pm. Z1, (R11's Family Member) stated, "I brought (R11) here on 12-30-2010 at 4 or 5 :00pm. I returned on 10-31-2010 at 10 or 11:00am. (R11) was without her pain patch. The [MEDICATION NAME] was all waded up, stuck together, and stuck to her sweat-suit top sleeve. No medication was in contact, from the patch, to (R11's) skin. I immediately requested the day nurse, I don't recall her name, and (E3, RN/Registered Nurse, DCD/Director of Care Delivery) come into the room. I showed both of them (R11's) pain patch was off and told them there was no excuse for this, as (R11) has severe pain. (E3, RN/DCD) said Oh, nothing more. They applied another pain patch. I hired a person to come in from 9:00am. to 1:00pm. everyday and I come in from 1:00pm. to 7:30pm. or 9:00pm. everyday. My staff, I hired to come in and care for (R11), came in at 9:00am. today and said (R11) did not have her pain patch on. They had to tell facility staff. Then they put her patch on. Today is the first day staff have asked (R11) about pain and rating the pain." E13, (RN) on 1-11-2011 at 1:45pm. stated, "(R11) did not have her pain patch on this morning. One of (R11's) family members came and told me, around 9:30am. this morning, that her pain patch was missing. I searched (R11's) room, bathroom, bed, bedding, garbage can and could not locate the patch. I checked (R11) and she did not have the pain patch on." After review of R11's MAR for 1-10-2011 and 1-11-2011 at 9:00am. Pain Numeric Rating Scale, E13 stated, "(R11's) pain was an 8 on both days. I applied another pain patch after (R11's) family member told me and I couldn't locate it. Around 9:00am. I gave (R11) a pain pill for right sided pain. Administration is calling the night nurse, (E18/RN), to ask about (R11's) pain patch." R11's MAR contains documentation that prior to E13, (RN) applying the [MEDICATION NAME] on 1-11-2011 at 9:30am. the last [MEDICATION NAME] was applied 1-8-2011 at 6:00am. E1, (Administrator), E2, (DON), and E3, (Director of Care Delivery) on 1-13-2011, between 9:25am. and 10:20am., all verbally affirmed the Facility did not have a daily or any other policy and procedure or practice of checking, resident's with three day, pain patch application placement. E3, (RN/DCD) on 1-11-2011 at 2:01pm. stated, "I've been the DCD since May 2010. I found out (R11) didn't have her pain patch on this morning. (E13, RN) found out from the family member that (R11's) pain patch wasn't on. We're trying to get ahold of the night nurse, (E18/RN) to see what happened. I don't remember (Z1/R11's Family Member) ever expressing concerns about (R11's) pain patch to me. I just can't remember." On 1-12-2011 at 1:22pm., E3, (RN/DCD) stated, "We faxed to (Z2/Physician), in the afternoon, on 1-11-2011 that (R11) didn't have her pain patch on." The 1-11-2011 at 5:54pm. fax to Z2, (Physician) is, "[MEDICATION NAME] was supposed to be placed on patient at 6:00am., not placed on until 9:30am., for your information." B). R11's 1-3-2011 Physician order [REDACTED]." The 1-7-2011 Physician order [REDACTED]., one tablet 30 minutes prior to therapy." R11's 1-7-2011 through 1-12-2011 MAR does not contain documentation that R11 received [MEDICATION NAME] thirty minutes prior to [MEDICAL CONDITION] therapy. On 1-13-2011 at 9:10am. a request to E2, (DON) for supporting documentation, from 1-7-2011 through 1-12-2011, that R11 had received her [MEDICATION NAME] 5/325mg. pain medication, 30 minutes prior to [MEDICAL CONDITION] therapy. E1, (Administrator) on 1-13-2011 stated, "(Z1/R11's Family Member) did not request in writing, she verbally requested (R11) receive pain medication, ([MEDICATION NAME]), thirty minutes prior to [MEDICAL CONDITION] therapy." On 1-13-2011 at 10:17am. E2, (DON) stated, "There is a notation on (R11's) MAR to receive [MEDICATION NAME] thirty minutes prior to therapy, but this isn't the Physician Order, it's an FYI, (for your information)." R11 on 1-13-2011 at 11:20am. was dusky grey, with eyes closed, and labored speech stated, "I'm sorry I scream, because of my pain, it hurts so bad sometimes. It hurts so bad to sit, I can't hardly stand it. It's all I can do to sit and go to therapy. It's such bad pain." Z1, (R11's Family Member) and Medical Power of Attorney on 1-13-2011 at 11:40am. stated, "I told a staff nurse and (E3/DCD/RN), and put in writing, the request for (R11) to receive her pain medication, [MEDICATION NAME], thirty minutes before [MEDICAL CONDITION]. The doctor, (Z2) gave an order for [REDACTED]. (R11) can't sit for any length of time without hurting." R11's Facility file contained the following untitled, undated notation, "Please give pain pill prior to [MEDICAL CONDITION], Monday through Friday, 11:15am." C). The 1-12-2011 MDS, (Minimum Data Set), contains documentation that R11 requires extensive assistance of two staff members for transfers, toilet usage, and is not steady when moving on and off the toilet and requires human assistance. Additionally, the 1-12-2011 MDS contains documentation, that in the last five days, R11 has frequently had pain that has limited her day to day activities with the worst pain being an 8. On 1-11-2011 at 1:10pm. R11's call light was on and sounding. Z1, (Family Member), verbalized R11's call light had been on for approximately ten minutes. R11 was sitting on the bedside commode in her room wincing, grimacing, writhing in pain, and screaming, "I hurt, I hurt, help me, please, please help me I hurt, help me." At 1:18pm. E23, (CNA/Certified Nursing Assistant) entered the room to assist R11 off the commode and into bed. Z1 then stated, "It can take 15 to 20 minutes for assistance from staff. A lot of the other patients scream for help or from pain and don't have family her to help them." D). The 12-31-2010 Physical Therapy evaluation contains documentation that R11 has "generalized weakness, poor functional endurance, muscle weakness, decreased standing and sitting balance, kyphotic posture, (curvature of the upper back), decreased range of motion (in the) left hip due to pain, weakness, and disease process, bilateral leg/foot swelling and left hip/thigh pain." R11's 1-1-2011 Occupational Therapy evaluation contains documentation that R11 has "decreased strength bilaterally in the upper extremities, decreased balance, decreased endurance, limited active range of motion, and left hip/thigh pain." E2, (DON) on 1-12-2011 at 2:15pm. E2, (DON) stated, "We do not have a Pain Policy and Procedure. We use the Pain Practice Guide. This is what we use to train staff. It was developed by Corporate. Resident's level of pain is assessed every morning, during the 9:00am. medication pass. During the 9-27-2010 Staff Meeting we changed assessment and documentation of pain. We no longer document pre and post pain scores on administration of scheduled pain medications. This is a copy of that training and staff attendance records. If a resident has a pain score of 4-7 twice in a 7 day period or a pain score of 8, 9, or 10, we staff note this on their 24 hour report. We do not retain the 24 hour report. This is reported to the resident's physician. We review the 24 hour report on the Quality Assurance and Assessment Audit Tool: Privileged Work Document and review and adjust the resident's Pain Treatment Plan. I cannot provide you with (R11's) Quality Assurance and Assessment Audit Tool: Privileged Work Document. Here is a copy of a blank Tool. (R11's) Pain Treatment Plan has not been changed. (R11) has [MEDICAL CONDITION] and was admitted on a pain patch and as needed pain medication. There has not been a need to review (R11's) Pain Treatment Plan, nor has (R11's) Pain Treatment Plan been changed. There wouldn't be a reason to change her Pain Treatment Plan." After being shown R11's 9:00am. 1-10-11 and 1-11-11 MAR containing documentation of R11's Pain Scales of 8, E2 stated, "No the Pain Plan of Care have not been changed. (R11's) doctor, (Z2) is here everyday. (Z2) is our Medical Director." E3, (RN/DCD) on 1-13-2011 at 9:25am. provided the 1-13-2011, (time not documented), Physician Note Z2 completed. This same Physician Note is, "I had spoken to (R11) yesterday, (no time documented), and she was not complaining of significant discomfort. I reviewed pain regimens. Nursing had done so with family as well. I would like to maintain her current regimen. Will adjust in future if warranted." E). R11's 12-30-2010 Physician order [REDACTED]. one tablet every four hours as needed for 1-5 pain. [MEDICATION NAME] 5/325mg. two tablets every four hours as needed for 6-10 pain. Goal 0 out of 10." R11's 12-30-2010 through 1-11-2011 MAR contains documentation that R11, with a pain scale of 6 or greater, on 11 out of 22 occasions, (or fifty percent of the time), was administered one not two [MEDICATION NAME] 5/325mg. as needed pain medication tablets. R1 is a [AGE] year old female who was admitted to the facility on [DATE] with a right [MEDICAL CONDITION]. R1's pain was managed with [MEDICATION NAME] sulfate in the hospital. Upon admission to the facility R1 had orders for [MEDICATION NAME] and [MEDICATION NAME] with [MEDICATION NAME] for pain. Review of the care plan for pain indicates the goal is to manage pain "within acceptable limits" without clearly stating what this means. Further the care plan does not indicate pain scale guidance to follow in administering either [MEDICATION NAME] or [MEDICATION NAME] with [MEDICATION NAME]. Review of the M.A.R. ( medication administration record) and nurses notes reflect that nurses do not consistently do pre and post administration pain level charting. Also the facility's pain management procedure for R1 does not address how to handle pain level that remains above the baseline pain level established. R1 was interviewed on 01/11/11 at 10:15 am and stated that she does not get relief from [MEDICATION NAME] with [MEDICATION NAME]. R1 further stated that she has told the nurses that it is ineffective and plans to tell the doctor when he visits her that she needs a new pain medication order. Further review of nurses charting shows that when nurses did document pain levels they were documented at a level of "2 or 3". R3 was admitted to the facility on [DATE]. R3 is on hospice and has a [DIAGNOSES REDACTED]. R3's physicians orders include [MEDICATION NAME] 50 mcg. (micrograms) per hour every 72 hours. R3 also has orders for [MEDICATION NAME] and [MEDICATION NAME] for pain prn, (as needed.) R3's care plan for pain does not clearly identify the location of the pain, what an acceptable pain level is and when the two prn pain medications should be administered. R8 is a [AGE] year old, alert and oriented non ambulatory male who was admitted to the facility on [DATE]. R8 has [MEDICAL CONDITION] and chronic pain issues. His current medical orders in the chart include; [MEDICATION NAME] 40 mg. T.I.D. (three times a day), [MEDICATION NAME] 8 mg every 3 hours as needed, [MEDICATION NAME] 650 mg every 4 hours as needed and [MEDICATION NAME] 10 mg every 3 hours as need. During interview on 01/13/11 at approximately 12:30 PM, E16 (R.N., Director of Care Delivery) stated that R8 is on a functional pain assessment scale. R8's care plan revised on 01/05/11 reflects that R8's pain goal will be at an "acceptable level" within 1 hour (without clearly stating what this means.) The goal also states that R8 will express that pain is "within acceptable limits". The care plan does not list R8's medications or guidance to follow for administration of R8's 3 prn pain medications. There is also no reference to the functional pain scale in the care plan. The M.A.R. notes "pain scale for [MEDICATION NAME] ER 40 mg.", with no further guidance for monitoring pain. Nursing documentation on the M.A.R. lists pain levels as high as an 8. However, the functional pain scale form provided by E16 only rates pain from 0 to 5 which is inconsistent with the pain documentation on the M.A.R.

Based on observation, interview and record review the facility failed to ensure that a resident was sufficiently supervised to prevent falls and failed to ensure that planned interventions to prevent falls were followed. The facility also failed to ensure that staff were knowledgeable about the proper functioning of personal alarm devices. This is for 1 resident (R14) out of 7 reviewed for falls in the sample of 21. These failures resulted in R14 falling 2 times in a 3 day period. The first fall resulted in an emergency room visit and sutures. The second fall resulted in hospitalization . Based on observation, the facility has failed to keep the resident environment free of extended electrical cords on the floor of hallway corridors. This failure has the potential to impact the ambulatory residents in the West Hallway on the 3rd floor of the building. The examples include: R14 has multiple [DIAGNOSES REDACTED]. R14 has a history of falls with injuries according to the 12/15/10 MDS. On 12/3/10 (7:30 PM)12/8/10 (7:00 PM) 1/1/11 (2:15 PM) and 1/3/11 (10:15 AM) R14 was found on the floor according to documentation in the nursing notes and/or incident reports. The care plan (initiated 12/30/09, revised 12/9/10) documents, "Ensure that tab alarm is in place when in w/c and sensor alarm in bed." The care plan documents that R14 has several risk factors for falls including poor safety awareness and attempts to transfer/ambulate without assistance. Fall Investigations dated 12/3/10, 12/8/10 and 1/1/11 do not indicate whether or not the alarm was in place at the time of R14's falls. The investigations do not evaluate the effectiveness of the current intervention of applying an alarm to the wheelchair. The Fall Investigation dated 1/3/11 documents, "chair alarm not sounding." R14's care plan documents an intervention of a "tab alarm" when in the wheelchair as opposed to the sensor pad alarm that was in place on 1/3/11. On 1/13/11 at 10:55 AM E13 (Nurse) stated that R14 was found on the floor in the resident's lounge on the 3rd floor on 1/3/11. E13 said that she was alerted to R14's fall by E15 (CNA). E13 stated that R14 had a wheelchair sensor pad alarm in place but it was not correctly connected. E13 confirmed that the alarm was not sounding at the time of R14's fall. On 1/13/11 at 2:30 PM E1 (Administrator) provided a written addendum to E13's previous statement. The addendum states, "CNA stated that wire was not inserted all the way that connect senser pad to alarm." On 1/13/11 at 11:35 AM E13 (CNA) stated that she was alerted to R14's fall when she heard a big crash coming from the resident's lounge and saw R14 moving on the floor. E13 stated that the alarm was not sounding. E13 said that R14 was bleeding around the nose or face area. As a result of her fall on 1/1/11 R14 sustained a laceration of her finger which required an emergency room visit and sutures according to documentation in the nursing notes. As a result of her fall on 1/3/11 R14 sustained a nose bleed, laceration to the upper bridge of her nose and a reddened forehead with 2 small abrasions according to documentation in the nursing notes. The notes also document that R14 complained of pain to the nasal area, jaw and all extremities when a range of motion assessment was attempted. R14 was sent to the emergency room and admitted with a [DIAGNOSES REDACTED]. Nursing notes document that R14 was readmitted to the nursing home on 1/10/11. On 1/10/11 between 2:30 and 2:45 PM R14 was observed in her room in bed with her son (Z3) at her bedside. R14 was noted with a 1/2 inch scab on the bridge of her nose, abrasions on her forehead and a fading yellow bruise under her right eye. An intermittent chirping sound was noted coming from the personal bed alarm device box located on R14's headboard. Z3 stated that the chirping sound has been audible since his mother was put into bed. At 2:45 PM E19 (Nurse) entered R14's room. E19 was asked about the chirping personal alarm box. E19 stated that the chirping sound was "normal" and that it meant that the personal alarm was "working." The instruction manual (page 7) for this device states, "NOTE: you will hear an intermittent "CHIRP" when new batteries are needed. Fresh batteries should be inserted immediately..." On 1/11/11 at 2:15 PM R14 was observed in her bathroom on the toilet without staff supervision. There were no staff present in R14's room or in the hallway outside R14's room. On 1/11/11 at 2:18 PM E22 (CNA) stated that she was not aware that R14 was on the toilet. On 1/11/11 at 2:19 PM E20 (Nurse) came out of another resident's room down the hall. E20 stated she placed R14 on the toilet and left the room. On 1/12/11 E21 (CNA) stated that R14 should not be left on the toilet unsupervised because she just returned from the hospital because of a fall. On 1/10/11, at 11:15 am, during the initial tour of the building, surveyor observed an electrical cord on the hallway floor, stretched from an electrical outlet across from room 300, and going into room 300. After making this observation the surveyor noted E17 emerging from Room 300 with a vacuum cleaner, and then unplugging the device from the hallway outlet. At the end of the day, the facility provided documentation that an in-service was conducted with housekeeping staff. The documented topic of this in-service was Vacuuming Carpets.

Based on interview and record review the facility failed to follow Physician order [REDACTED]. This is for 2 residents (R21 and R14) in the sample of 21. As a result of the facility failures in pain medication administration R11, who has a [DIAGNOSES REDACTED]. Findings include: On 1-13-2011 at approximately 10:15am. E1, (Administrator) stated, "The Facility did not have Policies and Procedures. The Facility uses Practice Guides for staff trainings that were developed by our Corporation. Our Medical Director did not have input into the development of the Practice Guides, nor has he reviewed them." The 3-2010 Medication Administration: Medication Pass Nursing Procedure is: "Purpose: To safely and accurately prepare and administer medication according to Physician order [REDACTED]. 1. The 12-30-2010 Patient Admission Screen contains documentation that R11 was admitted to the facility on [DATE] at 4:00pm., with [DIAGNOSES REDACTED]. Section 2. Pain: "Patient is experiencing aching, left leg and thigh pain, at a five that is aggravated by walking and position changes, and negatively affects (R11's) activities of daily living." According to the Facility 1-2008 Pain Practice Guide, page 4, "Numeric Pain Rating. The Numeric Pain Rating Scale is used for alert and oriented patients. In using the numeric rating scale, the patient is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable)." A). R11's admission orders [REDACTED]., (milligrams)/325mg., 1-2 tablets every four hours as needed for pain. Pain scale every morning with medication pass, goal 0 out of ten, (Numeric Pain Scale)." [MEDICATION NAME] is an opiod narcotic agent used to [MEDICAL CONDITION] pain. With chronic use for pain management tapering of dose is required to prevent withdrawal. Monitoring parameters include assessment of patient pain relief. [MEDICATION NAME] is a narcotic [MEDICATION NAME] combination used for moderate to severe pain relief. Monitoring parameters include assessment of patient pain relief. Pharmacologic Category, Use Information, and Monitoring Parameters obtained from Lexi-Comp's Drug Reference Handbooks, 12th Edition Geriatric Dosage Handbook The 12-30-2010 MAR, (Medication Administration Record) contains documentation that R11's [MEDICATION NAME] 25mcg. [MEDICATION NAME] is due on 1-2-2011. On 1-11-11 at 1:17pm. Z1, (R11's Family Member) stated, "I brought (R11) here on 12-30-2010 at 4 or 5 :00pm. I returned on 10-31-2010 at 10 or 11:00am. (R11) was without her pain patch. The [MEDICATION NAME] was all waded up, stuck together, and stuck to her sweat-suit top sleeve. No medication was in contact, from the patch, to (R11's) skin. I immediately requested the day nurse, I don't recall her name, and (E3, RN/Registered Nurse, DCD/Director of Care Delivery) come into the room. I showed both of them (R11's) pain patch was off and told them there was no excuse for this, as (R11) has severe pain. (E3, RN/DCD) said Oh, nothing more. They applied another pain patch. I hired a person to come in from 9:00am. to 1:00pm. everyday and I come in from 1:00pm. to 7:30pm. or 9:00pm. everyday. My staff, I hired to come in and care for (R11), came in at 9:00am. today, (1-11-2011) and said (R11) did not have her pain patch on. They had to tell facility staff. Then they put her patch on. Today is the first day staff have asked (R11) about pain and rating the pain." E13, (RN) on 1-11-2011 at 1:45pm. stated, "(R11) did not have her pain patch on this morning. One of (R11's) family members came and told me, around 9:30am. this morning, that her pain patch was missing. I searched (R11's) room, bathroom, bed, bedding, garbage can and could not locate the patch. I checked (R11) and she did not have the pain patch on." After review of R11's MAR for 1-10-2011 and 1-11-2011 at 9:00am. Pain Numeric Rating Scale, E13 stated, "(R11's) pain was an 8 on both days. I applied another pain patch after (R11's) family member told me and I couldn't locate it. Around 9:00am. I gave (R11) a pain pill for right sided pain. Administration is calling the night nurse, (E18/RN), to ask about (R11's) pain patch." R11's MAR indicated [REDACTED]. the last [MEDICATION NAME] was applied 1-8-2011 at 6:00am. E1, (Administrator), E2, (DON), and E3, (Director of Care Delivery) on 1-13-2011, between 9:25am. and 10:20am., all verbally affirmed the Facility did not have a daily or any other policy and procedure or practice of checking, resident's with three day, pain patch application placement. E3, (RN/DCD) on 1-11-2011 at 2:01pm. stated, "I've been the DCD since May 2010. I found out (R11) didn't have her pain patch on this morning. (E13, RN) found out from the family member that (R11's) pain patch wasn't on. We're trying to get ahold of the night nurse, (E18/RN) to see what happened. I don't remember (Z1/R11's Family Member) ever expressing concerns about (R11's) pain patch to me. I just can't remember." On 1-12-2011 at 1:22pm., E3, (RN/DCD) stated, "We faxed to (Z2/Physician), in the afternoon, on 1-11-2011 that (R11) didn't have her pain patch on." The 1-11-2011 at 5:54pm. fax to Z2, (Physician) is, "[MEDICATION NAME] was supposed to be placed on patient at 6:00am., not placed on until 9:30am., for your information." Z1, (Family Member) on 1-13-2011 at 11:40am. stated, "(R11's) pain patch is on her with a date, but no initials or time." On 1-13-2011 at 11:40am. R11 had a [MEDICATION NAME] on the left upper shoulder blade labeled with date of application, no time or initials were labeled. Facility 3-2010 Medication Administration [MEDICATION NAME] Drugs Nursing Procedure is: "Procedure: 8. Label medication administration paper or disk with date, time, and initials." (The B). R11's 1-3-2011 Physician order [REDACTED]." The 1-7-2011 Physician order [REDACTED]., one tablet 30 minutes prior to therapy." R11's 1-7-2011 through 1-12-2011 MAR indicated [REDACTED]. On 1-13-2011 at 9:10am. a request to E2, (DON) for supporting documentation, from 1-7-2011 through 1-12-2011, that R11 had received her [MEDICATION NAME] 5/325mg. pain medication, 30 minutes prior to [MEDICAL CONDITION] therapy. E1, (Administrator) on 1-13-2011 stated, "(Z1/R11's Family Member) did not request in writing, she verbally requested (R11) receive pain medication, ([MEDICATION NAME]), thirty minutes prior to [MEDICAL CONDITION] therapy." On 1-13-2011 at 10:17am. E2, (DON) stated, "There is a notation on (R11's) MAR indicated [REDACTED] (for your information)." R11 on 1-13-2011 at 11:20am. was dusky grey, with eyes closed, and labored speech stated, "I'm sorry I scream, because of my pain, it hurts so bad sometimes. It hurts so bad to sit, I can't hardly stand it. It's all I can do to sit and go to therapy. It's such bad pain." Z1, (R11's Family Member) and Medical Power of Attorney on 1-13-2011 at 11:40am. stated, "I told a staff nurse and (E3/DCD/RN), and put in writing, the request for (R11) to receive her pain medication, [MEDICATION NAME], thirty minutes before [MEDICAL CONDITION]. The doctor, (Z2) gave an order for [REDACTED]." R11's Facility file contained the following untitled, undated notation, "Please give pain pill prior to [MEDICAL CONDITION], Monday through Friday, 11:15am." C). R11's 12-30-2010 Physician order [REDACTED]. one tablet every four hours as needed for 1-5 pain. [MEDICATION NAME] 5/325mg. two tablets every four hours as needed for 6-10 pain. Goal 0 out of 10." R11's 12-30-2010 through 1-11-2011 MAR indicated [REDACTED]. as needed pain medication tablets. R14 has multiple [DIAGNOSES REDACTED]. R14 has had issues concerning her left eye since at least October 2010 according to documentation dated 10/6/10 in the physician's notes. R14 had a change in eye condition which required an emergency visit according to nursing notes dated 12/25/10. Nursing notes dated 12/25/10 10 PM document, "noted redness at the eyeball, grey iris with white pupil. MD paged. Contacted family regarding the change in the eye condition." Nursing notes dated 12/27/10 document that R14 was seen by MD and orders were received for [MEDICATION NAME] drops in left eye for corneal ulcer and [MEDICATION NAME] eye ointment for blepharitis. Physician notes dated 12/30/10 document "Corneal Ulcers OS improving (healing). Still significant inflammation." R14 has physician's orders [REDACTED]." R14 has orders dated 12/27/10 for [MEDICATION NAME] 0.5% eye drops - 1 drop into left eye every 2 hours while awake for a [DIAGNOSES REDACTED].[REDACTED]. R14 did not receive 13 doses of [MEDICATION NAME] 1% eye drops between 12/31 and 1/3/11 according to documentation in the MAR. On 1/12/11 E12 (Director of Care Delivery) stated that the nurse should document the reason on the back of the MAR indicated [REDACTED]. E12 confirmed that there was a lack of documentation regarding the reason these medications were not given.