Every finding on record at Belvidere Health and Rehab

Based on observation, interview, and record review the facility failed to ensure the pureed macaroni and cheese was a smooth consistency, not requiring chewing. This applies to 4 of 4 residents (R30, R17, R38, R44) reviewed for puree diets in the sample of 23. The findings include: Facility provided Thicken Liquids/Fluid Restrictions/Puree form dated 7/1/26 shows R30, R17, R38, and R44 receive Puree Diets. On 7/6/26 at 11:11 AM, V6 (Food Service Director) finished pureeing the macaroni and cheese. V6 tested the consistency of the puree macaroni and cheese and was chewing while V6 said, nobody is going to choke on that. The puree macaroni and cheese appeared chunky as V6 scooped it into a steam table pan. On 7/6/26 at 12:35 PM, the facility provided test tray of pureed macaroni and cheese and pureed green beans was tested by this surveyor. The macaroni and cheese consistency was not smooth, had chunks of macaroni, and required this surveyor to chew. On 7/6/26 at 11:20 AM, V6 said the purees should be a smooth consistency. Chicken broth would be added if the product is too thick and food thickener would be added if the product is too thin. Facility Texture and Consistency-Modified Diets policy, no date, states, . 5. The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered.

Based on observation, interview and record review the facility failed to ensure the prescribed treatment was provided for a resident with a venous ulcer and failed to assess an open wound and obtain treatment orders. This applies to 2 of 12 residents (R2, R7) reviewed for quality of care in the sample of 23. The findings include: 1.R2's face sheet shows he has diagnosis including type 2 diabetes, non-pressure chronic ulcer of left lower leg, peripheral vascular disease and acquired absence of right leg above the knee. On 7/7/26 at 8:51 AM, V8 (Registered Nurse-RN) donned PPE (Personal Protection Equipment) to provide wound care. V8 removed R2's left lower leg dressings. R2's left lower leg was reddened. His skin was dry and scaly, with multiple white patches of cream scattered on his leg with open areas noted. V8 cleansed R2's distal portion of the leg with a wound cleanser but did not cleanse or wash off the white cream. V8 applied the A & D ointment over the white cream, the medicated cream with the moist gauze and wrapped his leg with the elastic bandage. On 7/7/26 at 9:10 AM, V8 (RN) said the white cream is zinc oxide, from a previous treatment order. We try to remove the cream, but his skin is so fragile, and we can't wash the cream off. On 7/7/26 at 12:12 PM, V5 (Wound Nurse) said R2 has a chronic venous ulcer to his left lower leg. The current treatment is to cleanse with the wound cleanser, apply A & D ointment, wet gauze, absorbent pad, and elastic bandage. V5 said R2's treatment orders recently changed, and she updated the orders on 7/6/26. R2 was previously receiving zinc cream. We have been discussing the residual of the cream being on the leg and that's why the treatment was discontinued. The wound physician said staff should be using soap and water to remove the cream and then cleanse the leg with the wound cleanser. V5 stated, I don't see an order for the zinc cream to be applied to his leg, but I know he did. On 7/7/26 at 12:35 PM, R2 was observed in his room sitting in his wheelchair. R2 stated, some of the nurses use white cream and some don't. R2 said a nurse applied the white cream a couple of days ago. They are supposed to wash my leg with soap and water first; not all the nurses change the dressing the same. R2 said for a while it was not healing. R2's Wound Progress note dated 6/25/26 shows left lower venous ulcer measuring 10.5 cm x 11 cm with treatment orders including cleanse with Hibiclens (skin cleanser), apply Dakin 1/2 strength wet to dry, calcium alginate, A & D ointment to peri wound and left lower extremity, secure with absorbent pad (ABD), elastic bandage change twice a day. R2's Treatment Administration Record dated July 2026 shows two concurrent treatment orders to the left lower leg. The first treatment order (Initiated 4/26/26 and discontinued 7/6/26): Dakins (1/4 strength) apply to venous ulcerations topically, Apply A & D ointment to peri wound skin and LLE (left lower extremity). Apply Dakin's half strength moistened gauze to open areas. Cover with calcium alginate then absorbent pad, wrap kerlix, elastic bandage from foot to lower leg, twice a day. The second treatment order (Initiated 6/29/26) Hibiclens (skin cleanser) apply to left lower leg, apply A&D to peri wound skin and LLE. Apply Dakin's half strength solution moistened gauze to open areas. Cover with calcium alginate then absorbent pad, wrap with kerlix and elastic bandage twice a day. The T.AR. shows both treatments were signed off by staff as being administered from 7/1/26 to 7/6/26. R7's face sheet dated 07/07/2026, shows R7 has diagnoses to include diabetes, muscle wasting and atrophy, and schizoaffective disorder. On 07/07/2026 at 8:18am, R7 was in his wheelchair, self-propelling down the hallway. R7's had 2 bandages on his right knee. One of the undated bandages was peeling back exposing pink exudate on the bandage. On 07/06/2026 at 10:33 am, R7 was lying in bed wearing a T-shirt and shorts. R7 had multiple scabs on the lower right leg R7 had two square bordered dressings near their right knee, neither were dated. On 07/07/2026 at 9:23 AM, R7 was sitting in his wheelchair in his room. R7 stated a couple days ago the nurse put these dressings on. These are the same ones from that day. R7 stated they apply ointment (lower scabbed areas) every few days. R7 then proceeded to remove his shoes and socks. The top of R7's left foot second and third toe, top of foot and outer ankle had multiple scabbed areas. The top of R7's right foot and second toe also had several scabs. Resident stated that he scratches his foot on the bed, and he continues to pick his scabs. V11 Registered Nurse walked into R7's room. V11 removed R7's bandages to right knee. There were two open wounds approximately half a centimeter each. V11 was not aware he had wounds to right knee but was aware R7 is to have ointment applied to his legs every night to prevent him from picking at his legs. On 07/08/2026 at 10:30am, V2 Director of Nursing, stated that she was R7's nurse on Saturday 07/04/2026, the 2-10pm shift and there were no bandages on R7's knees or wounds, but he had scabs and pointed to the lower shin area. On 07/08/2026 at 12:18 PM V9 (Registered Nurse) stated she worked Sunday 7/5/2026, the 2-10pm shift with R7. V9 stated she applied the ordered ointment to both lower legs, on his scratches, and she denies seeing any new wounds on R7's right knee. She denied putting bandages on. V9 stated that when there are new wounds, they assess the wounds and notify the wound nurse who assesses the new wounds; and notify the physician for treatment orders. On 07/07/2026 at 3:17pm, V5 Wound Nurse/MDS Coordinator stated, today was first time she was aware R7 had wounds (V5 assessed seven new wounds). V5 stated that facility staff usually alerts her when a resident has a new wound or skin issue. V5 stated that the nurse on duty, if she is not available, can assess the wound and she will follow up on the next shift she works. V5 also stated dressings should not be applied without an order. R7 Physician Order Summary does not show an order for his right knee until 07/07/2026. R7's Initial Skin Impairment/Wound evaluation form dated 07/07/2026 completed by V5, shows the following wounds. Wound #1 Location: right knee Measurement of wound: 0.3x0.2x0.1 Partial thickness Scant sanguineous drainage Wound #2 Location: Right outer leg below knee Measurements: 0.4x0.4x0.1 Partial thickness Scant sanguineous drainage Wound #3 Right inner ankle Measurement: 0.8x0.5x0.1 Partial Thickness Scant sanguineous drainage Wound #4 Left outer ankle Measurement: 0.7x0.5x0.1 Partial Thickness No drainage Wound #5 Location; top of left foot Description: scab Measurements: 7.5x0.3x0 Thickness not documented No drainage Wound #6 Location: R second toe Measurement: 0.5 x 0.5 x 0.1 Partial thickness Scant serous drainage Wound #7 Location: left third toe Measurement: 1 x 0.5 x 0.1 Partial thickness Scant serous drainage R7's Skin Impairment/Wound Evaluation dated 07/07/2026, completed by V5 shows R7's physician was notified and treatment orders were obtained. The facilities wound treatment management policy dated 01/5/2025, shows wound treatments will be provided in accordance with physician orders. In the absence of treatment orders the licensed nurse will notify the physician to obtain treatment orders.

Based observation, interview and record review, the facility failed to implement the recommendations from the criminal history analysis report for a convicted sex offender, and failed to invite residents to their quarterly care plan meetings for 2 of 12 (R7and R39), reviewed for care plans in the sample of 23.The findings include: 1.On 07/06/2026 at 1:35pm, R39 was sitting in his recliner in his room. R39 had a private room and bathroom. R39 stated that he keeps to himself.R39's criminal history analysis security recommendation report dated 10/24/2020, shows R39 is a, convicted and or registered sex offender and must be placed in a single resident room with a private bathroom facility.R39's current care plan shows R39 is an identified sex offender. R39's care plan does not include the resident must be placed in a single resident room with a private bathroom.On 07/08/2026 V1 Administrator, was not aware that the specific recommendations for the private room and bathroom were not care planned. 2.On 07/06/2026 at 1:35pm, R39 was sitting in his recliner in his room. R39 was asked about being invited to participate in his individual care plan meetings to discuss his specific needs, he replied no, they only invite my guardian, not me.R39's Minimum Data Set, dated [DATE], shows R39 has mild cognitive impairment.On 07/07/2026 at 12:49 pm, V4 (Social Worker Director) stated when notifying residents and families of upcoming care plan meetings, she emails or mails the invitation to the family or guardian and verbally tells the residents. She stated that she does not usually document the giving of the invitation or refusals to attend the meeting. She only documents who attends the care plan meeting.3.On 07/06/2026 at 10:06am, R7 was lying in his bed. R7 stated that he is never invited to participate in his care plan meetings. On 07/08/2026 at 9:45am, the facility provided R7's notice of care plan conference invitation dated 03/24/2026 and 6/23/2026. On 07/08/2026 at 9:47am, V4 reviewed R7 care plan conference invitations and stated, this is what I handed R7 for his care plan conference. On 07/08/2026 at 9:54am, R7 was presented with the care plan conference invitations. R7 stated that he had never seen the invitations before.R7's Minimum Data Set, dated [DATE], shows R7 has mild cognitive impairment.R7's Social Service Notes from March 2026 to June 2026 were reviewed. There were no notations of invitations or refusal to attend his care plan conference.The facility's Care Plan Conference Meeting policy, with an implemented date of 01/05/2025, shows, The resident and or family are invited to attend the care conference. An invitation is sent to the families by Social Services or designee.

Based on observation, interview and record review the facility failed to provide the prescribed therapeutic diet for 1 resident (R14) of 12 residents reviewed for therapeutic diets in the sample of 23. The findings include: R14's face sheet shows she has diagnoses including end stage renal disease, type 2 diabetes, dependence of renal dialysis, and cerebral infarct. R14's Physician Order Sheets dated July 2026 shows orders including liberalized diet, double protein all meals, low potassium, and 2000 cc fluid restriction, high protein snack at night. On 7/6/26 at 12:28 PM, the lunch service was observed by a surveyor. At the end of service V6 (Food Service Director) utilized all the regular macaroni and cheese and even the gluten free macaroni and cheese. There were no leftovers after everyone was served their regular portion/meal. V6 scooped every last bit of macaroni and cheese from both the gluten free and normal meals to serve all residents with one portion served to all residents. On 7/6/26 at 12:46 PM, R14's noon plate was served with one bowl of macaroni and cheese and was not served double protein. On 7/6/26 at 3:01 PM, R14 said she received one serving of the macaroni and cheese. I got one bowl of the mac & cheese. On 7/7/26 at 2:14 PM, V6 (Food Service Director) said R14 is on a liberalized renal diet and gets double proteins with each meal. She received one bowl of mac and cheese and the staff came back and got another one.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 3 residents (R2 and R3) reviewed for infection control in the sample of 3. The findings include:R2's Skin Impairment/Wound Evaluation dated 7/19/25 shows R2 has a Stage 2 Pressure Injury of his right buttock. R2's admission Record dated 9/30/25 shows R2's diagnoses include, but are not limited to, Type 2 diabetes mellitus, hypertension, and anemia. R2's current Order Summary Report dated 9/30/25 shows an active order for dressings to the open area on R2's right buttock every other day and as needed. R2's Treatment Administration Records beginning 7/1/25 through 9/30/25 all show R2 has been receiving wound treatments beginning on 7/20/25 through 9/30/25 to his right buttock wound.R3's admission Record dated 9/30/25 shows she was admitted to the facility on [DATE]. The facility's Pressure Ulcer Tracking log dated 9/30/25 shows R3 was identified as having a Stage 2 left buttock pressure injury on 9/3/25.On 9/30/25 at 10:09 AM, V6, Registered Nurse (RN), said R2 is back from his shower, and she is going to do his wound care. V6 used gloved hands, without donning a gown, to clean and dress R2's right buttock wound. There were no EBP or other transmission-based precaution signs on his door or near the entrance to his room and no PPE (personal protective equipment) was outside his room.On 9/30/25 at 09:13 AM, R3's room had no EBP or other transmission-based precaution signs on her door or near the entrance to her room and no PPE (personal protective equipment) was outside her room.On 9/30/25 at 10:21 AM, V3, Wound Care Nurse, said R3 has a stage 2 pressure ulcer on her left buttock, present on admission. V3 said R3 was admitted on [DATE] and is having daily wound treatment.On 9/30/25 at 2:43 PM, V8, RN, said if a resident has some type of wound, staff are supposed to wear a gown, glove and masks when doing wound treatment to protect themselves. V8 said she knows when someone is on EBP they put the order in the computer, place gowns and PPE outside the resident room, and signs outside their door.On 9/30/25 at 2:48 PM, V2, Director of Nursing (DON)/Infection Prevention Nurse, said residents who have pressure wounds require EBP. V2 said EBP are essentially contact precautions directed at potential exposure to the patient. Gloves and gowns are required to be worn with close contact care activities, there are signs on the patient's door that says EBP, and it's in the resident chart. V2 said they do not require a doctor's order to initiate the precautions; nursing can initiate EBP. V2 said wound care is a close contact care activity.The facility's Enhanced Barrier Precautions Policy (implemented 2/25/25) shows it is the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. EBP applies to all residents with wounds. Staff need PPE during high contact resident care such as wound care: any skin opening requiring a dressing. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound.

Based on observation, interview, and record review, the facility failed to assess and implement prevention interventions for 1 of 3 residents (R2) reviewed for pressure wounds in the sample of 3.The findings include: R2's Skin Impairment/Wound Evaluation dated 7/19/25 shows R2 has a Stage 2 Pressure Injury of his right buttock. R2's admission Record dated 9/30/25 shows R2's diagnoses include, but are not limited to, Type 2 diabetes mellitus, hypertension, and anemia. R2's current care plan provided by the facility does not show any skin alterations or wounds and no interventions to treat or prevent further wounds or worsening of existing wounds. R2's current Order Summary Report dated 9/30/25 shows an active order for dressings to the open area on R2's right buttock every other day and as needed. R2's Treatment Administration Records beginning 7/1/25 through 9/30/25 all show R2 has been receiving wound treatments beginning on 7/20/25 through 9/30/25 to his right buttock wound.On 9/30/25 at 10:09 AM, V6, Registered Nurse (RN), said R2 is back from his shower, and she is going to do his wound care. V6 used gloved hands to clean R2's right buttock wound with normal saline and gauze. V6 changed her gloves then applied xeroform and a foam dressing. V6 said R2's dressing change is every other day and as needed.On 9/30/25 at 10:21 AM, V3, Wound Care Nurse, said all skin abnormalities are reported to the primary care provider (PCP) and to herself. V3 said she goes in and assesses the wound and takes measurements, communicates with the wound care doctor, V4, and gets treatment orders. V3 said she does a weekly wound assessment. V3 said she has never assessed R2's wound. V3 said she would have to look at R2's wound to know what type of wound it is. V3 said R2's wound was not brought to her attention, and the wound care doctor has not seen it either. V3 said V4 sees all pressure wounds in the facility.On 9/30/25 at 11:17 AM, V2, Director of Nursing (DON)/Infection Prevention Nurse, said when nursing identifies a skin alteration, they should notify V3. V2 said pressure wounds should be assessed weekly or more often by V3 and V4. The assessment includes measurements, tissue appearance, any undermining or tunneling, odor, and drainage type and amount. V2 said V3 sees all pressure wounds and V4 gets involved with wound treatment at V3's request.On 9/30/25 at 12:20 PM, V4 said he has not seen R2. V4 said it would be new to him if R2 had a pressure wound.On 9/30/25 at 9:03 AM, V7, RN, said V3 does weekly wound measurements and wound treatments.The facility was unable to provide weekly assessments of R2's Stage 2 pressure injury of his right buttock identified on 7/19/25.The facility's Pressure Injury Prevention and Management Policy (reviewed 6/17/25) shows licensed nurses will conduct a full body skin assessment after any newly identified pressure injury. Assessments of pressure injuries will be performed by a licensed nurse and documented. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

2. R41's Physician Order Sheet dated 6/25 show R41 has diagnosis of cerebral infarction hemiplegia and hemiparesis following stroke affecting right side. On 6/24/25 at 8:45 AM, during the initial tour, R41 was in bed with his right contracted arm towards his chest, his right hand with closed tight fist. There was no device noted to R41's right hand. On 6/24/25 at 10:17 AM, R41 was in bed. There was no device noted to R41's right contracted hand. V3 (Registered Nurse) who was with this surveyor said R41 was admitted with contracted right hand and had not noticed the resident with a splint. On 6/25/25 at 8:53 AM, V7 (R41's Niece) during a family interview said her main concerns were R41 being in bed most of the time, his contracted right hand, and that she wants R41 to have exercises or therapy. On 6/25/25 at 1:25 PM, V5 Restorative Nurse said R41 does not have a splint for his contracted right hand. A splint helps to prevent further decline of the contracted hand. R41's last Restorative Assessment was 6/14/24. The facility has no formal restorative program, assessments were done through MDS. On 6/25/25 at 11:45 AM, V8 (Rehab Director) said R41 was just now put on OT (Occupational Therapy) with the recommendation to wear a carrot/splint 4 hours on, 4 hours off for comfort measures. Based on observation, interview, and record review the facility failed to complete quarterly restorative assessments and/or failed to provide restorative services for residents with physical limitations. This applies to 4 of 5 residents (R25, R19, R7, R41) reviewed for restorative services in the sample of 16. 1. On 6/23/2025 at 9:35AM, R25 was observed sitting up in his room in his wheelchair near the door with a right-hand contracture. R25 said they used to do range of motion with him more in the past. On 6/23/2025 at 1:48PM, R19 was observed sitting up in his wheelchair with a brace on his right wrist and a contracture to his right hand. On 6/24/2025 at 1:35PM and 6/25/2025 at 1:26PM, V5 Restorative Nurse said restorative assessment should be completed quarterly. V5 said restorative services are done three times per day (every shift) for residents in restorative. V5 said passive range of motion and range of motion should be addressed every shift. V5 said R25, R19, and R7 had hemiparesis affecting their right dominant side. V5 said R7 has hemiparesis affecting her left side. R25's Task: Restorative Program Passive Range of Motion (PROM) for the last 30 days shows resident received restorative minutes 1 - 2 per day for the last 30 days and no restorative minutes for 6/5/2025 (with no refusal documented on that day). R25's Minimum Data Set (MDS) section GG dated 5/16/2025 lists impairment to one side under functional limitations range of motion for both upper and lower extremities. R19's MDS section GG dated 1/27/2025 lists impartment to one side under functional limitations range of motion for both upper and lower extremities. R7's MDS section GG dated 5/14/2025 lists impairment to both sides under functional limitations range of motion for both upper and lower extremities. The facility failed to provide restorative assessments in 2025 for R25, R19, and R7. The facility provided Restorative Nursing Programs policy, copyright date 2024, states. all residents will receive maintenance nursing services.

Based on interview and record review the facility failed to identify a change in condition in a timely manner. This applies to 1 of 16 residents (R23) reviewed for quality of care in the sample of 16. The findings include: R23's face sheet shows she is a [AGE] year old female admitted on [DATE]. Her face sheet lists her diagnoses to include: peripheral vascular disease, chronic heart failure, non-ST elevation (NSTEMI) myocardial infarction (heart attack), atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness. R23's progress notes dated 6/21/25 at 2:58 PM shows, pt (patient) c/o (complained of) not feeling well, refused breakfast, and lunch. Drank 240cc (cubic centimeter) of fluids at lunch, nothing for breakfast. T99.3 (temperature) Tylenol given at 1230 (12:30 PM) c/o shortness of breath, sats (oxygen saturation) 89% on ra (room air), applied oxygen at 2 liters per n/c (nasal cannula). 1430 (2:30 PM (2 hours later)) reassessed by 2 nurses, abdominal breathing noted and heart rate is irregular. Called V14 Nurse Practitioner (NP), sending to local ER (emergency room) for evaluation . R23's progress notes dated 6/21/25 at 8:04 PM shows, pt admitted to local hospital for non-stemi (heart attack) diagnosis. On 6/24/25 at 11:06 AM, V11 Registered Nurse (RN) stated she was the nurse that sent R23 out on 6/21/25. That morning she was sitting in her room not eating or drinking. R23 was saying she was short of breath and it was hard to breathe. V11 said R23's oxygen saturation was 89% in the morning. She said she notified V14 NP who told her to put oxygen on R23 and keep an eye on her. (There is no documentation in R23's medical record of that conversation/order). She also stated, R23 doesn't normally wear oxygen. When another nurse came in for PM shift, they assessed her together and that is when they decided to send her out. She stated the only documentation was the progress note at 2:58 PM. I should have documented more. The local hospital initial admission note dated 6/21/25 shows, History of Present Illness: Patient reports that she has been short of breath going on for the last few days, denies having any cough. Patient also with increased lower extremity swelling The facility's change of condition process policy dated 2/4/25 shows, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Situations requiring notification include: 2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. This may include: a. life threatening conditions, or b. Clinical complications. 3. A need to alter treatment significantly; that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This may include: a. a new infection or wound. b. Discontinuing a treatment or changing medication due to i. adverse complications. ii. acute condition. iii. Exacerbation of a chronic condition

Based on interview and record review the facility failed to ensure a resident wasn't prescribed an unnecessary antibiotic. This applies to 1 of 6 residents (R23) reviewed for unnecessary medications in the sample of 16. The findings include: R23's progress notes show: -6/12/25- a UA (urine analysis) was ordered and going to be picked up from the laboratory on 6/13/25. -6/13/25- V14 Nurse Practitioner (NP) aware of failed attempt to collect urine on day shift. Lab not here to collect . -6/14/25- urine was collected and awaiting pick up by laboratory. -6/15/25- urine culture noted to be in fridge called laboratory and spoke [to someone who] stated she doesn't understand why specimen was not picked up and now it needed to be entered as STAT (right now) -6/16/25- V14 NP notified that lab did not pickup urine, DON (V2- Director of Nursing) also notified Urine to be sent to another lab in AM per NP. -6/16/25 continue to show: R23's urine specimen was collected and ready for pick up by laboratory. -6/17/25, R23's progress notes show, Nursing manager and writer contacted daughter to update on blood draw and urine collection. Resident will begin a ABT (antibiotic) today -6/18/25, R23's progress notes show, (V14) NP notified about wrong lab picking up residents urine, resident is currently on antibiotic without adverse reaction. R23's electronic medical record does not show, any urinanalysis results. R23's June MAR (medication administration record) shows, Cefuroxime Axetil Oral Tablet 250 MG (milligram), Give 1 tablet by mouth two times a day for presumed UTI (urinary tract infection) for 7 Days. Start Date 06/17/2025, D/C (discharge) Date 06/23/2025. (She received 8 doses). On 6/25/25 at 10:33 AM, V2 DON stated, the facility ordered a UA on R23 because she had decreased energy and not being herself. They had issues with the lab not picking up the urine. They never did get a urine specimen. R23 was started on an antibiotic while they were waiting for the results. On 6/25/25 at 11:40 AM, V14 NP stated, she was aware the facility had issues with the lab picking up R23's urine specimen. They still gave her an antibiotic with out knowing whether it was a UTI or not. They were going to re-check her urine after the course of antibiotic but she was admitted to the hospital. She never had her urine re-checked. The facility's unnecessary drugs dated 1/8/25 shows, Policy: It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Definitions: Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any safer treatments have been deemed clinically contraindicated. Also, inadequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.

Based on interview and record review the facility failed to follow their antibiotic stewardship program to ensure residents weren't prescribed unnecessary antibiotics. This applies to 1 of 6 residents (R23) reviewed for unnecessary medications in the sample of 16. The findings include: R23's electronic medical record (EMR) shows, she was prescribed a antibiotic for a presumed UTI (urinary tract infection). The facility attempted to get a urinanalysis done but the urine specimen was never picked up by the laboratory. R23 remained on the antibiotic without knowing whether she had a indication for it. On 6/24/25 at 1:50 PM during the infection control interview V2 Director of Nursing (DON) stated, the nurses use the McGeer's (set of guidelines used to diagnose urinary tract infections (UTIs) in long-term care facilities) and a SBAR (Situation, Background, Assessment, and Recommendation) to help when determining whether a resident needs a antibiotic or not. She also monitors residents on antibiotics. This is part of the facility's antibiotic stewardship program. R23's EMR does not show a SBAR form for possible UTI or a urinanalysis. The facility's antibiotic prescribing practices dated 1/8/25 shows, Policy: Antibiotic use protocols, including prescribing practices, are implemented as part of the facility's antibiotic stewardship program for the purpose of optimizing the treatment of infections and reducing adverse events associated with antibiotic use. The facility's infection prevention and control program dated 2/25/25 shows, .6. Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. c. The infection Preventionist, with oversight for the Director of Nursing, serves as the leader of the antibiotic stewardship program. d. The medical director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program.

Based on interview and record review, the facility failed to protect a resident (R2) from abuse. This applies to 1 of 3 residents reviewed for abuse in the sample of 9. The findings include: R1's electronic face sheet printed on 10/2424 showed R1 has diagnoses including but not limited to altered mental status, psychosis, and adjustment disorder with mixed anxiety and depressed mood. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and experiences verbal behaviors directed towards others. R1's care plan dated 10/10/24 showed, (R1) demonstrates behavioral distress related to generalized anxiety disorder and adjustment disorder. Problems are manifested by exhibiting physical and verbal aggression. Triggers may include poor impulse control, not personally identifying the situation/environment; demonstrate mood lability, showing little ability to self-regulate anger/temper and mood state . R1's care plan dated 8/7/23 showed, (R1) has a behavior problem he asks staff for sexual favors, tries to intimidate staff members, may use profanity towards staff members and tries to start fights with other residents related to diagnosis and noncompliance with treatment. R2's electronic face sheet printed on 10/24/24 showed R2 has diagnoses including but not limited to delusional disorders, chronic kidney disease, and insomnia. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and experiences verbal behaviors directed towards others. R2's care plan dated 10/26/23 showed, I have a history of mental health problems (psychotic disorder and adjustment disorder) and I display dysfunctional behavior. This problem is manifested by behaving in a derogatory and condescending manner towards others. I am territorial and have a misguided belief that I am entitled to identify areas where peers are allowed to be within the facility. R2's care plan dated 5/23/24 showed, I am challenged by mental illness (psychotic disorder and adjustment disorder) and rigid personality traits. I am impulsive in my judgment/is verbally aggressive & I tend to target female staff with making socially inappropriate comments. I am quick to use provocative words and objectify female staff as a misguided means of asserting my dominance. I have received counseling and requested to refrain from this behavior. However, I do not accept responsibility and falsely alleging I am the victim in the situations I have initiated. The facility's undated Final Abuse Investigation Report showed, Residents (R2) and (R1) both attending community bingo event. Sudden verbal altercation immediately followed by physical aggression when (R1) struck (R2). Staff immediately separated the residents . On 10/24/24 at 9:46AM, R2 stated, We play bingo every few days and we always have the same seats. I got up to go to the bathroom before we started and when I came back (R1) was in my spot. I asked him if he was going to sit there and he said, Not if your stinky a** is going to sit here. I said, Whoa why are you talking like that? and then he punched me in the face five times. My lip was bleeding and bruised but that was it. It's over now but I'm tired of being beat up. On 10/24/24 10:15AM, R1 stated, They put me at (R2's) table and he wasn't there. When he walked up to me, he sat down and was running his mouth, so I punched him in the face a few times. He was bleeding a little from his lip but that's all. I don't feel bad because he has been messing with me for about a year now. I have had enough .I meant to hit him, and it was intended to hurt him specifically. It wasn't a random event. On 10/24/24 at 11:10AM, V5 (Registered Nurse) stated, I was the only staff that witnessed the altercation between (R1) and (R2). I was at the nurse's station while the residents were getting ready to play bingo. (R2) and (R1) were at a middle table in the dining room and they started arguing and yelling at each other. (R2) said something like, Bring it on and before we could get to them, (R1) hit (R2) at least 4 times in the head and face. We separated them immediately and (R2) had some blood coming from his lip and his lip got bruised. We sent (R1) out to the hospital a few days later for a psychiatric evaluation and they added a new medication for him to control his anger. On 10/24/24 at 1:14PM, V2 (Director of Nursing) stated, I was here the day of the altercation between (R1) and (R2). I heard commotion but by the time I got to the dining room, they were already separated. (R2) said to (R1), My sister hits harder than you. I gave (R2) an ice pack because he was bleeding and had a swollen lip. They have not had any issues since this altercation, and we try to redirect them when they are in the same vicinity. I am not the abuse coordinator, but I see where (R1's) actions are viewed as willful and intentional. The facility's policy titled, Abuse Prevention Program dated 10-2022 showed, This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but no limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to ensure sufficient Certified Nursing Staffing from October through December of 2023. This has the potential to affect all residents residing in the facility. The findings include: The facility's document CMS form 671 dated 6/11/24 showed 53 residents residing in the facility. The facility's Facility assessment dated [DATE] showed under nursing services that the number of CNAs (Certified Nursing Assistants) on the evening shift should be 4. The facility's October 2023 CNA schedule showed on 10/7/23, 10/14/23, 10/15/23 10/21/23, 10/22/23, 10/28/23 and 10/29/23 there were 2.5 CNAs scheduled on the evening shift. The facility's November 2023 CNA schedule showed on 11/4/23, 11/12/23, 11/18/23, and 11/19/23 there were 2.5 CNAs scheduled on the evening shift and on 11/25/23 and 11/26/23 there were only 2 CNAs scheduled for the evening shift. The facility's December 2023 CNA schedule showed on 12/3/23, 12/9/23, 12/16/23, 12/17/23, ad 12/24/23 there were 2.5 CNAs scheduled on the evening shift and on 12/10/23 and 12/23/23 there were only 2 CNAs scheduled for the second shift. On 6/13/24 at 12:03 PM, V2 DON (Director of Nursing) said, We had a plan of correction in place toward the end of last year for our staffing. We usually have 2 nurses on day shift, 2 on evening shift, and 1-2 on night shift but we only need one. Our CNA staffing goal is 4 aides up plus restorative on days, 3 and a half on evenings, and 3 on night shift as well. Call off's are handled by asking for staff already here to stay over and see if someone can come in early. If we can't find someone then it falls to us administrative staff to cover. If they are short, then we come in and work as CNAs if that is what is needed. Our Activity Director, Receptionist, and Dietary Manager are all CNAs as well so they can all help if needed. On 6/13/24 at 12:07 PM, V1 (Administrator) said at the end of the year last year it would have been some of their evening staffing that caused them to trigger for the pay-roll based journal staffing. V1 said she struggles with keeping people for evening shift. V1 said at the end of the year (2023) it was that they were short staffed and had a call off issue. V1 said she thinks she fixed that when she hired a couple people but only one stayed. V1 said if the administrative staff covered the floor it was reported in the system so if the facility triggered it would have been an actual shortage. V1 said minimum staffing for CNA's is 4 on day shift, 3 on evening shift, and 2 on night shift. The facility's policy reviewed 6/12/24 showed, Staffing Policy . To have appropriate number of staff available to meet the needs of residents . Staffing is based on a formula for determining numbers and levels of staff and on the needs of the residents . Staffing is supplemented as needed by outside agencies .

Based on observation, interview, and record review the facility failed to ensure multi-dose insulin pens were dated when opened and failed to dispose of an expired medication for 3 of 5 residents (R9, R22, R156) in the sample of 17 and 2 residents (R13, R33) out of the sample. The findings include: 1. R9's June 2024 order summary report showed an order start dated 4/16/24 for Basaglar Kwikpen (insulin) 30 units one time daily. R22's June 2024 order summary report showed an order start dated 3/25/24 for Fiasp Pen-Injector (insulin) four times a day per sliding scale. R156's June 2024 order summary report showed an order start dated 6/8/24 for Glargine Pen-Injector (insulin) 15 units in the morning. R13's June 2024 order summary report showed an order start dated 3/11/24 for Toujeo Pen-Injector (insulin) 15 units every 12 hours. R33's June 2024 order summary report showed an order start dated 3/2/23 for Lantus Pen-Injector (insulin) 40 units every 12 hours. On 6/12/24 at 7:53 AM, the 300-hall medication cart had five insulin pens in the top drawer. The pens were labeled with the names of R9, R22, R156, R13 and R33. All five pens had a white sticker on the side that stated to discard after 28 days. Every pen was missing the date to indicate when it had been opened. V6 (RN-Registered Nurse) was present and stated the pens should have been dated as soon as they were opened. They are only good for 28 days. Without the dates there is no way of knowing when to discard them. Outdated insulin has the potential to be less effective. The facility's Vials and Ampules of Injectable Medications policy dated 1/2018 states: 2 .The date opened and this triggered expiration date are both important to be recorded on multidose vials (on the vial label or an accessory label affixed for that purpose). At a minimum, the date opened must be recorded. 2. On 6/12/24 at 7:53 AM, the 300-hall medication cart had a multi-dose vial of Fiasp insulin labeled with R22's name. The vial was dated with an open date of 4/4/24. V6 (RN) said the medication was no longer any good. It is expired and should have been disposed after the 28 days. On 6/13/24 at 10:49 AM, V2 (Director of Nurses) stated expired medications need to be disposed to prevent accidental use. There is the potential of less effectiveness and a change in how it works. Staff can accidentally use it if it is still left in the medication cart. Insulin pens should be dated as soon as they are opened. If it is used beyond the expiration date it can lose its potency. That is the standard procedure. The facility's Storage of Medication policy dated 9/2003 states: 3. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed.

Based on observation, interview, and record review the facility failed to ensure monitoring a resident on dialysis treatment, failed to ensure emergency equipment for dialysis was at bedside, and failed to care plan treatment for a dialysis patient for 1 of 1 resident (R3) reviewed for dialysis in the sample of 17. The findings include: On 6/11/24 at 7:01 AM, R3 was in her room lying in her bed. The local medical transportation company was in the hallway preparing to pick R3 up and transport her to dialysis treatment. R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage, Chronic Kidney Disease (Stage 4), end stage renal disease, hyperkalemia, acute kidney failure and Type 2 Diabetes. R3's facility assessment dated [DATE] showed she has no cognitive impairment and requires dialysis treatments. R3's Physician Order Sheet showed an order started 1/19/2024, Dialysis at [local dialysis treatment center], Tuesday/Thursday/Saturday at 8:30 AM . R3's Current Complete Care Plan showed no care plan related to R3's dialysis treatment. R3's medical profile showed no name or contact information for R3's dialysis treatment center. R3's January 2024 eTAR (electronic Treatment Administration Record) showed no monitoring of R3's dialysis site. On 6/13/24 at 10:47 AM, V5 RN (Registered Nurse) said communication with the dialysis company is done by fax usually. V5 said recently she had to start a phosphorus binder, we can call or fax them. We don't have to weigh her before or after she comes back. I don't know what her port is called its something I haven't heard of before, its not one where you have to listen to a bruit or a thrill. We do have to monitor the site, we look for swelling or bleeding. We monitor that daily. We don't send any kind of communication with her. If they have new orders they will either send them back with her or fax us. At 11:19 AM, V5 said, I've never had to call the dialysis company but I know she goes to [a local dialysis treatment center] so it would be easy enough to look up their phone number, I would just Google the phone number if I needed to call them. On 6/13/24 at 11:48 AM, V2 DON (Director of Nursing) said, We send them and take care of them when they come back. If there are changes they will either fax them or send them back with the patient. We don't do pre and post treatment weights. They do that there. She had a j graft which clotted so she had a temporary in her chest for a while and then they put one in her left arm. I believe it was going to be a fistula at least that is what they said we were sending her for. I lose track of time as to when she had that done . 3/27/24 is when they did the new access. I don't know if its a fistula because it doesn't specifically say in here (V2 was reviewing R3's medical records.) V2 confirmed the discharge packet from March 2024 showed an AV fistula (arteriovenous fistulas) to the left upper arm. V2 said when R3 comes back from dialysis she should have a dressing in place. V2 said when R3 comes back from dialysis the nursing staff should check that to make sure her site isn't bleeding. V2 said, In general for monitoring the site, they should be checking for redness, warmth, or infection with cares just like everything else. The dialysis center looks at it a lot. It would have a palpable turbulence. In someone who is actively getting dialysis three days a week, its a thought that as an established fistula site, I wouldn't expect them to document monitoring for thrill and bruit every shift. If there was an issue to site, it would be included as a focused assessment. For example, is she was complaining of swelling or pain they would assess for the thrill and bruit as part of that focused assessment. If there were an emergency they would be expected to hold direct pressure over the sit and call for help. There are gloves in all the rooms but no special equipment in her room for an emergency. They would have gowns and gloves on to care for her because she is on enhanced barrier precautions. She should be care planned as being a dialysis patient. The facility's undated policy titled Hemodialysis showed, . To implement processes to promote the comfort, safety, and management of hemodialysis residents . Contractual agreement will include but may not be limited to the following a. Medical and non-medical emergencies. b. Development and implementation of a resident's plan of care. c. Interchange of information useful/necessary for the care of the resident. d. Identifying roles and responsibilities between the facility and the dialysis center Clinical responsibilities might include the following but are determined based on patient needs. a. Assessment and documentation of fistula or graft site. b. Obtaining post dialysis weights as determined by the interdisciplinary team in collaboration with the dialysis center g. Revise and update the resident's care plan as needed.

Based on observation, interview, and record review the facility failed to document the administration of a narcotic on the count sheet and failed to reconcile the count between shifts for 1 of 1 resident (R158) reviewed for pharmacy services outside the sample. The findings include: R158's June 2024 order summary report showed an order start dated 6/7/24 for: Tramadol HCl 50 milligrams oral tablet give 1 tablet by mouth every 6 hours for pain. On 6/12/24 at 7:58 AM, the 300-hall medication cart narcotics box was reviewed with V6 (Registered Nurse-day shift) present. R158's Tramadol card had 19 tablets remaining. The corresponding count sheet showed 20 tablets remaining. V6 stated she caught the miscount this morning when she started her AM shift. V6 said she did the shift change narcotic count with V10 (Registered Nurse-night shift) and realized three doses of the Tramadol had not been signed out on the previous shifts. V6 said V10 corrected the count sheet for the doses she had given. V6 said V9 (Licensed Practical Nurse-PM shift) had given the third dose and that was the one missing tablet on the count sheet. V6 said she did not realize until now that V10 had not given all three doses. V6 said the missed documentation and incorrect count should have been caught between shift change but it was not. R158's electronic medical record did show documentation of the three doses given the day prior. One on the PM shift by V9 and two on the night shift by V10. R158's paper count sheet (already corrected) did show documentation of the two doses given by V10, but nothing documented by V9. R158's shift change sign-out report sheet dated June 2024 was blank for the 6/11 day shift to PM shift change. The report was blank for the 6/11 PM shift to night shift change. The report was blank for the 6/12 night shift to day shift change. On 6/13/24 at 10:49 AM, V2 (Director of Nurses) stated R158's Tramadol was missed on the reconciliation between shifts. Nurses should be signing it out as soon as it is given. That is when the resident received it and the count sheet should be accurately reflecting it. Shift change is a second chance to ensure counts are correct. Two nurses are required to count the remaining doses. Any mistakes should be caught and reported immediately. The facility's undated Narcotic Policy states: 5. Individual Narcotic Sign Out record should include date give(n), time given, dosage, signature of nurse administering medications and number remaining. 7. Two nurses must count narcotics at the beginning and end of each shift, initialing the narcotic count record. The two nurses should be the incoming and outgoing nurse. 8. If there is a discrepancy in the narcotic count, the DON should be notified immediately.

Based on observation, interview, and record review the facility failed to ensure physician orders and interventions were in place for oxygen administration for 1 of 1 resident (R28) reviewed for oxygen in the sample of 17. The findings include: R28's face sheet printed on 6/12/24 showed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, and presence of cardiac pacemaker. R28's facility assessment dated [DATE] showed moderate cognitive impairment. On 6/11/24 at 7:56 AM, R28 was asleep in bed. Oxygen was running via a nasal cannula at 1.5 liters per minute. At 10:57 AM, R28 was seated on the edge of his bed and the oxygen tubing was next to him. The oxygen was still running at 1.5 liters per minute. R28 stated he wears the oxygen at night while he is sleeping to help with his breathing. R28 said he occasionally puts it on himself during the day if he is napping. On 6/12/24 at 9:42 AM, R28 was out of his room. The oxygen condenser was still located next to his bed. At 12:50 PM, R28 was out of his room and the oxygen was running at 1.5 liters per minute. R28's order summary report and care plan printed on 6/12/24 did not include any physician orders or care interventions related to the oxygen use. On 6/12/24 at 1:08 PM, V5 (Registered Nurse) stated R28 uses the oxygen when he is sleeping. It is for his COPD (chronic obstructive pulmonary disease). I think it needs to be set at 2 liters per minute. V5 reviewed R28's electronic medical record and said she did not see any orders for it. V5 said he needs physician orders to indicate the rate of flow, when to change the tubing, if humidification is needed, and things like that. He should have a care plan for the use of the oxygen too. The interventions are important to ensure he is being monitored for hypoxia and when to check his oxygen saturation levels. On 6/12/24 at 1:14 PM, V2 (Director of Nurses) stated R28 definitely needs orders for the oxygen administration. Oxygen is a medication and requires a physician order. Incorrect use of oxygen can cause respiratory distress or dependency. V2 reviewed R28's medical record and confirmed there was no physician orders or care interventions for the use of the oxygen. The facility's undated Oxygen Administration policy states: 1. Obtain or review order from the physician for oxygen administration. The order should include flow rate and method of administration. 4. Monitor resident during oxygen administration. 5. Document use of oxygen and response to oxygen administration.

Based on observation, interview, and record review the facility failed to ensure a resident was free of restraints for 1 of 1 residents (R156) reviewed for restraints in the sample of 17. The findings include: On 6/11/24 at 9:40 AM, R156 was lying in bed on his right side, curled up. R156 had a blue cast extending from his upper arm down to his hand, in a flexed position. The right side of R156's bed was pushed against the wall and the left side of his bed had a side rail pulled up. The side rail extended from R156's shoulder area to his ankles. R156 was facing the wall. The side rail was only able to be placed in the up and down position from someone outside of the bed. R156 would not be able to remove it himself. On 6/12/24 at 10:42 AM, R156 was lying on his right side in bed with the side rail pulled up. On 6/13/24 8:55 AM, R156 was in bed, lying on back with bent knees, facing the left side rail. R156 was rocking his knees, as if trying to sit up. R156's left arm in a blue cast and he was unable to use it to grab the left side rail. R156 continued to rocked his knees and upper body, but was unable to sit up or move much in the bed. R156 made no attempts to use his right arm to grab the side rail on the left side of the bed. R156 just continued the rocking motion. At 9:34 AM, the surveyor was in the hallway outside R156's room, facing his room during an interview with V7 (CNA - Certified Nursing Assistant). R156 was in the same position and wiggling his legs, like he was trying to wiggle down in bed, to get around the side rail. V7 said R156 had dementia and yells out for his wife most of the day. V7 said he doesn't do a lot of activity. V7 said R156 was admitted with the cast because he fell and broke his arm at home. V7 said R156 can usally roll side to side during care, but can't use his hands to hold on to anything. V7 said R156 wouldn't be able to put the side rail down himself. V7 said R156's side rail was a fall precaution. V7 said R156 is a fall risk, that's why he's close to the nurses' station. V7 said R156 was admitted from the hospital with a Fall Risk band on his arm. During interview, resident continues to have restless legs and attempts to wiggle his body down the bed. R156 finally yelled out, [his wife's name]! V7 looked in the room and told R156 she'd be in a minute. R156 settled. At 9:40 AM, R156 started the rocking and wiggling motion with his legs again. R156 had gotten his feet closer to the edge of the bed, but his legs were resting up against the side rail. R156 yelled, [his wife's name]! V11 (CNA) went into R156's doorway and asked if he needed help. R156 replied, I have to go to the bathroom. V7 and V11 (CNA's) assisted R156 to the bathroom. R156's Facesheet printed 6/13/24 showed he was admitted on [DATE] with diagnoses to include, but no limited to: left arm fracture, atrial fibrillation, stage 4 CKD (chronic kidney disease), diabetes, dementia, CHF (congestive heart failure), dysphagia, and depression. This document showed R156 was admitted for m a local hospital. The Advance Directive portion of this document was blank (no information was entered). R156's Physician Order Sheets did not contain an order side rails for mobility, nor did it contain an order for restraints. R156's EMR (Electronic Medical Record) was reviewed. The Form tab did not include a Side Rail Assessment for Mobility, Restraint Assessment or a Consent form for Restraint Use. The Misc tab (where scanned documents can be viewed) did not contain either of these assessments. R156's Care Plan did not address side rails usage for mobility or restraint use. R156's Fall Risk completed 6/1/24 showed he was a High Fall Risk. On 6/13/24 at 9:41 AM, V8 (RN - Registered Nurse) said R156 was admitted to the facility after a fall. V8 said R156 broke his arm and came to the facility with the cast on his left arm. V8 said R156 is alert to person only most of the time, but occasionally he's more oriented and can answer appropriately. V8 said R156 is a fall risk. V8 said she thought the side rail on R156's bed was more for repositioning in bed. V8 acknowledged that the side rail was on the same side as R156's coasted arm and he would not be able to use his left arm to grab the side rail, but he might be able to reach over with his right arm. V8 said there should be an assessment for side rails. V8 reviewed R156's chart and said she didn't see a side rail assessment. The surveyor asked V8 if R156's side rail could be considered a restraint. V8 replied, Possibly, he wouldn't be able to get up on his own. The surveyor asked if R156 had a Restraint Assessment. V8 replied, I don't see that either. If the side rail was used as a restraint then there should be be a consent form also. On 6/13/24 at 9:55 AM, V3 (MDS Coordinator/Restorative Nurse) said she had several duties at the facility. V3 said R156 is fairly new at the facility. V3 said R156 was admitted to the facility after some falls at home and a broken arm. V3 said R156 is at the facility for rehab and needs extensive assistance from staff for ADLs (Activities of Daily Living). V3 said R156's abilities fluctuate from being described as dead weight to him trying to get himself up. V3 said she is responsible for completing Side Rail Assessments. V3 said a Side Rail Assessment is found in the Forms tab of the EMR. The surveyor asked V3 if R156 had an assessment. V3 replied, He doesn't have one in here. I have not done an assessment with him. I usually do those with the MDS schedule and I haven't done one on him yet. I'll be doing it this week. The surveyor asked if R156's side rail could be considered a restraint. V3 replied, If it's preventing him for getting out of bed, then it would be a restraint. We try not to use restraints here. If it was a restraint, then we would completed a Restraint Assessment and obtained consent from the family. V3 said R156 did not have a Restraint Assessment or a Restraint Consent in the EMR. V3 said if something restricts a resident's movements, then they would try other things. V3 said there should be a care plan in place for side rails and restraints. V3 said R156's care plan did not address the use of side rails. The facility's undated Side Rail Policy provide on 6/13/24 showed, Side rails may be used for mobility, and or positioning . All residents are assessed for side rail use upon admission. 2. Based on the assessment a determination of how many and which side rails are used is made . The facility's Restraint Policy revised 8/4/22 showed, To ensure residents are provided a safe environment and the use of restraints is carefully monitored to protect resident rights, personal comfort and safety, assuring the least restrictive means are used. Guidelines: Residents are admitted with a Physician's Order for restraint use shall have a restraint use assessment performed and a physician order obtained for the release of restraints with supervision during the assessment process, as appropriate, or an order to discontinue use. 2. Periodic assessments shall address the resident's status in an effort to reduce or eliminate restraints whenever possible and assure the restrictive method is used which allows the resident to function at their highest practicable level . 4. Restraint assessments are performed at a minimum with the initial application, change in type of restraint and change in the resident's condition which affects how the resident responds to current treatment. 5. Less restrictive measures such as pillows, pads, low beds, removable trays, or behavior plans together with appropriate exercise shall be considered prior to use of more restrictive restraints . 10 . The Care Plan should reflect specific circumstances and medical symptoms for restraint sue. In the event restraint use is altered, the Care Plan will be revised.

Based on observation, interview, and record review the facility failed to ensure a resident had an order or care plan for advance directives for 1 of 1 residents (R156) reviewed for advance directives in the sample of 17. The findings include: R156's Facesheet printed 6/13/24 showed he was admitted on [DATE] with diagnoses to include, but no limited to: left arm fracture, atrial fibrillation, stage 4 CKD (chronic kidney disease), diabetes, dementia, CHF (congestive heart failure), dysphagia, and depression. This document showed R1 was admitted for m a local hospital. The Advance Directive portion of this document was blank (no information was entered). R156's Progress Note dated 6/1/24 showed he was R1 was a Full Code. R156's Physician Order Sheets did not contain an order for Advance Directives. R156's EMR (Electronic Medical Record) did not contain a scanned POLST (Practitioner Orders for Life-Sustaining Treatment). R156's Care Plan did not have address Advance Directives prior to 6/13/24 (after surveyor interviewed V4 (SSD - Social Services Director). ON 6/13/24 at 9:41 AM, V8 (RN - Registered Nurse) said she had worked at the facility almost 2 years. The surveyor asked V8 what the facility's Advance Directives process was. V8 replied, It's in their chart, on the Face Sheet. When a resident comes from the hospital, the nurse gets report and the resident records from the hospital. The nurse will enter the order for advance directives and it will show up here. V8 opened R156's EMR and stated, Oh, it's not here. Usually it will show up here (V8 pointed near the resident picture and profile information in the upper left area of the computer screen). It may also be on the Facesheet. (V8 opened R156's Facesheet). This is blank. There should be Advance Directives listed in both these places. He doesn't have either. The surveyor asked V8 to check the Physician Order Sheet and she replied, There should be an order, but I don't see one. V8 said V4 (Social Services) also reviews advanced directives with the residents and families and enters the a care plan. V8 said she doesn't know why R156's EMR doesn't have an order for advanced directives, advanced directives entered on the Facesheet, nor a care plan for advanced directives. V8 said it's important to ensure this information is in the EMR to ensure the resident's wishes are being followed in an emergency. On 6/13/24 at 10:08 AM, V4 (SSD) said R156 was admitted to the facility, from the hospital, after falling at home and breaking his left arm. V4 said R156 had dementia and had severe cognitive impairment. V4 said R156's wife visits him frequently, in the evenings. The surveyor asked V4 what the facility's Advanced Directives process was. V4 replied, The nurse gets report from the hospital. The hospital should state if resident is Full code or DNR. The nurses would enter the order (into the EMR). The survey asked V4 to reviewed R156's EMR. V4 said R156 did not have an order for Full code, didn't have a POLST form, and he did not have an Advanced Directive Care Plan. V4 said the nurse should have entered the order and she should have initated the care plan. V4 stated, I take responsibility for the care plan. I don't know why his chart doesn't have this information. I'm usually very on top of things. I'll do it right now. The facility's Advance Directives Policy effective 5/3/22 showed, To ensure that all residents and/or resident representatives are informed concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. Advanced Directives shall not be required as a provision of service or admission. Guidelines: For purposes of this policy and procedure Advanced Directives means instrument, such as a living will or life prolonging procedure declaration, appointment of health care representative and power of attorney for health care purposes. These directives are established under state law and relate to the provision of medical care when the individual is incapacitated. 1. At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law .

Based on observation, interview, and record review the facility failed to ensure the facility's ice machine was free of a black mold like substance. This has the potential to impact all 53 residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions of Residents form dated 8/7/23 shows the total number of residents within the facility is 53. On 8/9/2023 at 10:40AM, the facility's ice machine was observed to have black mold like spots on a plastic piece of the machine above the ice hopper full of ice. There was also a black mold like substance on a seal at the top of the ice hopper folding door. On 8/9/2023 at 10:50AM, V4 said the ice machine was the only ice machine in the building. V4 Dietary Manager said the ice machine was used for all the residents in the facility. V4 said maintenance staff are responsible for cleaning the ice machine. On 8/9/2023 at 11:02AM, V5 Maintenance used a paper towel to wipe the seal and plastic piece inside of the ice hopper with black mold like spots. A dark brown or black color appeared on the paper towel after V5 wiped the paper towel past those areas. V5 said I eat that ice all day and that's gross, that shouldn't be that way after wiping the ice machine with a paper towel. The facility provided Ice Machine Cleaning Log states, . clean and sanitize parts of the ice machine considered food contact surfaces .

Based on observation, interview, and record review the facility failed to follow physical therapy recommendations for a resident with a contracture. This applies to 1 of 5 residents (R31) reviewed for restorative services in the sample of 15. The findings include: R31's electronic medical records show his diagnoses to include: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and cerebral infarction. R31's physical therapy discharge summary dated January 26, 2023 shows, Discharge recommendations: .Right AFO (ankle foot orthoses) to prevent worsening of plantarflexion (foot/ankle) contracture. On August 7, 8 & 9th, 2023, R31 was observed sitting up in his wheelchair at various times throughout the survey. He was wearing a sling on his right arm. He did not have any other braces/splints on. His right foot had a mild contracture. On August 9, 2023 at 9:30 AM, R31 stated, he did not have a brace (AFO). He was never assessed for one. He would wear it if he had one to help his right foot. On August 9, 2023 at 10:13 AM, V3 Restorative Nurse stated, the recommendation was missed. R31 was never assessed or received an AFO following his physical therapy recommendations. The facility's guidelines for use and care of orthotic devices (no date) shows, Guideline: Residents requiring orthotic devices for support, immobility or contracture prevention will have such devices applied and removed as ordered .

Based on observation, interview, and record review, the facility failed to ensure a resident (R1) was free from mental abuse, failed to ensure a resident (R2) was not denied goods to maintain comfort. These failures resulted in R1 experiencing increased emotional lability and R2 experiencing increased anxiety and anger. These failures apply to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. The Immediate Jeopardy began on 10/16/21 when V3 Registered Nurse restrained R1 in his room by holding the door shut not allowing R1 to exit his room. The Immediate Jeopardy was identified on 10/20/21. V1 (Administrator) was notified of the Immediate Jeopardy on 10/26/21 at 11:38AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/26/21, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. The findings include: 1) R1's electronic face sheet printed on 10/21/21 showed R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 9/25/20 showed, (R1) demonstrates significant mood distress related to [CONDITION(S)], major depressive disorder, and social isolation. R1's care plan dated 9/25/20 showed, (R1) demonstrates a pattern of situational and/or coping problems in areas such as: psychosocial well-being, mood state and/or behavioral symptoms. Intervene on an incidental or episodic basis to re-direct behavior symptoms that impact others. On 10/20/21 at 8:58AM, V1 (Administrator) stated, V3 (Registered Nurse-RN) told me that (R1) got up out of his chair and she thought he was going to hit her so she closed the door and held it so he could calm down. (R1) said that (V3) came in his room and grabbed his arm and shook it and he called her a [OBSCENITY] and then she called him a bastard. I have started my interviews and am basically done with my investigation. (R1) has a history of telling people he is mentally retarded and that we hold it against him that he's a sex offender. On 10/20/21 at 9:04AM, R1 stated, On Saturday night (10/16/21) I had my door cracked open and (V3) came and shut my door. I went and opened it and then she kept closing it so I told her I was going to knock the[OBSCENITY]out of her if she didn't leave it open. After that, she closed the door and held it closed so I couldn't get it open. I tried like hell several times to open that door and I almost fell trying so hard. I was starting to panic because I just wanted my door open like it always is. I wasn't going to do anything to her. She finally let go of the door and I was able to open it. I went to bed because I was scared of what she would do to me. She came in my room awhile later and grabbed my arm and shook it and I called her a [OBSCENITY] and she called me a rotten bastard. I don't have any marks on me where she grabbed my arm but it hurt like hell. My stomach hurt when I saw her come into work last night and I was so scared of her this morning when she gave me my medication that I didn't talk to her at all. I don't know why they would let her work when she just did this to me a few days ago. I should have stayed calm the other night but I was so upset with her that I said those bad things to her and now I feel bad. Throughout interview with R1, he was anxious and tearful and kept repeating that he did not want to be kicked out of the facility and he never should have told anyone about it because now the staff are all going to be upset with him and be mean to him. On 10/20/21 at 9:42AM, V6 (Certified Nursing Assistant-CNA) and V7 (RN) stated, It is never appropriate to hold a residents door closed. This would be isolation and entrapment which are both forms of abuse. If we are ever fearful of a resident we assure the resident is safe, and call for help. You never close a resident in their room and prevent them from getting out. That could lead to increased behaviors and have long-term effects on a resident such as anxiety and fear. We have both worked with (V3-RN). Residents don't necessarily say she is abusive but they all call her a [OBSCENITY] and say she is very gruff with them and doesn't care about them. She has zero compassion for these residents. On 10/20/21 at 10:40AM, V8 (RN) stated, At no time is it acceptable to hold a resident's door shut as this is considered isolation. If a resident becomes agitated you are to try and deescalate the situation and re-approach later if necessary. On 10/20/21 at 11:09AM, V5 (CNA) stated, (R1) is pretty independent and very rarely does he get angry. He get obsessed over things but I wouldn't call him aggressive at all. I was working the night (10/16/21) that (V3) and (R1) got into an argument over his door being open. I heard them arguing while I was at the other nurses station. I got up to see what was going on, saw (V3) holding (R1's) door closed and asked if everything was ok and (V3) let go of the door and said everything was fine. (V3) told me that they were arguing because she told him he had to go to bed because it was late and she was trying to shut his door to make him go to bed. In my opinion she is not appropriate with the residents. She is not nice to them and I wouldn't want her taking care of my family after seeing how she talks to some of the residents. On 10/20/21 at 12:10PM, V3 (RN) stated, On Saturday night (10/16/21), I was asking (R1) why he didn't go to bed. He got mad and I thought he was coming after me so I held the door shut until I heard him sit back down. He tried to open the door a few times but I wouldn't let him until I heard him sitting down. This was a reaction to protect myself. The CNA working at the other end of the building (V5) heard what was going on and asked if everything was ok and I told her it was fine. What I did wasn't abuse, it was self-defense. It didn't last long, maybe 30 seconds or so. The next time I went into his room was for his morning medications on Sunday morning (10/17/21) and he didn't say anything to me, just took his medicine. I was suspended Monday night (10/18/21) but then came back to work on Tuesday night (10/19/21) because the investigation was over. I worked on (R1's) hall and gave him his morning medication this morning. He didn't talk to me at all and just took his medicine and turned away from me. On 10/21/21 at 8:46AM, V1 (Administrator) stated, I think this might just be how (V3) acts. It's just the way she is and that's just the attitude she always has. I guess I don't really consider this abuse but I definitely need to look into it if she is going to continue working here. A lot of times she is the only nurse in the building at night so that might be a problem. On 10/21/21 at 9:40AM, V9 (Licensed Practical Nurse-LPN) stated, (R1) has obsessive behaviors, he obsesses over medications and treatments. He does get loud and follows staff around sometimes but he has never tried to hurt anyone. He just doesn't understand his boundaries. (V3) and (R1) have always butted heads. (V3) is short and to the point and is not a warm person. She doesn't tolerate resident behaviors and doesn't take the time to try and calm them down. I received nursing report from (V3) on Sunday morning after the incident (10/17/21). (V3) told me the argument started because she wanted his door shut because his rocking chair was making noise. She said he got up quickly from his chair so she held the door shut until she heard him sit back down. On 10/21/21 at 10:26AM, V10 (psychiatrist) stated, I do not see (R1) being an aggressive person at all. When his name comes to mind the last thing I think of is aggression. 10/19/21 was my first visit with him although we have seen him before in my hospital. None of the staff reported any aggressive or angry behaviors to me. They all stated his behaviors are obsessive and sexual so that's what I am focused on with him. If anything negative happens with him he becomes very emotionally labile and is fearful that something bad will happen to him. He is a very high acuity and complex patient that requires a lot of patience and care as far as emotions go. On 10/21/21 at 11:03AM, V2 (Director of Nursing) stated, When an allegation of abuse is made, the perpetrator and victim are separated immediately. If it is a staff to resident abuse allegation I think the staff member might not be allowed to work with the resident but I'm not sure for how long. I think it depends on what the allegation is. On 10/21/21 at 12:50PM, V1 stated, I was first notified about the incident between (R1) and (V3) on Monday (10/18/21). I began my investigation and suspended (V3). I thought I was done with my investigation because nobody was telling me anything so I brought (V3) back to work on Tuesday night. I had her statement and I told her that if another issue came up with (R1) that another staff member should take care of him. There isn't always another nurse available so (V3) may have access to (R1) at times but not very often. I did continue to interview staff on 10/20/21 but for the most part my investigation is done. The facility's in-service titled, Abuse dated 4/7/21 showed V3 did not attend the annual in-service on abuse for 2021. The facility's policy titled, Abuse Prevention Program dated 2/7/17 showed, This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property, and mistreatment by anyone including but not limited to facility staff, other residents .unreasonable confinement or involuntary seclusion means the separation of a resident from other residents or from their room or confinement to their room against the resident's will .VI. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse will be removed from resident contact immediately. The employee shall not be permitted to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse is unsubstantiated. 2) R2's electronic face sheet printed on 10/21/21 showed R2 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan dated 10/20/21 showed, (R2) has a behavior problem. He can be very argumentative and demanding. Anticipate and meet needs. Caregivers to provide opportunity for positive interactions. On 10/20/21 at 9:25AM, R2 stated, The nurse last night came into my room and I told her to get me a blanket. She said that I had to say please and again I said get me a blanket. She said I had to say pretty please so I did and then she left the room and never got me one. I was freezing for the rest of the night. On 10/20/21 at 9:28AM, V7 (Registered Nurse) stated, (V3-RN) was the nurse working this side last night and took care of (R2). On 10/20/21 at 9:35AM, V1 was informed by surveyor of R2's allegations of the incident involving R2 and (V3). V1 stated, (R2) is really on a kick today. He complains about everyone and everything all the time. I don't even know if this even happened. For all we know he made it up. I guess I will have to suspend (V3) again. I don't even know if I need to investigate this or report it. This is just how (V3) is with the residents. The facility's nursing schedule showed V3 worked on 10/19/21 from 10:00PM-6:00AM. V3 was allowed access to R2 at this time. R2's behavior tracking for 10/19/21 showed no behaviors exhibited on 10/19/21. On 10/20/21 at 12:10PM, V3 stated, I went into (R2's) room around 5:30AM on 10/20/21 to give him his morning medicine and check his blood sugar. He asked me for a blanket and was snooty with me and said Get me a blanket in a mean tone. I said to him Do you know how to say please? Then he said pretty please and told me to do what I was told. I left the room and continued passing medications for other residents. I didn't get him a blanket because they were all the way down on the other end of the hall and I must have forgot to get it for him. He's always demanding things and it's ridiculous. R2's nursing progress notes for 10/19/21-10/21/21 were reviewed and no documentation was present regarding the alleged incident between V3 and R2. The Immediate Jeopardy that began on 10/16/21 was removed on 10/26/21 when the facility took the following actions to remove immediacy: Park Place of Belvidere Abatement Plan for Immediate Jeopardy on 10/26/21: Vice President of Clinical Services in-serviced (V1) on 10/21/21 and (V2) on 10/25/21 on the following: -Policy and Procedure for investigating allegations of potential abuse -The abuse prevention program-with emphasis on definition and examples of events with a potential to be considered unreasonable confinement or involuntary seclusion -Reviewed regulatory requirements for abuse -Instructed to notify nurse consultant with all details of events to ensure thorough investigation is conducted Developed and implemented a Self-Report checklist form on 10/21/21 for facility to utilize to ensure each component required for a comprehensive investigation is completed-also utilize form for communication with nurse consultant. Conducted training with (V1) on using the new form on 10/21/21. Conducted a comprehensive investigation regarding (V3) holding the door closed on resident (R1). Final investigation completed 10/22/21. Resident and staff interviews were conducted 10/22/21 to ensure all allegations have been reported and subsequently investigated appropriately. Five resident and five staff interviews will be conducted weekly by (V11) or designee for 90 days to ensure all allegations of abuse have been identified at the facility. The Self-Report checklist form will be completed by (V1) on an ongoing basis and submitted to the nurse consultant for review with each allegation that has the potential to be abuse to ensure a comprehensive investigation (including all required components or pertinent data) has been completed or obtained. The nurse consultant will audit each self-report checklist form on an ongoing basis to ensure all investigative data is obtained and investigation is thorough. Audits will be submitted to the quality assurance committee monthly for further review and/or recommendations. All managers were in-serviced on 10/26/21 on Facility Abuse Prevention Program with emphasis on reporting any and all events with the potential for abuse including unreasonable confinement, and instructed to contact nurse consultant, corporate or Illinois Department of Public Health (IDPH) for issues that are not investigated or addressed appropriately at the facility level. All staff in-service by their department manager either in person or over the phone on Abuse Prevention Program will be conducted with emphasis on reporting any and all events with the potential for abuse including unreasonable confinement. Additionally, staff will be instructed to contact nurse consultant, corporate or IDPH for issues that are not investigated or addressed at the facility level. All staff will be in-serviced prior to the start of their next shift. On 10/26/21 at 3:30PM, V1 Administrator provided documentation that 41/52 staff members had received training and education on the facility's abuse policy, reporting of abuse allegations, and protection of residents during an abuse investigation. V1 stated that all remaining staff were not currently working in the building but will be in-serviced prior to the start of their next shift.

Based on interview and record review, the facility failed to provide a resident (R1) with an antipsychotic medication for 19 days after returning to the facility from an inpatient psychiatric stay at a local mental health facility. This failure resulted in R1 continuing to experience sexual and obsessive behaviors. This failure applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's electronic face sheet printed on 10/21/21 showed R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 9/25/20 showed, (R1) demonstrates significant mood distress related to [CONDITION(S)] and major depressive disorder. R1's care plan dated 9/30/20 showed, (R1) has a behavior problem he masturbates on a pink stuffed animal and also makes inappropriate comments to staff r/t major depressive disorder, recurrent, unspecified. R1's care plan dated 9/25/20 showed, (R1) demonstrates a pattern of situational and/or coping problems in areas such as: psychosocial well-being, mood state and/or behavioral symptoms. This appears related to [CONDITION(S)] and major depressive disorder, recurrent, unspecified. Symptoms are manifested by: Cognitive deficits (poor reasoning, poor judgement) Lack of self-confidence, self-esteem, and self-worth. Mood distress/anger/anxiety/sadness/[CONDITION(S)]. Conflictual relationships with staff and peers. Distress over lost/changing roles, status. R1's psychiatric note from R1's nurse practitioner dated 9/14/21 showed, Patient had inpatient psychiatric hospitalization on [DATE] for increased bizarre behavior and sexually acting out behaviors in addition to [CONDITION(S)]. Patient was stabilized and discharged back to facility on 8/27/21 with prescription for [MEDICATION(S)] 7.5mg .In the last 2 weeks the patient has gotten progressively more behavioral including increased sexual thoughts, obsessing over sexual thoughts and medications as well as religious preoccupation. Medications were reconciled from discharge from inpatient psyche and [MEDICATION(S)] had been decreased upon readmission to the facility to 5mg will increase [MEDICATION(S)] back to 7.5mg every evening starting 9/14/21. R1's local hospital discharge medication orders dated 8/27/21 showed, [MEDICATION(S)] 7.5mg every night for 30 days. Next dose due this evening. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not receive any [MEDICATION(S)] on 9/15/21. R1's MAR for September 2021 showed R1 did not begin receiving the [MEDICATION(S)] 7.5mg dose until 9/15/21. On 10/21/21 at 9:40AM, V9 (Licensed Practical Nurse) stated, When a resident returns from the hospital, the admitting nurse goes through the medication list, calls the physician to verify orders, and transcribes any new orders onto the resident's MAR. If a physician does not agree with a medication ordered from the hospital then the nurse will enter that information into a progress note. If there is no progress note then the assumption is that the orders were all agreed upon by the physician. If a resident is not given the correct dose of their antipsychotic medications that can lead to increased behaviors and possibly mental status changes. If a resident receives the incorrect dose of this class of medications for weeks that would be considered a significant medication error. On 10/21/21 at 10:26AM, V10 (R1's psychiatrist) stated, (R1) is on [MEDICATION(S)] for [CONDITION(S)]. He has chronic psychotic disorders dating back to his childhood. He was hospitalized at my hospital in August 2021 for psychiatric behaviors and medication management. I was not aware that he had not received the full dose of his [MEDICATION(S)] that was prescribed to him during the August hospitalization . He very likely would have had an exacerbation of symptoms. He is probably one of the most intense residents I have at the facility as far as complexity and his medications should be given exactly as ordered. Negative situations will make him emotionally labile and he will be fearful that something bad will happen to him. It takes a great deal of patience and care for someone to take care of a resident as complex as he is and it just makes things worse for him when his medications are not given as ordered. I just increased his [MEDICATION(S)] again and if he would have been given the full dose when he returned from the hospital, there is a good change we would be ahead of the game with (R1) and his behaviors. On 10/21/21 at 11:03AM, V2 (Director of Nursing) stated, Medication reconciliation is performed when a resident is new or a readmission to the facility. All medications should be confirmed with the resident's physician and if it is approved then the medications are put onto the MAR. If they are not approved, then the nurse enters a progress note into the resident's chart indicating why a medication was not continued. All medications should be given as ordered. Antipsychotics should be given at the ordered dosage. Failure to do so could result in increased behaviors. R1's nursing progress notes dated 8/28/21 showed, Educated repeatedly today that he cannot sit nude in his chair. He stated he showered and was drying and then he would get dressed. Hours later still nude. Door kept closed although he reopens at times and tries to sit with a blanket barely covering himself. The facility's undated policy titled, Admission/Readmission showed, 12. The admitting nurse completes the nursing assessment and obtains admitting orders. Once the admitting orders are verified, the orders are transcribed onto the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to protect a resident (R1) from further potential abuse during an abuse investigation after an allegation was made regarding potential abuse from a nurse. The facility failed to remove a staff member alleged of abuse from working prior to the completion of an abuse investigation. The nurse witheld care to R2 by not providing a blanket. These failures contributed to a nurse having access and withholding care to R1 and R2. R1 was experiencing crying episodes, increased anxiety, increased obsessions, fear of being discharged from the facility, and fear of V3 (Registered Nurse) taking care of him. R2 experienced increased anxiety and anger. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. The findings include: 1) R1's electronic face sheet printed on 10/21/21 showed R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 9/25/20 showed, (R1) demonstrates significant mood distress related to [CONDITION(S)], major depressive disorder, and social isolation. R1's care plan dated 9/25/20 showed, (R1) demonstrates a pattern of situational and/or coping problems in areas such as: psychosocial well-being, mood state and/or behavioral symptoms. Intervene on an incidental or episodic basis to re-direct behavior symptoms that impact others. On 10/20/21 at 8:58AM, V1 (Administrator) stated, V3 (Registered Nurse-RN) told me that (R1) got up out of his chair and she thought he was going to hit her so she closed the door and held it so he could calm down. (R1) said that (V3) came in his room and grabbed his arm and shook it and he called her a [OBSCENITY] and then she called him a bastard. I have started my interviews and am basically done with my investigation. (R1) has a history of telling people he is mentally retarded and that we hold it against him that he's a sex offender. On 10/20/21 at 9:04AM, R1 stated, On Saturday night I had my door cracked open and (V3) came and shut my door. I went and opened it and then she kept closing it so I told her I was going to knock the[OBSCENITY]out of her if she didn't leave it open. After that, she closed the door and held it closed so I couldn't get it open. I tried like hell several times to open that door and I almost fell trying so hard. I was starting to panic because I just wanted my door open like it always is. I wasn't going to do anything to her. She finally let go of the door and I was able to open it. I went to bed because I was scared of what she would do to me. She came in my room awhile later and grabbed my arm and shook it and I called her a [OBSCENITY] and she called me a rotten bastard. I don't have any marks on me where she grabbed my arm but it hurt like hell. My stomach hurt when I saw her come into work last night and I was so scared of her this morning when she gave me my medication that I didn't talk to her at all. I don't know why they would let her work when she just did this to me a few days ago. I should have stayed calm the other night but I was so upset with her that I said those bad things to her and now I feel bad. Throughout interview with R1, he was anxious and tearful and kept repeating that he did not want to be kicked out of the facility and he never should have told anyone about it because now the staff are all going to be upset with him and be mean to him. On 10/20/21 at 10:04AM, V12 (R1's guardian) stated, On 10/19/21 I was visiting (R1) at the facility when he reported to me that on 10/16/21 he had his door partially open and the nurse (V3) came and shut the door. He stated they were arguing and she held the door shut so he couldn't open it. When she finally let go he opened the door and then laid down in his bed and she came back into his room and he called her a [OBSCENITY] and she called him a bastard and grabbed his arm and shook it. He said he is scared of (V3). I reported this to (V1) during my visit on 10/19/21 and she said she knew about it but hadn't reported it yet because she had not spoken with (V3) yet. (V1) stated she knew (R1) was lying but would report it anyway. It is very unusual for (R1) to complain and he usually minimizes things. In the past he has reported to me that (V3) is passive aggressive with him and does things like turn the ice machine off so he can't get ice at night. On 10/20/21 at 12:10PM, V3 (RN) stated, On Saturday night around 1:30-2:00AM, I was asking (R1) why he didn't go to bed. He got mad and I thought he was coming after me so I held the door shut until I heard him sit back down. He tried to open the door a few times but I wouldn't let him until I heard him sitting down. This was a reaction to protect myself. The CNA working at the other end of the building (V5) heard what was going on and asked if everything was ok and I told her it was fine. What I did wasn't abuse, it was self-defense. It didn't last long, maybe 30 seconds or so. The next time I went into his room was for his morning medications on Sunday morning and he didn't say anything to me, just took his medicine. I was suspended Monday night but then came back to work on Tuesday night because the investigation was over. I worked on (R1's) hall and gave him his morning medication this morning. He didn't talk to me at all and just took his medicine and turned away from me. On 10/20/21 at 1:15PM, R1 stated, Why would they let (V3) come back to work and take care of me? Please don't let her come back, she's going to do something to me now that I told you guys what happened. I just know it. Please help me. R1 began obsessing over V3 returning to work, began shaking his legs uncontrollably and he began to cry. On 10/21/21 at 8:46AM, V1 (Administrator) stated, I think this might just be how (V3) acts. It's just the way she is and that's just the attitude she always has. I guess I don't really consider this abuse but I definitely need to look into it if she is going to continue working here. A lot of times she is the only nurse in the building at night so that might be a problem. On 10/21/21 at 11:03AM, V2 (Director of Nursing) stated, When an allegation of abuse is made, the perpetrator and victim are separated immediately. If it is a staff to resident abuse allegation I think the staff member might not be allowed to work with the resident but I'm not sure for how long. I think it depends on what the allegation is. On 10/21/21 at 12:50PM, V1 stated, I was first notified about the incident between (R1) and (V3) on Monday. I began my investigation and suspended (V3). I thought I was done with my investigation because nobody was telling me anything so I brought (V3) back to work on Tuesday night (10/19/21). I had her statement and I told her that if another issue came up with (R1) that another staff member should take care of him. There isn't always another nurse available so (V3) may have access to (R1) at times but not very often. I did continue to interview staff on 10/20/21 (after V3 had been cleared to work on 10/19/21) but for the most part my investigation was done. In my opinion these instances constitute abuse and never should have happened. I don't know what (V3) was thinking. These should have been reported to me right away and they weren't. The facility's nursing schedule for 10/19/21 showed V3 worked from 10:00pm-6:00am and was the only nurse in the facility during these hours. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's final investigation report dated 10/22/21 showed, Based on the resident's behavior triggering an emergency response to provide a barrier for a brief period, the facility could not substantiate that abuse occurred; however, the nurse (V3) was terminated for failure to meet facility expectations. The facility's policy titled, Abuse Prevention Program dated 2/7/17 showed, This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property, and mistreatment by anyone including but not limited to facility staff, other residents .unreasonable confinement or involuntary seclusion means the separation of a resident from other residents or from their room or confinement to their room against the resident's will .VI. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse will be removed from resident contact immediately. The employee shall not be permitted to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse is unsubstantiated. 2) R2's electronic face sheet printed on 10/21/21 showed R2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's facility assessment dated [DATE] showed R2 has mild cognitive impairment. R2's care plan dated 10/20/21 showed, (R2) has a behavior problem. He can be very argumentative and demanding. Anticipate and meet needs. Caregivers to provide opportunity for positive interactions. On 10/20/21 at 9:25AM, R2 stated, The nurse last night came into my room and I told her to get me a blanket. She said that I had to say please and again I said get me a blanket. She said I had to say pretty please so I did and then she left the room and never got me one. I was freezing for the rest of the night. On 10/20/21 at 9:28AM, V7 (Registered Nurse) stated, (V3-RN) was the nurse working this side last night and took care of (R2). On 10/20/21 at 9:35AM, V1 was informed by surveyor of R2's allegations of the incident involving R2 and (V3). V1 stated, (R2) is really on a kick today. He complains about everyone and everything all the time. I don't even know if this even happened. For all we know he made it up. I guess I will have to suspend (V3) again. I don't even know if I need to investigate this or report it. This is just how (V3) is with the residents. The facility's nursing schedule showed V3 worked on 10/19/21 from 10:00PM-6:00AM. V3 was allowed access to R2 at this time while the investigation was still ongoing for R1. V3 was allowed access to all residents in the facility before the abuse investigation involving her was completed. R2's behavior tracking for 10/19/21 showed no behaviors exhibited on 10/19/21. On 10/20/21 at 12:10PM, V3 stated, I went into (R2's) room around 5:30AM on 10/20/21 to give him his morning medicine and check his blood sugar. He asked me for a blanket and was snooty with me and said Get me a blanket in a mean tone. I said to him Do you know how to say please? Then he said pretty please and told me to do what I was told. I left the room and continued passing medications for other residents. I didn't get him a blanket because they were all the way down on the other end of the hall and I must have forgot to get it for him. He's always demanding things and it's ridiculous. R2's nursing progress notes for 10/19/21-10/21/21 were reviewed and no documentation was present regarding the alleged incident between V3 and R2.

Based on observation, interview, and record review, the facility failed to implement the appropriate use of personal protective equipment (PPE) in a manner to prevent the spread of COVID-19, failed to prohibit symptomatic direct care staff from working, failed to transport bio hazardous material in a manner to prevent the spread of COVID-19, failed to isolate residents as a Person Under Investigation (PUI), failed to cohort residents with similar COVID-19 statuses, and failed to follow isolation precautions to prevent the spread of COVID-19. These failures resulted in an outbreak of COVID-19 among staff and residents that resulted in 46 residents and 25 staff members becoming COVID-19 positive. This applies to all 58 residents in the facility reviewed for infection control. The Immediate Jeopardy began on November 2, 2020 when the facility received positive COVID-19 tests for 4 staff members and 10 residents. The Immediate Jeopardy was identified on 11/20/20. V1 Administrator was notified of the Immediate Jeopardy on 11/20/20 at 10:34AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 11/23/20, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and education on employee illness. The findings include: The facility census sheet printed on 11/17/20 showed 58 residents residing in the building. 1. On 11/17/20 at 8:40AM, V9 (maintenance) came to the front desk wearing an N95 face mask with a full beard hanging down to his chest. V9 was not wearing any eye protection. On 11/17/20 at 8:50AM, V3 (Registered Nurse) was walking from the front desk through the facility with no eye protection. On 11/17/20 at 9:55AM, V7 (acting Administrator) was observed wearing an N95 mask with a full beard. V7 stated he has not been FIT tested for his N95 mask. On 11/18/20 at 9:45AM, V11 (dietary aide) stated, I tested positive for COVID on 11/9/20. At first they had us wearing a gown, mask, gloves, and face shield but now that we aren't going down the hallways we just have to wear surgical masks and a face shield. When we are in the kitchen we just have to wear a surgical mask and no eye protection. On 11/17/20 at 10:12 AM, V8 (Regional Nurse) stated, If anyone is in the general area of the facility, they are to wear either a surgical mask or N95 mask. No eye protection is needed unless they are providing direct patient care. If staff are on any of the hallways, I expect them to have at least a surgical mask on with their N95 mask and face shield available in case they need to do patient care. Staff wearing an N95 mask should be clean-shaven to ensure a proper seal is achieved. On 11/18/20 at 10:53AM, V8 stated, If dietary staff are down on the hallways they should be wearing N95 masks and face shields. If they are in the common area then they only need an N95 mask. 2. On 11/17/20 at 9:40AM, V13 (housekeeper) was observed cleaning room [ROOM NUMBER] that was marked as contact/droplet isolation. V13 came out of the room with her gown, gloves, face shield, and mask on. V13 went to the clean linen cart on the 300 hall and then re-entered room [ROOM NUMBER] without removing her personal protective equipment (PPE). V13 stated she is unsure if she is allowed to leave the room with personal protective equipment (PPE) on to obtain clean linens. On 11/17/20 at 10:30AM, V14 (Certified Nursing Assistant-CNA) was working on the 100 hall (COVID-19 positive hallway). V14 took her gown and gloves off, tied 4 biohazard bags shut, walked out of the 100 hall while touching the door handle. V14 walked through the front of the facility and out the front door with the biohazard bags in her hands. V14 re-entered the facility and came back to the 100 hall. V14 tied 4 more biohazard bags shut with no gloves on, walked out of the 100 hall again and through the front of the facility with the remaining 4 biohazard bags. V14 re-entered the facility and came down the 100 hall before performing any hand hygiene. On 11/17/20 at 4:41PM, V15 (local health department COVID response staff member) and V16 (local health department Public Health Administrator) stated, Staff should not be in COVID positive areas without full PPE on and definitely should not be carrying biohazard bags through the facility. This is all very concerning to us. 3. On 11/18/20 at 9:35AM, V17 (CNA) stated, I tested positive for COVID-19 on 11/9/20. I was working on the 200 hall taking care of positive and negative residents before I tested positive. I don't recall the facility asking me what residents I worked with prior to testing positive. On 11/17/20 at 10:12AM, V8 stated, I believe our outbreak started around 11/2/20 with testing. If a staff member tests positive we look at the date they last worked, where they worked, and if they were within 6 feet of anyone. On 11/18/20 at 10:53AM, V8 stated, If a staff member reports to work with symptoms we would do a rapid COVID test and send them home. I don't remember any conversations with the local health department regarding staff caring for positive and negative residents. On 11/17/20 at 4:41PM, V15 and V16 stated, The facility is putting negative residents at risk by having the same staff caring for COVID positive and negative residents. Staff should be dedicated to caring for positive patients only. By allowing staff to care for positive and negative residents at the same time puts the negative residents at risk for contracting [MEDICAL CONDITION]. The facility's COVID census report showed, R9-R13 all reside on the 300 hall. R9-R13tested positive for COVID-19 on 11/10/20 and 11/11/20. The facility's policy titled Infection Prevention and Control COVID-19 Interim Policy revised on 10/16/20 showed, Employees who have signs and symptoms of COVID-19 while on the job should: i. Immediately stop work and self-isolate at home. Ii. Inform the Director of Nursing, Infection Preventionist or designee, and include information on individuals, equipment, and locations the person came in contact with. 4. On 11/17/20, R14 was located in a room on the 100 hall under contact/droplet isolation for a positive COVID-19 test on 11/9/20. R15 was sharing room with R14 and is COVID-19 negative with last known positive COVID-19 test on 5/2/20 (6 months prior). The facility's report of room changes showed R14 was moved to room with R15 on 11/4/20. The facility's census form printed on 11/18/20 showed R14 and R15 continue to reside in the same room together. The facility's policy titled Infection Prevention and Control COVID-19 Interim Policy revised on 10/16/20 showed, Residents with confirmed COVID may be transferred to the COVID unit and cohort with other COVID positive residents. The Centers for Disease Control article titled Duration of Isolation and Precautions for Adults updated on October 19, 2020 showed, .the probability of [DIAGNOSES REDACTED]-CoV-2 reinfection if expected to increase with time after recovery from initial infection due to waning immunity. As the COVID-19 pandemic continues, we expect to see more cases of re-infection. 5. The facility's report of room changes and COVID positive census showed R13 tested positive for COVID-19 on 11/11/20. R4 was R13's roommate at the time he tested positive. R4 was moved to another room on 11/12/20. R4 was not placed on contact/droplet isolation precautions as a Person Under Investigation after possible exposure from R13. On 11/17/20, R4 was in room and no isolation precautions were posted on his door or being taken by staff entering and exiting R4's room. On 11/17/20 at 10:12AM, V8 stated, If a resident tests positive for COVID and their roommate is negative, the roommate is moved out of the room. I'm not sure if we place them on isolation or not. I'm just filling in for the Infection Preventionist so I'm not sure what all they do in this specific facility. The CDC article titled, Response to COVID-19 showed, Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). The Immediate Jeopardy that began on November 2, 2020 was removed on 11/23/20 when the facility took the following actions to removed the immediacy: The facility conducted an immediate audit on 11/20/20 for the following: -Employees with facial hair utilizing N95 respirator. -Visualization of all employees to ensure donning of appropriate PPE - including eye protection while out on the unit/hall or providing care. -A COVID symptom screening was completed for each employee currently at the facility to ensure no employee is working while experiencing symptoms of COVID. -Appropriate implementation of isolation for PUIs - to include implementation of TBP and signage on the door to alert staff. TBP were implemented and signage placed on the door for the resident identified by surveyor. -Review of cohorting residents with active or history of COVID infection with a resident of negative or unknown COVID status. Resident identified as having a history of COVID past 90 days currently has recovered roommate and not a roommate with active infection. -Biohazardous waste will not be transported through the front of the building - system for transporting will be revised. The facility will complete inservicing for each employee currently working on 11/20/20 and for each employee prior to starting their next scheduled shift accordingly (employees who are off work due to illness/personal leave will not be allowed to return to work until inservices are completed either telephonically or in person and each will be contacted on 11/20/20).As of 11/20/20 no employee will be allowed to start their shift without completing inservicing. Staff in servicing will be completed on 11/24/20. -All male staff will be inserviced on being clean shaven for wearing a N95 or restrictions that will be imposed if not clean shaven. -All staff will be inserviced on wearing eye protection appropriately. -All staff will be inserviced to stop work immediately if experiencing COVID symptoms and report symptoms to supervisor. -Nurses and supervisors/management will be inserviced to remove an employee form work who reports COVID symptoms and notify the Administrator immediately. -Staff who handle biohazardous material will be inserviced on transporting safely and performing appropriate hand hygiene when handling biohazardous material. -Nurses, DON and Administrator will be inserviced on implementing TBP for PUIs and placing the appropriate signage to alert staff. -DON and Administrator will be inserviced to audit recovery date of a previously COVID positive resident when cohorting with an infectious COVID positive residents A follow up visit was made on 11/23/20 at 10:35AM. V1 Administrator stated that all but 2 staff members were able to be reached to deliver the in-service training. At this time, 96% of staff members have been in-serviced on proper application and removal of PPE, biohazardous wasted and linen removal, employee illness policy related to COVID-19, proper cohorting of residents with similar COVID statuses, transmission-based precautions. when to isolate a resident with possible COVID-19 exposure and symptoms of COVID-19. V1 stated that the 2 remaining staff members will not be working at the facility until they have received the training. Interviews were conducted with staff present at the facility who all confirmed they have received in-service training prior to starting their shifts since 11/20/20.

Based on observation, interview and record review the facility failed to identify three pressure ulcers on a resident's buttocks and sacrum and left heel prior to being classified as Stage 3 and Unstageable. The facility also failed to put interventions in place to prevent worsening of the wounds and to assist with healing. These failures resulted in R1 developing an unstageable discoloration to her Left heel on 5/1/19, an unstageable open wound on her right buttocks on 5/4/19, and a stage 3 pressure ulcer on her sacrum on 5/6/19. The facility also failed to ensure a resident's heel lift boots were applied correctly to prevent his heels from resting on the bed. This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 3. The findings include: 1. R1's (MONTH) 2019 physician's orders [REDACTED]. R1's Minimum Data Set (MDS) of 4/6/19 shows that R1 scored a 3 on her BIMS (Basic Interview for Mental Status) showing severe cognitive impairment. This same document shows that R1 is always incontinent of bowel and bladder and requires extensive assist of 2 staff for bed mobility and transfers. R1's Skin Observation Form dated 5/1/19 shows an area to left heel 4.7 x 6.4cm described as discoloration. R1's Skin Observation Form dated 5/4/19 shows an open area to right buttocks measuring 1.5 x 1.0 x 0.1cm. (There is no further description of the wound). The Specialty Physician Wound Evaluation and Management Summary dated 5/6/19 shows that R1 received an initial evaluation of 3 wounds: Site 1: Unstageable Deep Tissue Injury of the Right Buttocks measuring 1.8 x 0.9 x 0.1cm. It is described as 40% Thick adherent devitalized necrotic tissue, 20% slough and 40% skin. treatment for [REDACTED]. Recommendations include Off-load wound and reposition per facility protocol. Site 2: Stage 3 Pressure Wound Sacrum measuring 0.8 x 0.4 x 0.1cm. It is described as 100% granulation tissue. Recommendations include Off-load wound and reposition per facility policy. (This wound was not previously identified by facility staff) Site 3: Unstageable Deep Tissue Injury of the left heel measuring 4.3 x 6.5 x Not Measurable cm. It is described as Unstageable deep tissue injury with intact skin. Recommendations include Off-load wound, reposition per faciltiy protocol and sponge boot. The Specialty Physician Wound Evaluation and Management Summary dated 5/13/19 shows that R1's right buttocks wound and sacrum wound have had no change. Throughout the survey on 5/14/19, R1 did not have any type of pressure reducing mattress on her bed nor was there a pressure reducing cushion in her wheelchair. On 5/14/19 at 10:15AM, V7 (CNA Supervisor) assisted R1 after R1 was incontinent of bowel and bladder. V7 completed the care without any other staff assisting her. When trying to turn R1 onto her right side to perform pericare, R1 pushed her hand against the wall not allowing V7 to turn her off of her right buttocks. V7 stated, She is pushing back, I can't turn her. As R1 was turned partially on her right side it was observed that there was no dressing covering R1's sacral wound. R1's right buttocks wound was not able to be visualized at this time. V7 stated she was not aware that R1 had wounds on her buttocks. R1 was also observed to have multiple quarter-sized, deep red areas of petechiae (pinpoint round spots) on her left buttocks. V7 stated she was not sure what that was caused by and proceeded to position R1 onto her right buttocks by placing a wedge cushion under her left hip. On 5/14/19 at 10:50AM, V3 (RN) completed the dressing changes on R1's wounds. R1's left outer heel showed a golf-ball sized open area with a moderate amount of serosanguineous drainage. The wound bed appeared beefy red and there was a large fluid fill blister just above the open wound bed. R1's right buttocks showed a deep, dime-sized area with a brownish red center and a small amount of serosanguineous drainage. R1's sacrum showed a pencil eraser sized area with a dry, dark gray wound bed. There was no dressing covering the wound. V3 was asked about the areas of petechiae on R1's left buttocks. V3 did not seem concerned and stated it looked like the scratches on R1's shins. All dressings were completed as ordered then R1 was positioned back onto her right buttocks as V6(CNA) placed the wedge cushion under R1's left hip. At 12:25PM R1 was still positioned on her right side with her head elevated while she was being fed her lunch in bed. At 1:47PM R1 remained positioned on her right side with the wedge pillow under her left hip. On 5/14/19 at 1:00 PM, V2(Director of Nursing) was asked why R1's pressure ulcers were not found prior to becoming unstageable. V2 stated, I can't answer that for (R1). She gets care every shift, she is incontinent. V2 was asked how often skin checks are done on residents. V2 stated, In general it is based on risk. The CNAs document on skin every shift. If they see something there is a place that they can document it in (EMR-Electronic Medical Record) or on the shower sheet. If they see something they should report it to the nurse. The Task Section of the EMR (where the CNAs document) shows a heading of skin condition. When activated this section shows that barrier cream is to be applied to resident's buttocks following each incontinent episode. The month of (MONTH) 2019 shows multiple checkmarks daily under the yes column. There is no further documentation of R1's skin condition under this area and no documentation related to open areas on R1's buttocks, sacrum or left heel. R1's Shower Sheet dated 5/1/19 shows R1 has redness on her left heel and scratches on shins, the Shower Sheet dated 5/5/19 shows no skin issues, the Shower Sheet dated 5/8/19 shows no skin issues and old wound (there is no documentation of where the old wound is located), and the Shower Sheet dated 5/12/19 shows no issues and scratches on shins. R1's Braden Scale for Predicting Pressure Score Risk dated 1/5/19 shows that R1 scored a 17, At Risk. On 5/14/19 at 1:20PM V5 (Assistant Director of Nursing) stated, The Braden scale should be done quarterly. It should have been done in March. I must have missed it. V5 also stated, The air mattresses are better if they have pressure. V5 not sure why R1 did not have an air mattress on her bed. R1's current care plan does not address her pressure ulcers. The facility policy entitled Pressure Ulcer Prevention date 7/25/16 states the following: - All individuals, regardless of mobility must be assessed for pressure ulcer development on admission, weekly for the first four weeks after admission, then quarterly using a valid pressure ulcer risk assessment. - An integral part of any skin care program is a systematic skin assessment. It is through these inspections that early skin problems can be detected and intervention started. Assessment must continue according to an appropriate schedule. Staff should evaluate skin condition and should pay attention to bony prominences. - All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours . - All residents assessed to be at risk for breakdown should be placed on a pressure reducing overlay. 2. R2's (MONTH) 2019 physician's orders [REDACTED]. This same document shows that R2 has an order for [REDACTED]. The Minimum Data Set of 3/1/19 shows that R2 requires extensive assist of two staff for bed mobility and is totally dependent on two staff for transfers. R2's Braden Scale for Predicting Pressure Sore Risk dated 3/7/18 (provided by the facility when asked for the most current) shows that R2 scored an 18, At Risk. R2's current Care plan states, At risk for impaired skin integrity related to impaired mobility, friction and shearing and moisture related to incontinence. This care plan does not address R2's use of the Pressure Relieving Protection boots. On 5/14/19 at 12:30PM R2 stated, I need new boots. These don't do anything. I have told many people but they don't do anything. They should hold me feet straight and they don't do that. R2 pulled the blanket up and showed surveyor his feet. The boots were on but the velcro straps were not fastened to hold them in place. R2's heels were both resting on the bed. R2's right ankle was turned inward (towards his left foot) and his left ankle was turned outward. On 5/14/19 at 12:35PM, V8 (RN) stated, (R2) has had foot drop for a long time. The boots are to protect his feet. On 5/14/19 at 12:45PM, V7 (CNA Supervisor) stated, That is it how the boots are supposed to be on. His heels are resting on the bed. The facility policy entitled Pressure Ulcer Prevention dated 7/25/16 states, Residents who are constantly immobile should have pressure reducing devices used to totally relieve pressure on heels and raise heels completely off the bed.

Based on interview and record review the facility failed to identify the cause of a resident ' s fall, failed to implement interventions to provide a safe place for R1 to sleep, and failed to supervise R1 to prevent a fall. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure contributed to R1 falling and sustaining a Subdural Intracranial Bleed on [DATE]. The findings include: R1 ' s facility face sheet shows R1 had [DIAGNOSES REDACTED]. R1 ' s admission fall assessment dated [DATE] shows R1 was at high risk for falls due to " intermittent confusion, medications, and predisposing diseases." R1 ' s care plan dated [DATE] shows R1 is high risk for falls related to confusion, deconditioning, wandering, and impaired cognition secondary to dementia. R1s progress notes dated [DATE] at 17:19 (5:19pm) show " at 1430 (2:30PM) resident fell forward out of chair he was sitting in ...When we got him up asked resident what happened he said " I fell asleep." Has small laceration above right eye-steri strips applied, small bump also to same area, neuro checks have been started ...Resident on daily 325mg aspirin so he was sent to ER ... " R1 ' s [DATE] 3:56 PM progress notes shows " hematoma to right forehead. Ecchymosis to right eye, forehead and check. 2 steri-strips intact to forehead ... " R1s [DATE] at 9:18 PM progress note shows " at 1845 (6:45 PM) I was alerted by another resident that R1 had fallen out of chair. I first to arrived and observed resident face down on floor by 300 nurses station, resident has laceration above left eye and bump, resident state he did have pain ...3 steri strips applied, ice bag to forehead ... " R1 ' s Incident/Accident Report dated [DATE] shows " resident (R1) was in chair behind me ...he fell out of chair landing on forehead, when we got resident up he said he fell asleep." This report shows " Resident is recently admitted to facility. He is ambulatory and confused ...He fell asleep in chair at nurse station, falling forward and striking his head. Resident is generally very busy ambulating through the facility. He would greatly benefit by lying down and taking a rest in the afternoon. This should prevent the drowsiness that prompted the fall." R1 ' s [DATE] Incident/Accident report shows " I was alerted by another resident (R1) had fallen out of chair while sitting by 300 nurse station ...(R1) said " I was sleeping then I was on the floor somehow." This report shows " (R1) is ambulatory and wanders through the facility. He will occasionally sit down to chat and become drowsy. Staff attempt redirection to bed for a nap ...Occasionally he will deny being tired and refuse to go ...He may awaken ,[DATE] minutes later and resume walking. " R1 ' s [DATE] at 11:56 PM progress note shows " at 2300 neuro check resident was very lethargic, would not wake up ...obtained ok to send resident to ER ..." R1 ' s Emergency Department physician documentation dated [DATE] at 12:04 AM shows " [AGE] year old male presents to ER ...with complaints of ...fall injury, Unresponsive." The [DATE] at 1:28 am ER note shows " [DIAGNOSES REDACTED]. On [DATE] at 2:10 PM, E3 (Licensed Practical Nurse- LPN) said he was working both days R1 fell . E3 said R1 was new to the facility and he cared for him most of the ,[DATE] shifts since he was admitted . E3 said R1 was " very confused " and he " couldn ' t understand why he was here." E3 said after the first couple days at the facility R1 " got it through his head that he would not sleep in his room because there was another guy in there." E3 said R1 would say " I ' m not sleeping with another guy " and R1 would not go in his room and sleep. E3 said he was getting report at the nurse station on [DATE] and R1 " fell forward out of the chair." E3 said after the first fall, if the staff members saw R1 sitting in the hall they were to " keep an eye on him (R1) and try to get him to lie down in bed." E3 said if they took R1 to his room he would come back out and wander in the halls or sleep in chair at the nurse station. E3 said he was working the second time R1 fell from the same chair. E3 said R1 was sitting in the same place, and in the same chair (located at the 300 wing nurse station). E3 said " I left and went to the side dining room to let the smokers out and another resident came and told me he fell and was laying on the floor." E3 said R1 was sitting in a regular, hard back chair (like in the dining room) and there were no witnesses to the fall because he was in another room and the Certified Nurse Assistants (CNA ' s) would have been laying other residents down for bed. E3 said when he assessed R1, R1 said " I was sleeping and next thing I know I was on the floor." E3 said R1 had a laceration to his head from the fall. E3 said after the second fall he moved a recliner to the nurse station so R1 could sleep in it and recline back. E3 said R1 could put his feet up in the recliner and lay back which was " safer to sleep in than the other chair " . E3 said no changes were made after R1 fell the first time except to try to get him to lay down in his bed. E3 said R1 would not sleep in his room but would lay down on the physical therapy bed outside the dining room, sleep in the dining room chairs, or sleep in the chair outside the nurse station. E3 said after R1 fell the second time he called R1 ' s wife to let her know. E3 said R1 ' s wife told him to talk to R1 about fishing trips he used to take and remind him he slept in a cabin with men for many years. E3 said about an hour after talking with R1 about the fishing trips, R1 agreed to go sleep in his room. E3 said prior to this R1 would sleep in chairs in the hallway or wander throughout the facility during the night. E3 said every time they tried to direct him to his room he would come back out to the hall. E3 said he was not sure if another room was offered to R1 but the Director of Nursing - DON, and " all staff " knew R1 was not sleeping in his room. On [DATE] E4 (CNA) said she had provided care for R1. E4 said R1 was very confused and would wander a lot during the night. E4 said R1 would not sleep in his room and would say " I have never slept with a man for [AGE] years and I ' m not going to now." E4 said R1 would " a lot of times go to the dining room on second shift " or he would sit in the chair by the nurse station and sleep. On [DATE] at 3:00 PM, E5 (LPN) said R1 was confused and would pace a lot. E5 said they would try to redirect R1 to his room on day shift and he would " become agitated and attempt to leave." E5 said R1 would not stay in his room on day shift, and would often sit in the chair in the hall outside of the 300 wing nurse station. On [DATE] at 1:00 PM, E2 (DON) said R1 was a high risk for falls on admission to the facility. E2 said R1 was confused and would wander throughout the facility. E2 said R1 fell two separate times on ([DATE] and [DATE]) from the same chair, located in the same spot. E2 said R1 hit the right side of his head with the first fall, and the left side of his head with the second fall. On [DATE] at 2:40 PM, E2 said after the first fall, the only intervention added was to lay R1 down after meals so he would not fall asleep in the chair. E2 said R1 would leave his room and come out to hallway, wander around, and fall asleep in the chair at the nurse station. E2 said there was an issue with R1 not staying in his room. E2 said the fact R1 was not sleeping in his room should have been care planned and attempts at a room change should have been made. E2 said the family should be interviewed about possible ways to fix the problem. E2 said after the first fall, another chair could have been put at the nurse station to help prevent R1 from falling. E2 said a recliner could have been used or a reclining wheelchair which would prevent R1 from falling forward. On [DATE] at 2:45 PM, E6 (Social Service Director) said R1 was very confused. E6 said she was not aware that R1 would not sleep in his room. E6 said if she had been made aware, she would have talked to R1 and his family to identify what the problem was, or met with the inter-disciplinary to come up with interventions to get him to sleep in his room. E6 said she also would have tried to move R1 to a different room if he did not get along with his roommate. On [DATE] at 11:15 AM, Z1 (Medical Physician) Z1 said he would expect the facility to identify why R1 was falling. Z1 said " yes " the facility should have provided a safe place for R1 to sleep if he did not want to sleep in his room. Z1 said after a fall occurs he would expect them (facility) to assess the situation and put new interventions in place to prevent the fall from happening again. Z1 said " according to the sequence of events" ; R1 ' s subdural hematoma was a result of the fall. On [DATE], R1 ' s fall care plan was updated to include one additional intervention to "Encourage resident to lie down for a rest/nap after lunch d/t falling asleep in chair." There were no interventions to address that R1 would not sleep in his room, or to provide a safe alternative place for R1 to sleep. There were no interventions to change the chair available outside the nurse station for R1 to sit/sleep in. There were no interventions to increase supervision for R1. The ,[DATE] facility policy " Fall Prevention Program " shows " The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents ...The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary ...Fall incident reports will be studied t codetermine any significant factors that may have caused the fall and to identify additional fall prevention strategies that may be indicated. "

Based on interview and record review the facility failed to provide the necessary care and services for R1 by not identifying a rapidly declining condition; not treating a critically low blood sugar; not immediately calling Emergency Services, and not initiating Cardiopulmonary Resuscitation to an unresponsive resident who was without a pulse and visible respirations. These failures contributed to R1 ' s Cardiopulmonary Arrest requiring intubation. R1 is currently non-responsive and requires mechanical ventilation for life support. An Immediate Jeopardy was identified on [DATE] at 4:00 PM. The Immediate Jeopardy was determined to have begun on [DATE] at 3:20 AM. While the immediacy was removed on [DATE] at 10:30PM the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 15 residents (R1) in the sample of 20. The findings include: The Physician order [REDACTED]. The Admission assessment dated [DATE] shows R1 is " oriented at all times " . R1 ' s Nurse Notes dated [DATE] documents " 0320 A.M., Resident has profuse diaphoresis. (Blood Glucose Check)=31. Two packs of sugar and (Nutritional Supplement)given. (Blood Glucose check) 33. One pack sugar given (Nutritional Supplement given. (Blood Glucose check)=34. Resident became unresponsive. Writer called 911. Resident has pulse, respirations, unable to respond. Skin cool to touch. 0441 A.M. 911 ambulance arrived with four paramedics.., paramedic assessing, began CPR on resident " . On [DATE] at 3:00 PM, E5 (Licensed Practical Nurse) said she was the only nurse working in the facility the morning of [DATE] at 3:20 AM. E5 did not know when R1 was found unresponsive " . R1 had " profuse diaphoresis " , was not talking, and only turned her head to answer yes or no. E5 said she was in R1 ' s room [ROOM NUMBER] minutes earlier (R1 ' s Nurse Notes document the time E5 was in the room at 2:40 AM) and R1 was " alert and oriented, funny, and cracking jokes " . R1 ' s condition was a " significant change " from before. E5 said R1 ' s first blood sugar was 31mg/dl (R1 ' s Nurse Notes documents time as 3:20 AM). R1 drank two cups (7 ounce each) of nutritional supplement with two packets of sugar. R1 ' s blood sugar the second time after finishing the nutritional supplement was 33mg/dl. E5 gave R1 a third glass of nutritional supplement with 1 packet of sugar and checked R1 ' s blood sugar for a third time which was 34mg/dl. R1 became unresponsive after she drank the third glass of nutritional supplement and E5 left the room and called 911. E5 said she did not know how long after R1 drank the nutritional supplement she became unresponsive and she did not know how long it took R1 to drink the supplement. E5 said she did not do Blood Pressure, Heart Rate, or Oxygen Saturation (Vitals) on R1. E5 said the facility had a [DIAGNOSES REDACTED] protocol she should have used which would include the administration of orange juice and sugar. E5 said [MEDICATION NAME] IM (Intramuscular) would have been appropriate and stated " I looked and couldn't find it " . E5 said the [MEDICATION NAME] should have been in the top drawer of the med cart and was not there and [MEDICATION NAME] would have been the first intervention done. E5 said she did not notify the Doctor of R1 ' s blood glucose levels. The undated facility " Policy and Procedure for treatment of [REDACTED]. On [DATE] at 8:48 AM, E6 (CNA) said she had cared for R1 the night before ([DATE]-[DATE]) and she (R1) was " alert and oriented " , could ask for what she wanted, and could walk with a walker and assistance with one person. E6 found R1 in bed during morning rounds on [DATE] " completely soaked from head to toes " . R1 was " sweating bullets, breathing was labored " and she (E6) " knew something was wrong " . E6 said she was shaking R1, calling her name, and R1 was " moaning, did not have words, speech was slurred, and had a hard time enunciating " . R1 was " responding a little bit, was looking for our voice, did not make direct eye contact " , and this was a " huge change " from before. E6 (CNA) said R1 was " turning her head away from the cup (of nutritional supplement) saying no " R1 stopped swallowing while drinking the third cup of nutritional supplement and the liquid was " running out the side of her mouth " . E6 said she was concerned they needed more help and 911 should have been called. On [DATE] at 9:15 AM, E7 (CNA) said she was called to R1 ' s room between 3:00 AM and 3:30 AM. R1 ' s eyes were not open and not alert, and R1 looked unresponsive. E7 said E6 " was still trying to get R1 to drink (nutritional supplement) and it was running out of the side of her (R1) mouth " . E7 said no oxygen was administered to R1 when she was in the room. On [DATE] at 11:10 AM, E8 (CNA) said E7 brought the wrong cart (treatment cart or medication cart) to R1 ' s room. E8 got to R1 ' s room with the correct crash cart, and R1 was " slightly breathing " and " not alert " . E8 said E5 (LPN) said the wrong things were on the crash cart and " I think she (E5) was looking for the cord to go on the oxygen " . E8 said she did not see R1 with oxygen at any time. On [DATE] at 12:58 PM, Z6 (EMS) said when EMS arrived to R1 ' s room, R1 was supine in bed unresponsive and was " not breathing and had no pulse " . The facility staff was not doing CPR. The nurse (E5) did not know R1 was not breathing; " that was a concern that they had not ' acknowledged she (R1) wasn ' t breathing " . Z6 said " CPR should have been initiated by the staff. " On [DATE] at 1:15 PM, Z7 (Paramedic) said when they arrived to the facility, R1 was not breathing, was unresponsive, and had no pulse. The facility staff was not giving R1 CPR. Z7 said " something should have been done before we got there, and there should have been more urgency " . The emergency response report dated [DATE] shows the alarm notification at 4:35 AM, and EMS arrival to the facility at 4:39 AM. This report documents " responded for diabetic emergency and after we arrived found pt (patient) pulseless and not breathing " . The Ambulance Service Report dated [DATE] states " dispatched with (Local) Fire to NH (nursing home) for an unresponsive diabetic. Upon our arrival found a pulseless, not breathing [AGE] year old female pt supine in bed ...pt lowered from the bed to the floor and CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated. Oral airway inserted ...pt with an asystole rhythm ... CPR continued. " The Hospital Emergency Department Physician Report dated [DATE] documents at 5:14 AM said a patient arrived by EMS to the Emergency Department in [MEDICAL CONDITION]. The patient was found at the nursing home with questionable respirations and " lo " blood sugar. CPR was started at the facility by EMS and the patient was intubated and CPR continued. R1 was transferred in critical condition to a different hospital. This report identifies " Critical Glucose Levels: adult <50 m/dL The Hospital Pulmonology Consult report dated [DATE] documents reason for consult: " Acute [MEDICAL CONDITION] status [REDACTED]. " The Hospital Consultation dated [DATE] documents " prognosis for good/normal neurological recovery poor at this time " . On [DATE] at 9:40 AM. E2 (Director of Nursing-DON) said R1 ' s condition would be considered an emergency situation and 911 should have been called immediately. E2 said the physician or physician extender should have been called for orders especially since R1 was symptomatic and her condition was rapidly declining. E2 said R1 should have been given [MEDICATION NAME] IM and should not have continued to receive nutritional supplement, especially since her condition was not improving and she was deteriorating. E2 said [MEDICATION NAME] should have been given immediately since R1 had hypoglycemic symptoms. E2 said E5 (LPN) should have called 911 and the physician immediately. On [DATE] at 10:05 AM, E2 said E5 did not handle the situation with R1 fast enough, should have called 911 earlier, and should have got an order from the physician for [MEDICATION NAME]. E2 said E5 did not call the physician on Wednesday night ([DATE]) on another resident who had an elevated blood sugar that was outside the physician ordered parameters. On [DATE] at 12:15 PM, Z4 (treating Nurse Practitioner) said if a patient has no response or minimal response to the first treatment for [REDACTED]. Z4 said the nurse (E5) should have called 911 after trying the first cup of nutritional supplement. On [DATE] at 2:05 PM, Z2 (Attending Physician) said the nurse (E5) did not call until 4:58 AM in which she did not leave a message for a return phone call. Z2 said he did not speak to E5 until 5:30 AM. E2 said he was not called during the night and did not give any orders to treat R1. Z2 said " that ' s a long time " to wait to call 911 from onset of symptoms at 3:20 AM to EMS call at 4:35 AM. Z2 said if the first treatment option did not work, E5 should have called to get a different order. On [DATE] at 2:30 PM, Z2 said if different interventions had been used to treat R1 ' s condition, the [MEDICAL CONDITION] could have been prevented. On [DATE] at 3:05 PM, Z3 (Treating emergency room Physician) said [DIAGNOSES REDACTED] can cause respiratory distress and [MEDICAL CONDITION] if the blood sugar is low enough for a prolonged period of time. Choosing the wrong interventions to treat R1 or not treating correctly could cause the condition R1 was in when she presented to the Emergency Department. Calling 911 earlier could have improved R1 ' s condition. Using different interventions could have prevented R1 ' s cardiac and respiratory arrest. Z3 said if the facility has a protocol for glucose gel, [MEDICATION NAME], or intravenous D50, they could have better results and treat more appropriately in the facility. The undated facility policy titled " Policy and Procedure for treatment of [REDACTED]. The undated facility policy " Accucheck/Blood Glucose Monitoring " states: " During episodes of increased/decreased blood glucose levels, nursing staff will utilize standard nursing practices to assure the health and welfare of the resident (i.e. calling 911...) " . The undated facility policy " Advance Directives and DNR Policy " states " 1. In the absence of a DNR, CPR and other emergency procedures will be initiated in all circumstances of cardiac or [MEDICAL CONDITION] arrest. The undated facility policy " Notification of Change in Resident Health Status " states " The facility will consult the resident ' s physician, nurse practitioner or Medial Director ...when there is ...(B)Acute illness or a significant change in the resident ' s physical, mental ...status ( ...life-threatening conditions or clinical complications). " Notification Time: Immediate E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 4:00 PM. Based on observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation on [DATE] at 10:30 PM: A. On [DATE] Received standing order for Diabetic protocol levels and PRN orders for [MEDICATION NAME] for symptomatic residents. B. All staff in-serviced all nurses on [MEDICATION NAME] being in the med cart and in the emergency box completed [DATE]. C. Each Nurse received a list of what medicine is in the emergency box to notify the physician of what is available on [DATE]. D. Reviewed all POS ' s of Diabetic/resident ' s on insulin to make sure the protocols are in place. Completed [DATE]. E. Added standing order with parameters to all diabetic/resident ' s on insulin charts completed [DATE]. F. Created and implemented a protocol on how to manage an unresponsive patient completed [DATE]. G. In-serviced all nursing staff on how to manage an unresponsive patient completed [DATE]. H. All nursing staff will be in-serviced on how to manage an unresponsive patient prior to start of their next shift starting [DATE].

I.Based on interview and record review, the facility failed to notify the attending physician when a resident (R1) had four critically low blood sugars. This failure resulted in R1 not receiving the needed treatment for [REDACTED]. R1 is currently non-responsive and requires mechanical ventilation for life support. An Immediate Jeopardy was identified on [DATE] at 4:00 PM. The Immediate Jeopardy was determined to have begun on [DATE] at 3:20 AM. While the immediacy was removed at [DATE] at 10:30PM the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 15 resident (R1) reviewed for diabetes management in the sample of 20. The findings include: The Physician Order Sheet (POS) dated [DATE] shows R1 has [DIAGNOSES REDACTED]. The Admission assessment dated [DATE] shows R1 is " oriented at all times " . The Physician Order Sheet (POS) dated [DATE] documents " Call (Nurse Practitioner) with all (blood glucose monitoring) " . R1 ' s Nurse Notes dated [DATE] documents " 0320 A.M., Resident has profuse diaphoresis. (Blood Glucose Check)=31. Two packs of sugar and (nutritional supplement) given. (Blood Glucose check) 33. One pack sugar given and (nutritional supplement) given. (Blood Glucose check)=34. Resident became unresponsive. Writer called 911. Resident has pulse, respirations, unable to respond. Skin cool to touch. 0441 A.M. 911 ambulance arrived with four paramedics.., paramedic assessing, began CPR on resident " . The Hospital Emergency Department Physician Report dated [DATE] documents at 5:14 AM said a patient arrived by EMS to the Emergency Department in [MEDICAL CONDITION]. The patient was found at the nursing home with questionable respirations and " lo " blood sugar. CPR was started at the facility by EMS and the patient was intubated and CPR continued. R1 was transferred in critical condition to a different hospital. This report identifies " Critical Glucose Levels: adult <50 mg/dL. On [DATE] at 9:40 AM E2 (Director of Nursing-DON) said the physician or physician extender should have been notified of the blood sugars, and called for orders especially since R1 was symptomatic and her condition was rapidly declining. On [DATE] at 10:05 AM, E2 (Licensed Practical Nurse on duty) said E5 should have got an order from the physician for [MEDICATION NAME] IM (Intramuscular) to treat R1 ' s symptomatic [DIAGNOSES REDACTED] and critically low blood sugar. On [DATE] at 2:05 PM, Z2 (Attending Physician) said the nurse (E5) did not call until 4:58 AM in which she did not leave a message for a return phone call. Z2 said he did not speak to E5 until 5:30 AM (Approximately 45 minutes after EMS arrived at the facility). Z2 said he did not give any orders to treat R1. Z2 said if the first treatment option did not work, E5 should have called to get a different order. On [DATE] at 3:05 PM, Z3 (Treating emergency room Physician) said calling the physician for treatment orders could have improved R1 ' s condition and prevented R1 ' s [MEDICAL CONDITION]. On [DATE] at 10:30 AM, Z1 (Physician) said after R1 stopped swallowing and was unable to drink, the nurse (E5) should have notified the attending physician. The undated facility policy titled, Notification of Change in Resident Health Status, states, " The facility will consult the resident ' s physician, nurse practitioner or Medical Director and when indicated notify the resident ' s legal representative or an interested family member when there is: (B) Acute illness or a significant change in the resident ' s physical, mental, or psychosocial status (i.e. deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications); Criteria: Life threatening conditions are such things as a [MEDICAL CONDITION] or respiratory distress ... Notification Time: Immediate" E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 4:00 PM. Based on observation, interview and record review, the surveyor confirmed the facility took the following actions to remove the immediacy of the situation on [DATE] at 10:30 PM: A. On [DATE] Received standing order for Diabetic protocol levels and PRN orders for [MEDICATION NAME] for symptomatic residents. B. All staff in-serviced all nurses on [MEDICATION NAME] being in the med cart and in the emergency box completed [DATE]. C. Each Nurse received a list of what medicine is in the emergency box to notify the physician of what is available on [DATE]. D. Reviewed all POS ' s of Diabetic/resident ' s on insulin to make sure the protocols are in place. Completed [DATE]. E. Added standing order with parameters to all diabetic/resident ' s on insulin charts completed [DATE]. F. Created and implemented a protocol on how to manage an unresponsive patient completed [DATE]. G. In-serviced all nursing staff on how to manage an unresponsive patient [DATE]. H. All nursing staff will be in-serviced on how to manage an unresponsive patient prior to start of their next shift. Starting [DATE]. II Based on interview and record review, the facility failed to notify a physician of elevated blood glucose levels per physician order or facility protocol. This applies to 4 of 15 residents (R3, R10, R15, R16), reviewed for diabetes management in the sample of 20. The findings include: R3 ' s Physician Order Sheet (POS) dated [DATE] documents " (Blood glucose monitoring) three times daily call MD if blood sugar <90 or >200 " . The Diabetic Record shows R3 ' s blood glucose level exceeded 200 seven times between [DATE] through [DATE]. No physician notification was documented for these levels in R3 ' s chart. R10 ' s POS dated [DATE] documents " (Blood glucose monitoring) BID (twice daily) - call MD (Physician) if <60 or >400. The Diabetic Record shows R10 ' s blood glucose level was 544 on [DATE] and no physician notification is documented in the chart. R16 ' s POS dated [DATE] documents " Call MD if (blood sugar) below 60 or above 300 " . The Diabetic Record shows R16 ' s blood glucose level was 310 on [DATE]. No physician notification is documented in R16 ' s chart. R15 ' s Diabetic Record documents a blood sugar of 409 on [DATE]. R15 does not have a physician order with parameters to notify the physician. No documentation of physician notification was documented in R15 ' s chart or the elevated blood glucose. The facility " Accucheck/Blood Glucose Monitoring " protocol states: " to report alert levels to the attending physician as warranted. Standard parameters are as follows: Blood glucose level of <60 or >400 unless otherwise specified by the physician. On [DATE] at 1:00 PM, E2 (Director of Nursing) said the nurses should follow the facility protocol for glucose monitoring if the resident does not have physician ordered parameters. E2 said the physician should be notified for any blood glucose reading outside of the parameters. E2 said she could not find documentation that the above blood glucose readings were called to the physician/physician extender.

Based on interview and record review the facility neglected to follow policies and procedures that direct staff to immediately call for emergency services (911) in the case of a medical emergency. The facility neglected to follow the policy to notify the attending physician when a resident (R1) presented with a critically low blood sugar. The facility neglected to initiate cardiopulmonary resuscitation (CPR) on R1 once she was pulseless and breathless. These failures contributed to R1 ' s Cardiopulmonary Arrest requiring intubation; R1 is currently non-responsive and requires mechanical ventilation for life support. This neglect began on [DATE] at 3:20 AM. An Immediate Jeopardy was identified on [DATE] at 4:00 PM. The Immediate Jeopardy was determined to have begun on [DATE] at 3:20 AM. While the immediacy was removed on [DATE] at 10:30 PM, the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 15 residents (R1) reviewed for Diabetic Management in the sample of 20. The findings include: A. The [DATE] facility policy titled, Emergency Policies, states, " In the case of a medical emergency, the following procedures shall be used: 1. The patient ' s attending physician shall be called; 2. In the event the patient ' s physician cannot be reached (and an alternate is not given..) the Medical Director is to be called; 3. Emergency ambulance service shall be called; 4. Paramedics may be called - (911); The nurse in charge may administer emergency oxygen ... " The [DATE] Physician order [REDACTED]. On [DATE] at 3:20 AM, R1 ' s nursing note shows R1 had a critically low blood sugar (31 mg/dL). The Emergency Department Physician ' s Report (dated [DATE]) defines, " Critical Glucose Levels: Adult <50 mg/dL ". R1 continued to decline and became unresponsive. The emergency response report (dated [DATE]) states, " Alarm [DATE] 04:35:00 ... (4.35 AM). " On [DATE] at 11:45 AM, Z8 (Dispatcher) confirmed a call was placed to 911 on [DATE] at 4:35 AM. There was a one hour and 15 minutes delay from when R1 was assessed to have a critical low blood glucose level and the when the facility initiated the call for emergency services (911). On [DATE] at 9:40 AM E2 (Director of Nursing) stated, " In (an) emergency like this, (staff should) call 911 and the physician. " On [DATE] at 12:15 PM, (Attending Nurse Practitioner) stated, " 911 should have been called immediately, " if R1 did not respond to initial treatment for [REDACTED]. " B. The undated facility policy titled, Notification of Change in Resident Health Status, states, " The facility will consult the resident ' s physician, nurse practitioner or Medical Director and when indicated notify the resident ' s legal representative or an interested family member when there is: (B) Acute illness or a significant change in the resident ' s physical, mental, or psychosocial status (i.e. deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications); Criteria: Life threatening conditions are such things as a [MEDICAL CONDITION] or respiratory distress ... Notification Time: Immediate" The [DATE] POS shows R1 had an order to notify the attending physician with a blood sugar " below 60, " and " Call (the Physician Extender) with all (blood sugar) checks " . On [DATE] at 2:05 PM, Z2 (Attending Physician) stated, " I received a call at 4:58 AM, " with no message. They (Facility nurse) called back at 5:30 AM. Z2 continued, " If different interventions had been used sooner ... This could have been prevented ... That's a long time "to wait to call 911." C. The undated facility policy titled, Advance Directives and DNR (Do Not Resuscitate) Policy), states, " GENERAL: When a resident is admitted to the facility, a discussion of advance directives will take place between the resident or family, if the resident is incompetent, and the facility staff. This enables the staff to readily and clearly ascertain how to treat the resident in advance of an emergency. ADVANCED DIRECTIVES: 1. Under state and federal law, people have the right to make decisions regarding health care treatment. This includes their right to determine in advance what life-sustaining treatment will be provided, if any, in the future if they are unable to communicate those desires themselves; 2. Life-sustaining treatment is the measures we take to sustain an individual ' s life and health ... POLICY: 1. In the absence of a DNR, CPR will be initiated in all circumstances of cardiac or [MEDICAL CONDITION] arrest. " The [DATE] Physician order [REDACTED]. R1 ' s emergency response report (dated [DATE]) states, " Remarks: responded for diabetic emergency and after we arrived found pt (patient) pulseless and not breathing. " On [DATE] at 1:00 PM, Z6 (Paramedic) stated, R1 " was supine in bed. (R1) was unresponsive, not breathing, and had no pulse. The nurse didn ' t know (R1) wasn't breathing, that was a concern. CPR (Cardiopulmonary Resuscitation) should have been initiated by facility staff " . On [DATE] at 1:15 PM, Z7 (Paramedic) stated, R1 " was supine in bed. (R1) had no respiration, no pulse, and was unresponsive ...Something should have been done before we got there. There should have been more urgency " . On [DATE] at 9:25 AM, E5 (Licensed Practical Nurse, LPN) stated, " I did not initiate life support (CPR) at any time " . E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 4:00 PM. The surveyor confirmed the facility took the following actions to remove the immediacy of the situation on [DATE] at 10:30 PM: A. Received standing order for Diabetic protocol levels and PRN orders for [MEDICATION NAME] for symptomatic residents. Completed [DATE]. B. All Staff in-serviced all nurses on [MEDICATION NAME] being in the med cart and in the emergency box. Completed [DATE]. C. Each Nurse received a list of what medicine is in the emergency box to notify the physician of what is available. Completed [DATE] D. Reviewed all POS ' s of Diabetic/ resident's on insulin to make sure the protocols are in place. Completed [DATE]. E. Added standing order with parameters to all diabetic/resident's on insulin charts completed [DATE]. F. Created & implemented a protocol on how to manage an unresponsive patient completed [DATE]. G. In-serviced all nursing staff on shift completed [DATE]. H. All nursing staff not present will be in-serviced on how to manage an unresponsive patient prior to start of their next shift starting [DATE].

Based on observation, record review, and interview the facility failed to monitor and document the effectiveness of pain medications, administer additional pain medication as ordered, and to notify the physician extender of unrelieved pain. The facility failed to assess and document vascular wounds for R7, and develop a care plan for [MEDICAL TREATMENT] services for R1. These failures contributed to R7 experiencing unrelieved pain. This applies to 3 of 7 residents (R7,R6, R1) reviewed for pain, vascular ulcers and [MEDICAL TREATMENT] in the sample of 13. The findings include: 1. R7's June, 2013 physician's orders [REDACTED]. R7's June, 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (4 doses of the prn [MEDICATION NAME] were given from June 1, through June 3, 2013) R7's May, 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The as needed (prn) hourly [MEDICATION NAME] ordered was 10 mg, every hour. (6 doses of prn [MEDICATION NAME] were given from 5/21 through 5/31) a period of 10 days. The MAR for May, 2013 documents inconsistently, the effect of the [MEDICATION NAME] as "helps a lot, or "relief". The June, 2013, MAR indicated [REDACTED]. (pain scale of 0-10) On 6/3/13 at 11:30 AM, R7 was observed laying in her bed. R7 had facial grimacing and said "I need pain medication." R7 said she had pain in her hips, knees, thighs, legs and back. R7 requested surveyor to come back at a later time. R7 was positioned on her left side, her pillows were on a chair in her room. R7's breakfast tray was on the over bed table, untouched. R7's admission Minimum Data Set (MDS) assessment of 5/10/13 documents that R7 has no cognitive impairment, and had a pain intensity of 9/10. (0-10 pain scale) The same assessment shows that R7 has multiple pressure and venous leg ulcers. No resistance to care is documented. On 6/3/13 at 12:55 PM, E8 (Certified Nursing Assistant) said that R7 drinks good, but she is not interested in eating. E8 said R7 is " in pain all the time, sometimes your not even touching her and she cries out oh my legs." E8 said that R7's legs are contracted and if they get her in the wheel chair she just cries, she does not want to be up. Her (R7's ) husband said it would be fine if she stays in bed. On 6/3/13 at 1:00 PM, E4 (Licensed Practical Nurse) said that R7 is "constantly in pain". R7 is supposed to go home with hospice care this week. On 6/4/13 at 11:00 AM, E12 (CNA) said that R7 had refused to turn, because she was in pain. E12 said R7 was getting some pain medication and they will wait for it to "kick in." E12 said R7 seemed to be hurting today more than usual. R7's Nursing Notes were reviewed and showed the following ongoing documentation of pain: 5/5/13 (3:31 PM) complains of pain even after being medicated. Often does not remember that she had her pain medicine and will accuse staff of not giving her any. Complains of severe leg and back pains. 5/7/13 (3:30 AM) Asks for large doses of pain medication. Complains of severe leg and back pain. 5/8/13 (4:31 AM) Patient is hyper-sensitive to touch. Forgets she had pain medication, and accuses staff of not giving them to her .Yells out when turned or with dressing changes. 5/10/13 (2:50 AM) complains of severe pain in back and extremities with any position changes or care, and dressing changes. 5/11/13 (7:37 AM) refusing repositioning and dressing changes. 5/12/13 (6:43 AM) does not like to be turned or repositioned. Resident is tolerating dressing changes fair. 5/13/13 (3:25 AM) continues to complain of pain with turning and dressing changes,on scheduled pain meds. 5/18/13 (7:39 AM) dressing changed under "painful protest." (8:45 PM) Has generalized chronic pain. It appears that resident is in so much discomfort/pain when she is repositioned. 5/19/13 (2:45 AM) Complains of pain with any movement or touching of skin. 5/20/13 (2:47 AM) Complains of pain with any movement, repositioning, dressing changes or even just touching her, on scheduled pain meds. Additional nursing notes document R7's pain 7 on other days. (5/21, 5/24, 5/25, 5/31, 6/1, 6/3) An incident report investigation dated 5/18/13 documented that R7 reported that E19 (LPN) was doing R7's treatments and R7 yelled out because of pain. E19 told her (R7) "she disagreed with her about the pain she was experiencing." E2 Director of Nursing said on 6/5/13 at 10:15 AM, that when they realized (on 6/4/13) that R7 would be staying another week, they thought they should get her pain medication increased. E2 said that R7 had been there since May 3rd, and always had pain at a 7-9 intensity. (0-10 pain scale) Z2 said on 6/6/13 at 2:30 PM, that she was not aware that R7's pain was not being relieved. Z2 said she had ordered [MEDICATION NAME] scheduled dose with a prn. Z2 said " I could have titrated her up, or added a long acting [MEDICATION NAME], if I would have known she wasn't getting relief." R7's Pain Care Plan dated through 8/3/13 documents the goal that R7 will require less pain medication. The facility policy and procedure for pain management documents on page 1) item 4 The resident has the right to expect a rapid and effective response to a complaint of pain. Treat the pain, reassess and continue to treat the pain until the resident is comfortable or side effects prevent further treatment. Notify the physician if pain relief can not be obtained. 2. The physician's orders [REDACTED]. The May 2013 Treatment Record shows that R6 has orders for treatments to his left medial calf and lower right leg. On 6/3/13 at 10:30 AM, R6 stated, "I have had those wounds for a long time. I was being seen by wound care but they say they have done all they can for me. " On 6/4/13 at 3:00 PM E2 (DON) stated, " They document (wound assessments) on the back of the treatment sheets or in the nurse's notes." On 6/4/13 at 8:00 AM, E14 (LPN) stated, "The wounds look the same." The Nurse's Notes from [DATE]- present show 3 documented wound descriptions: The NN dated 2/24/13 state, "Healing Progress: no change, Description: Appears more clean." The NN dated 3/10/13 states, "Healing Progress: improving, Description: becoming more shallow, appears more clean." The NN dated 4/20/13 states, "Right venous stasis ulcer wound bed with 40% yellowish slough, 60% beefy red- pinkish with serous drainage moderate in amount, Left leg venous stasis ulcer wound bed pinkish, clean with scant serous drainage with granulation." The Wound Care Specialist Evaluation dated 6/5/13 (completed during the survey) states, "2/25: wound now with exposed tendon.... 4/1/: Wound deteriorated..... 6/5: Wound no longer with exposed tendon. Healthy granular base throughout." R6's Care plan dated 6/10/13 states, "Document wound and surrounding area with dressing change." The facility's undated policy entitled, Policy and Procedure for Treatment Prevention of Skin Breakdown and Surgical Wounds states, "Chart at a minimum weekly on the Weekly Assessment of Skin Alteration Form. 3. On 6/4/13 at 8:15am, R1 was observed eating breakfast in the dining room; his [MEDICAL TREATMENT] was not visible. On 6/4/13 at 10:15am, E2 stated, "R1 goes out for [MEDICAL TREATMENT] but I am not sure which one." R1's Care Plan dated 9/25/12 and continued on 12/20/12 and 3/20/13 showed, "Potential alteration in fluid & electrolyte balance due to [MEDICAL TREATMENT] related to [MEDICAL CONDITION]; Assess shunt site for signs and symptoms of infection; Auscultate and palpate shunt for "shushing" sound and pulse like beat; No blood draws to right arm or blood pressures." The care plan does not show the location of R1's current [MEDICAL TREATMENT] access; days, time and transportation for [MEDICAL TREATMENT]; contact number of the [MEDICAL TREATMENT] center. The Nurses Notes for R1 showed, "2/13/13 - Right upper chest [MEDICAL TREATMENT] catheter intact. Left upper arm has non-functioning shunt.; 3/22/13 - [MEDICAL TREATMENT] stated that R1's right upper chest [MEDICAL TREATMENT] port is coming through the skin and the hospital in Madison wants R1 transported after [MEDICAL TREATMENT] is complete; 4/15/13 at 10:01am - R1 complained of right side pain this morning. Noted R1 leaning to the right. Assisted R1 into the van when leaving for [MEDICAL TREATMENT]. R1 appeared very weak. On 4/15/13 at 10:24am, received a call from [MEDICAL TREATMENT] - sent R1 to the hospital due to weakness; 4/20/13 - R1 returned from the hospital."

Based on observation, record review and interview the facility failed to ensure pressure sore prevention measures were implemented for a resident at high risk. These failures contributed to R5 developing a blister to her left heel that progressed to an unstagable wound. R10 and R13 had pressure ulcers without monitoring or assessments. This applies to 1 of 3 residents (R5) reviewed for skin breakdown in the sample of 13. The findings include: 1. R5's June 2013, physician's orders [REDACTED]. R5's admission Minimum Data Set (MDS) assessment of 4/26/13 (admit 4/15/13) shows that R5 is dependent on two or more for transfer. R5 requires extensive assistance of one person for bed mobility. R5 is incontinent of bowel and bladder. The same assessment shows that R5 had no pressure ulcers present. R5's Nursing Note (admission) on 4/16/13 documents that R5 had a surgical site with 5 incision areas on the outer lower thigh areas with a total of 65 staples and a small reddened area under the left breast "other wise skin is intact." The Nursing Notes for 5/2/13 documents a left heel blister with a blackish base. A Braden Scale for Predicting Pressure Sore Risk dated 4/15/13 documents a score of 15. (15-16 = low risk) No other skin risk assessments were documented. R5's Treatment Record for May, 2013 shows that R5 developed a fluid filled blister to her left heel. R5's left foot was [MEDICAL CONDITION] and red. The same document shows that R5 wears a hinge knee brace to the left leg. R5 is at high risk for skin breakdown and has orders to have a skin check daily and to document the results on the back of the sheet. R1 is to wear bilateral heel protectors at all times. The back of R5's Treatment Record showed only one entry for her left foot dated 5/4/13. On 5/8/13 Nursing Notes show the blister was broken and sloughing and a skin flap was present. The Site was draining sero sanguineous drainage. On 5/22/13 black eschar was present to left heel. The documentation did not show any other wound characteristics. (size, odor, periwound skin, signs of infection, wound pain) E2 (Director of Nursing) said on 6/4/13 that the majority skin assessments and treatments are done on the night shift. E2 said the schedule varies. The skin assessments and wound descriptions are documented on the back of the Treatment Administration Records. R5's Physician order [REDACTED]. High Risk for skin breakdown, assess skin integrity daily and document weekly on the back of the Treatment Administration Record. Pressure relieving device to bed and wheel chair. Apply thigh high antiembolism stocking to the left leg. (order of 4/18/13) R5's entire care plan dated through 8/3/13 was reviewed and showed no plan for skin breakdown or monitoring. No preventative interventions were documented. On 6/3/13 at 11:30 AM, R5 was sitting in her wheel chair. R5's left foot was resting on the floor. A hard metal type brace, with adjustment dials, was on the left leg. The brace extended from the knee to the ankle. R5 had one quilted type boot on her left foot. R5's right foot had a slipper sock covering the toes only and the foot was on the foot rest. R5 said she had fallen by her bed and broke her leg. At 11:45 R5 was in her room, seated in the wheel chair with her right foot swung over the side of the foot rest. R5 was attempting to get out of her chair. R5 said " I can't get out of here." At 12:20 R5 was in the dining room with both feet resting on the floor (through the middle of the foot rests). R5 had no pressure reducing cushion on her wheel chair. R5 did not have anti-embolism stockings on . On 6/4/13 at 8:15 AM, R5 was seated in the dining room, her left heel was resting on the foot pedal. Her right foot was resting on the floor. R5 was wearing a slipper sock on the right foot, and a quilted boot on the left. At 11:30, R5 was in the dining room with both heels resting on the foot rests, R5 was wearing slipper socks on both feet. (No boots) At 1:25 PM, R5 was sitting in the wheel chair in her room. Both feet were resting on the foot pedals. R5 had no pressure reducing cushion on her wheel chair. R5 was not wearing the anitembolism stockings. At 1:30 PM, R5 was observed in her room. E5 Certified Nursing Assistant and E12 (CNA) were present. E5 and E6 were made aware of R5's leg positioning. (Heels not off loaded) E5 and E6 were shown that R5 had the imprint of the dials from the left leg brace, on her right inner, lower leg. On 6/5/13 at 7:15 AM, R5 was seated in the dining room. She was angry and yelled out "I'm sick of this." R5 was wearing a quilted boot to the left foot, and a slipper sock to the right foot. Both of R5's feet were resting on the foot pedals. R5's left foot was [MEDICAL CONDITION] and purplish colored on all observations of the survey. R5 did not wear antiembolism stockings throughout the survey observations. A wound consult note of 6/3/13 documents a recommendation to off-load R5's wound. (heel) The Policy and Procedure for Treatment and Prevention of Skin Breakdown and Surgical Wounds shows on page 1) B. Identification of causal factors and clinical conditions which indicate risk for pressure ulcers should be used to implement prevention measures and develop the care plan. 2. On 6/5/13 at 10:49am, R10 was observed sitting in a wheelchair at a balloon activity in the dining room. R10 had a soft blue boot to her right foot that was dangling behind the foot pedal on her wheelchair. The Nurses Notes for R10 showed, "9/12/12 - Orders received for blister to right heel." R10's Care Plan dated 9/12/12 showed, "Blister - right heel." The Treatment Record for R10 showed a treatment order from 9/12/12 through 10/10/12 to cleanse her right heel blister with normal saline and apply skin prep until healed. The Treatment Record for R10 showed "healed" written as of 10/10/12 for R10's right heel. The Treatment Sheets and Nurses Notes for R10 from 9/12/12 through 10/10/12 showed no monitoring or assessment of the wound to R10's right heel. The Treatment Record for R10 showed a new treatment to R10's heel on 10/28/13," Cleanse right heel with normal saline. Apply enzymatic debridement ointment and wrap with gauze every day and as needed." The Treatment Record and Nurses Notes for R10 from 10/28/12 through 11/20/12 showed no monitoring or assessment of the wound to R10's right heel. On 6/6/13 at 9:30am, E11 (Registered Nurse - Corporate Consultant) stated, "R10's right heel pressure ulcer started on 9/12/12 and healed on 10/10/12. Then it reopened at the end of October 2012 but there is no documentation. The heel reopened on 10/28/12 and then there is no additional documentation before R10 went to the hospital in November 2012." The Wound Care Specialist Evaluation dated 6/5/13 for R10 showed, "R10 has a stage III pressure wound of the right heel of at least 174 days duration." 3. The June 2013 physician's orders [REDACTED]. The Nurse's Notes of 1/8/13 documents, "R13 has some new skin issues. Her left great toe and 2nd left toe have purple discoloration at tip has resemblance of a blood blister. The 2nd toe has area which may have been open, but is now healed over but remains purplish." No documentation of R13 toes to include measurements or weekly/daily skin checks were in the Nurses Notes. The care plan of 1/8/13 shows a problem of "dark areas left great toe and 2nd toe." The Care plan does not show risk factors, the cause of the blister/dark areas to the toe or measures to prevent reoccurrence. The Minimum Data Set of 2/20/13 assessed R13 as moderately impaired for decision making. R13 does not ambulate and is totally dependent on staff for mobility on and off the unit. R13 needs extensive assistance for dressing, bathing and toilet-use. No skin issues were noted on the previous assessment. The facility's pressure ulcer treatment policy revised October 2010 documents, "Suspected deep tissue injury: Purple or maroon localized area of discolored skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Determine cause of pressure and relieve. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. Skin will be assessed on a weekly basis or more frequently if indicated. Staff will perform routine skin inspections daily or every other day as needed."