Every finding on record at Berkeley Nursing & Rehab Center

Based on observations, interviews, and record reviews, the facility failed to provide a comfortable environment, temperature range of 71 degrees F (Fahrenheit) and 81degrees F, for residents during extreme hot weather conditions and failed to achieve relative humidity and temperature ranges outside of the caution level based on the heat index from the National Oceanic Atmospheric Administration chart. These failures had the potential to affect all 61 residents at the facility. The Facility's resident roster dated 6/30/2026, showed there were 61 residents who reside in the facility. Findings include:The AccuWeather report showed the outside temperature for the facility location was 93F on 6/30/2026, 7/1/2026, and 7/2/2026 at 12:00 PM. On 06/30/2026, V3 (Maintenance Director) measured the ambient air temperature of the following resident's rooms and common areas:room [ROOM NUMBER] = 84Froom [ROOM NUMBER] = 84Froom [ROOM NUMBER] = 83Froom [ROOM NUMBER] = 87FAt 11:31am, room [ROOM NUMBER]'s ambient air temperature registered at 84F. At this time, monitoring of the ambient air temperature of the residents' room and common areas concluded. V3 did not check the relative humidity inside the residents' rooms and common areas. The facility did not have a hygrometer available to measure the humidity of the rooms. On 07/01/2026 from 2:57pm to 3:47pm, V3 using a non-contact infrared thermometer checked the residents' rooms ambient air temperatures with the following results: room [ROOM NUMBER] = 84F. room [ROOM NUMBER] = 84F room [ROOM NUMBER] = 89F. room [ROOM NUMBER]= 86F. room [ROOM NUMBER] = 88F.room [ROOM NUMBER] = 86F. On 07/02/2026 from 11:08am to 1:54pm, with V3 using a non-contact infrared thermometer, checked the ambient air temperatures of the residents' rooms and common areas with the following results: [NAME] hallway = 84F. room [ROOM NUMBER]= 84F. room [ROOM NUMBER] = 86F. room [ROOM NUMBER] = 87F. room [ROOM NUMBER] - 86F. room [ROOM NUMBER] = 88F. room [ROOM NUMBER] = 84F. room [ROOM NUMBER] = 86F. room [ROOM NUMBER] = 86F. room [ROOM NUMBER] = 86F. East hallway = 86F.On 07/01/2026 at 10:32am, inquiring about monitoring the relative humidity inside the resident's rooms and common areas, V1 (Administrator) stated the Infrared thermometer is only checking the temperature not the humidity. The facility did not have a hygrometer to check the humidity level in the room.The (undated) Residents on High Risk for Heat Related Illnesses listed 12 residents including R1 and R3. R1's admission Record documented that this resident's diagnoses include but are not limited to Type 2 Diabetes Mellitus, hypertensive heart disease, and morbid obesity. R1's (04/01/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating the resident's mental status as cognitively intact. On 6/30/26, at 10:43am, room [ROOM NUMBER]'s ambient air temperature registered at 84F. R1 stated the room is hot and all she can do is to sleep in it.R2's admission Record documented that this resident's diagnoses include but are not limited to cerebral infarction, seizures, and hypertensive heart disease. R2's (06/23/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. On 6/30/2026, at 10:53am, room [ROOM NUMBER]'s ambient air temperature registered at 84F. R2 stated he is not at the greatest place in the world, and it would help if it is cooler.R3's admission Record documented that this resident's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness) affecting left non dominant side. R3's (04/15/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating the resident's mental status as cognitively intact. R4's admission Record documented that this resident's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness) affecting the right dominant side, hypertensive heart disease, and adult failure to thrive. R4's (04/03/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 08. Indicating the resident's mental status as moderately impaired. On 6/30/2026, at 10:54am, room [ROOM NUMBER]'s ambient air temperature registered at 86F. R3 stated it was hot in the room, and she is not happy about it. R4, who shares the room with R3, stated it was annoying. R5's admission Record documented that this resident's diagnoses include but are not limited to quadriplegia, cardiomegaly, reduced mobility. R5's (05/15/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R5's mental status as cognitively intact. On 6/30/2026, at 10:58am, room [ROOM NUMBER]'s ambient air temperature registered at 83F. R5 stated it was hot, and it is irritating. R6's admission Record documented that this resident's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness) affecting left non dominant side, seizures, and hypertensive heart disease. R6's (05/20/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. On 6/30/2026, at 11:18am, room [ROOM NUMBER]'s ambient air temperature registered at 87F. R6 stated it was hot in the room, and she was uncomfortable. The (07/13/11) Extreme High Temperature Procedures documented, in part Purpose. Should the temperatures in the facility rise above the upper limits for relative humidity and the temperature set forth in the Administrative Code, the following measures will be carried out. Maintenance Department Functions. Monitor air temperature in various locations of the facility to determine cooler rooms within the facility. The (undated) Hyperthermia Prevention and Management documented, in part Purpose: To protect residents from heat-related illness by maintaining safe temperatures, monitoring risk, and activating emergency procedures. Key Components: 1. Temperature maintenance (71 F-81 F when applicable). 1. Regulatory Requirements Federal CMS Temperature Standard: Facilities certified after [DATE] must maintain 71 F-81 F in all residents-occupied areas. 10. Resident Rights. Residents have the right to: A safe and comfortable environment. The (9.1.24) Homelike Environment documented, in part Policy Statement. Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: h. comfortable and safe temperatures.

Based on interview and record review, the facility failed to ensure residents are free from verbal abuse for one of three residents (R1) reviewed for abuse. Findings include:R1 is an [AGE] year-old male who was readmitted in the facility on 05/02/2024 with diagnoses of not limited to rhabdomylosis, dementia and schizoaffective disorder. R1's Brief Interview for Mental Status (BIMS) done on 04/02/2026 indicated R1 has BIMS score of 15 which indicated R1 is cognitively intact.On 04/30/2026 at 9:54AM during interview, R1 stated that V3 (Former Certified Nursing Assistant/CNA) was always mad at R1. R1 stated that whatever R1 says, V3 turns it against R1.On 04/30/2026 at 11:24AM during phone interview with V3, V3 stated that R1 had been calling her with racial slurs every time R1 sees her. V3 stated that she already talked to V5 (Registered Nurse/RN), V8 (RN) and V9 (Licensed Practical Nurse/LPN) about it, and she was always told to ignore R1. V3 stated that on the day of the incident, she was passing by R1 carrying a breakfast tray and heard R1 call her stupid but V3 ignored R1. V3 stated that she then heard R1 talk to another resident asking the resident when that resident would get a wig like V3's. V3 stated that R1 walked past her, so V3 told R1 to leave V3 alone without raising V3's voice, because R1 was just right in front of her. V3 stated that she felt like R1 just didn't want black people.On 04/30/2026 at 12:05PM during phone interview with V8, V8 stated that V3 never complained to her about R1 calling V3 with racial slurs.On 04/30/2026 at 12:09PM during phone interview with V9, V9 stated that V3 never came to her to complain about R1 making racial comments towards V3 or anyone. V9 stated that she is African American herself but never heard R1 make racial comments towards her.On 04/30/2026 at 12:32PM during phone interview with V5 (Registered Nurse), V5 stated that V3 came up to V5 telling V5 to tell R1 to stop talking about V3 in Spanish. V5 stated that R1 came up to her as well, then V3 started pointing at R1 and became really verbally aggressive towards R1 telling R1 that if R1 won't stop talking about V3, V3 would slap the shit out of (R1). V5 stated that she asked R1 to go behind V5 because she was scared that V3 would hit R1. V5 stated that she tried to deescalate, and reminding V3 that R1 is a resident in the facility and the facility is R1's home. V5 stated that she tried to calm V3 down but V3 was not hearing any of what she was saying. V5 stated that V3 looked like she had a nervous breakdown that day. V5 stated that R1 was a kind man and never heard R1 say any racial slurs or curse anyone. V5 stated that this is the first time V3 came up to her to tell her that R1 was talking about V3.On 04/30/2026 at 1:55PM during interview with V1 (Administrator), V1 stated that if any resident was making negative comments towards staff, the staff is expected to walk away, ignore or speak towards the residents in a calm, polite way. V1 stated that he expects staff to understand that the residents can present with behavioral symptoms, especially residents with dementia and mental illness, and still continue to provide compassionate care towards them. V1 stated that he never heard R1 make racial slurs or curse anyone, and R1 is an easily redirectable resident. V1 stated that he expects staff to treat and speak to all residents with respect and dignity.Review of R1's Care Plan revised 03/26/2026 indicated R1's comprehensive assessment reveals a history (hx) of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. It also indicated goals including R1 will be treated w/ (with) respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect). It also indicated interventions including assuring R1 that he is in a safe & secure environment w/ caring professionals.Review of IDPH (Illinois Department of Public Health) Incident Report Form involving R1 and V3 with incident date of 03/14/2026 indicated the following:Conclusion: (V3) became upset, believing that (R1) was speaking derogatorily about her to other residents in Spanish. (V3) reported this to the Charge Nurse in a loud and angry tone in the presence of (R1). Two nurses tried to calm (V3) down but (V3) continued yelling and cursing and was verbally abusive to (R1).Review of V5's Statement on incident date of 03/14/2026 indicated (V3) came up to (V5) yelling and screaming that (R1) was talking about (V3) in Spanish. It also indicated that (R1) came to (V5) and stated that (R1) never said anything to (V3). It indicated that (V3) raised her left arm to (R1) and stated you say one more thing about me in Spanish, (V3) going to f**king slap the sh*t out of (R1), you motherf**ker. It also indicated that (V3) told (V5) that (V3) is going to slap (R1).Review of facility's policy entitled Abuse, Neglect, Exploitation: Prevention - Investigation - Reporting revised 05/16/2016 indicated the following:Policy: It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. The following Procedures shall be implemented when an employee or agent becomes aware of the abuse or neglect of a resident or of an allegation of suspected abuse or neglect of a resident or by a 3rd party.

Based on interview and record review, the facility failed to follow their change in condition policy by not calling advance life support services (911) for two hours after R48 who was found with an altered mental status and verbally unresponsive. This failure resulted in R48 immediate intubation by emergency medical service and mechanical ventilation for 1 of 1 residents reviewed for change in condition. Findings Include: R48 has the diagnosis of Atrial Fibrillation, Lack of coordination, abnormalities of gait and mobility, need for assistance with personal care and Adult Failure to Thrive. R48's physician order summary dated 2/7/25 documents: Rivaroxaban (antithrombotic/prevent blood clots) fifteen milligrams given by mouth at bedtime for atrial fibrillation. Medication administration record dated 2/1/25-2/28/25 and 3/1/25 documents: R48 received Rivaroxaban as prescribed. Fall risk review dated 2/28/25 documents: R48 was at high risk for falls. Is resident receiving a medication that affects awareness, judgement or safety (e.g. anti-anxiety, antibiotics, anticoagulants) yes. Ambulation with assist. Gait Balance: balance problem while standing/walking. Requires use of assistive device. On 4/1/25 at 10:34am, V3 (Complainant) said, he was called to the facility for a fall. R48 had signs of a severe brain bleed (hemorrhage). R48 had a fall the previous day, was not assessed or sent to the hospital. R48 presented with his arm flexed, hyper-extended, leg stiff, and toes pointed. V3 said, he was not sure how long R48 was in that position. R48 had a decrease level of consciousness and a pulse oxygen saturation of 83% on room air. R48 was breathing at ten breathes per minutes which was irregular. R48 was started on oxygen, high flow non-breather mask, which did not adjust R48's rate/oxygenation. R48 was sedated for intubation to establish an airway. On 4/2/25 at 10:04pm, V15 (Nurse) said, she was informed by V18 (Certified Nursing Assistant/CNA) that R48 was on the floor. R48 was assessed and denied hitting his head. R48 was not wet and had a urinary catheter in place. V15 said, R48 was alert and orient times 1-2 at the time of the incident. That was R48 baseline. V15 said, if a resident has an unwitnessed fall and is taking anticoagulants that resident should be sent to the hospital at the time of the incident to rule out possible brain bleed. Statement dated 3/1/25 documents: CNA reported the resident (R48) was on the floor. Immediately responded. Observed resident on his left side laying on the floor. V18's statement dated 3/1/25 documents: I saw resident in room three on the floor informed the nurse (V15). Progress note dated 3/1/25 documents: 5:30pm (V18) CNA reported that resident (R48) is on the floor. Immediately responded. Observed resident on his left side laying on the floor. Assessment done. No visible injuries noted, no change of level of consciousness or range of motion, no complain of pain or discomfort at this time. Assisted resident back to bed via two person assist. Incident report dated 3/1/25 documents: CNA reported that resident is on the floor. (R48) stated he wanted to go to the bathroom when asked what he was trying to do. Predisposing environmental factors: wheelchair/recliner, medical equipment (IV pole, etc). Predisposing Physiological Factors: Fragile/sensitive skin, recent change in medication, medication affecting blood coagulation, recent illness, weakness/fainted, high risk for significant injury: use of anticoagulants and decrease strength/endurance. Predisposing situation factors: Incident during self-transfer from bed. On 4/2/25 at 1:49pm, V8 (CNA) said, she saw R48 on 3/2/25 in the bed around 7:00am. V8 said, she reports to work early at 6:30am to complete her resident rounds. V8 said, R48 was not yelling which was his baseline. V8 said, R48 was in bed sleeping when she saw him. V8 said, she took R48 his breakfast tray between 8:00am - 8:30am. V8 said, she called R48's name. R48 did not respond. V8 said, she shook R48 to get him to wake up, but did not respond. V8 said, she informed the nurse. V8 said, R48 needs help ambulation to the bathroom. R48 was shaky/unsteady when he stood up. V8 said, she did not get any report about R48 from the off-going CNA/Nurse. Facility Final Incident report form dated 3/6/25 document: R48 was observed on the floor next to his bed. No one witnessed R48 falling. The following morning, R48 was observed with a change in condition. Physician was notified with order to transfer resident to the hospital for further evaluation. On 4/4/25 at 2:46pm, V16 (Nurse) said, when she completed her morning rounds, nothing was out of ordinary with R48. V16 said, she completed a second round on R48. V16 said, R48 was observed not his normal self. R48 was usually very verbal, out spoken, making jokes and could make his needs known. V16 said, she was use to R48 speaking to her. V16 said, she called out R48's name with no reply. V16 said, R48 was breathing with his eye's open but wasn't as verbal per usual. V16 said, R48 did not eat his breakfast which was not normal. V16 said, she notified the doctor who gave orders to discharge R48 to the hospital. V16 said, she called basic life support ambulance service (BLS). V16 said, when emergency medical technician (EMT) from the basic life support ambulance arrive they stated that 911 should have been called. V16 said, when the EMT did their assessment, they felt R48 should have gone out 911. V16 said, she did not notice anything different with R48 after the EMT assessment that different from V16's initial assessment. V16 said, the EMT never shared why they felt R48 should have been discharged to the hospital via 911 instead of BLS. V16's progress note dated 3/2/25 at 9:22am documents: During rounds notice resident hasn't ate breakfast. Observed altered mental status. Nurse practitioner ok to send out to the hospital. Contacted ambulance states 30 (thirty) minute estimate time of arrival (eta.) Progress note dated 3/2/25 at 10:12am documents: BLS ambulance arrived 2EMTs with stretcher. After assessment (BLS) has decided to send resident out 911. Ambulance Run report dated 3/2/25 documents (10:08AM): Provider's Primary Impression: Unspecified Altered Mental Status. Initial Patient Acuity: Critical (Red) Basic life support unit called to the scene for R48 with chief complaint of altered mental status. Upon arrival to patient (R48), patient was found in the supine position. Patient was alert and oriented time one baseline was alert and oriented time four and would open his eyes to verbal stimulus. CSS was attempted but unable to be completed because patient was unable to respond to verbal. Slurred speech inconclusive. Arm lift inconclusive and no facial droop notices. Med control was contacted per trauma systems of care and advised to contact 911 for advance life support (ALS) upgrade. 911 was contacted. Fire department report dated 3/2/25 documents: Patient contact (10:35AM).Emergency medical service was greeted by a basic life support crew who had been called to transport the patient, but determined that patient needed advance life support intervention. EMS was informed the patient had been found down on the ground yesterday at 5:00pm, it was unwitnessed fall, and was unknown if the patient had loss of consciousness. This morning during checks around 9:00am staff at the nursing home reported finding the patient was altered level of consciousness (ALOC) and was having issues rousing him. Staff reported the patient was normally CAOx4 (Conscious. Alert and Oriented times four means a patient is fully aware and can accurately identify who they are (person), where they are (place), what time it is (time) and what is happening around then (situation) with a Glasgow Coma Scale (GCS) of 15. Pt was taking blood thinners. As EMS entered the room they found the patient laying supine in bed with decerebrate posturing (an abnormal body posture characterized by involuntary extension of the arms and legs with the head and neck arched backward) hyper-extension of the upper extremities. Patient was found to have irregular bradypnea (abnormally slow breathing), with ALOC, presenting with a GCS of 7 (score 7 indicated a severe head injury, often associated with a come and high risk of mortality), responsive to painful stimuli and pinpoint pupils. Patient was lifted and place on the cot and secured. Patients vital were obtained. A 4- lead ECG was obtained showing a-fibrillation (heart (atria) beats irregularly and rapidly, instead of contraction in a coordinated rhythm). EMS established intravenous access and place the patient on high flow oxygen. An inbound patient care report was called into the hospital emergency department via phone. Hospital recommended EMS attempt intubation of the patient. Patient was pre-oxgenated with a bag-value mask (BVM). Pt was intubated. Progress note dated 3/2/25 documents: Writer spoke with nurse at hospital that is caring for resident, Nurse inform writer that he is currently being intubated. Progress note dated 3/4/25 documents: R48 was diagnosis with fractured ribs. Hospital paperwork dated 3/2/25 documents: Patient brought in to Trauma A via Fire Department. Alerted Mental Status (AMS) after fall yesterday at 1700 (5:00pm). Positive + blood thinners. Patient was sating 90% on non-rebreather and posturing. Patient arrived EMS bagging. Patient found down at nursing home on 3/1/25. EMS called for AMS on 3/2/25. Patient was intubated for inability to protect airway. Transferred to ICU for ventilator management. Patient with left 8, 9 rib fracture, Covid and Pneumonia. Patient remains on vent. Patient not waking up. GSC 3 (lowest possible level of consciousness, suggesting deep unconsciousness or coma and is associated with very poor prognosis often indicating a high mortality rate) in trauma bay. Change on condition policy not dated: documents: During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital.

Based on observation, interview, and record review, the facility failed to follow the Food Safety and Sanitation Policy by dietary staff using gloved hand to directly scoop a piece of cornbread after handling multiple food ladles, and dietary staff observed without beard covering for their exposed beards, and by not ensuring a bag of frozen peaches and open bottle of dried parsley was labeled with a made/open date and expiration date. This failure has the potential to affect all 48 residents in the facility on oral diets. Findings include: On 4-1-25 at 12:05 PM, surveyor observed V5 (Cook) plating lunch meals in the main dining room. Surveyor observed V5 wearing gloves and handling different food ladles, grabbing Styrofoam plates, and scooping cornbread with his gloved hand that touched multiple surfaces. V5 did not change his gloves or sanitize his hands when grabbing plates or cornbread. On 4-2-25 at 9:49 AM, V4 (Dietary Manger) said staff should change their gloves after touching multiple surfaces to prevent cross contamination. On 4-3-25 at 8:44 AM, V5 (Cook) said staff should change gloves when touching multiple surfaces to prevent cross contamination. Food Safety and Sanitation Policy dated 4-17 documents: The facility must- (2) Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Cross contamination refers to the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels or utensils that are not cleaned after touching raw food and then touch ready-eat-foods. On 4-1-25 at 9:45 AM, surveyor was touring the kitchen and noted V5 (Cook) and V6 (Dietary Aide) with beards and no beard covers. On 4-2-25 at 9:49 AM, V4 (Dietary Manger) said beard guards are used to cover facial hair to prevent hair from going into the food. On 4-3-25 at 8:44 AM, V5 (Cook) said facial coverings are used to prevent contaminants from falling into the food. Food Safety and Sanitation Policy dated 4-17 documents: Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. On 4-1-25 at 9:45 AM, surveyor and V4 (Dietary Manager) observed a bag of frozen peaches and container of dried parsley without a label including open and expiration date. V4 removed these items from the freezer and dried food storage. On 4-2-25 at 9:49 AM, V4 (Dietary Manager) said labels are used to ensure that staff know when to throw out old food. The label should include the use/open and expiration date. On 4-3-25 at 8:44 AM, V5 (Cook) said V5 said food label should include the open date and expiration date. V5 said all opened food items should be label once opened and the label determines how long the food is good for. Dating & Labeling Policy (no date) documents: Commercially processed food that has a use-by-date that is less than seven days from the date the container was opened, will be marked with that use-by-date.

Based on observation, interview, and record review, the facility failed to provide a resident with dignity during mealtime. This affected one of three residents (R5) reviewed for dignity. Findings Include: R5 has a diagnosis of Hemiplegia and visual loss. Minimal data set section G (functional abilities) dated 1/10/25 documents: eating - R5 requires partial/moderate assistance. Helper does less than half the effort. Care plan revised on 1/15/25 documents: R5 required extensive assistance times one staff participation to eat. On 4/1/25 at 12:31PM, R5 observed in the main dining room, being fed by V8 (Certified Nursing Assistant/CNA). V8 told R5, she has to feed R5 like baby. On 4/2/25 at 1:09PM, V2 (Director of Nursing/DON) said, staff should not tell any resident they have to feed them like a baby, it is not appropriated, it takes away their dignity. Staff should tell the resident to let me assist you. On 4/3/25 at 1:49pm, V8 (CNA) said, she should have not told R5 she was going to feed him like a baby. V8 said, she spends so much time taking care of the residents, they become like family. V8 said, she has been informed to called residents by their names or mister/miss. On 4/4/25 at 1:51pm, R5 who was assessed to be alert and oriented, said sometimes, staff refers to him as a baby. R5 said, he does not like it. R5 said, it makes him feel like a baby/infant and not a man. Resident Rights not dated documents: your rights to dignity and respect-your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview and record review, the facility failed to provide an appropriate call light and accessibility to a call light for one resident who was identified with self-care deficits. This affected one of three residents (R22) reviewed for call light accessibility. Findings Include: R22 has a diagnosis of Quadriplegia. Minimal Data Set section C (cognitive pattern) dated 3/20/25 documents: a score of fifteen which indicates R22 is cognitively intact. Section GG (functional abilities) documents: impairment on both sides for upper and lower extremities. Dependent on staff. Care plan initiated 9/29/2020 documents: R22 has activities of daily living self-care performance deficit related contractures bilateral upper/lower extremities, Quadriplegia. On 4/1/25 at 12:02pm, R22 who was assessed to be alert and oriented to person, place and time, was observed in bed with the call light string hanging from the wall onto the night stand. R22 could not reach the call light/string. R22 said, he was quadriplegic. R22 said, he cannot use the call string. R22 said, he has to wait until see staff pass by his room, yell and ask for assistance. R22 said, some days he has to wait a long time until he see staff to get help with activities of daily living. R22 did not have any other devices in his room to call for staff assistance. On 4/2/25 at 12:03pm, V2 (Director of Nursing/DON) said, the call light should be within R22's reach. R22 said, he can't pull the call light string even if it was within reach. Concern form dated 4/2/35 documents: R22 did not have a call light he could access. Resolution: maintenance installed an accessible call light. Call light policy dated 6/2013 documents: If a call light is not functional, give the resident another means to call for assistance (i.e bell).

Based on observation, interview and record review, the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R5) reviewed for incontinence care. Finding Including: R5 has a diagnosis of Hemiplegia. Minimal data set section G (functional abilities) dated 1/10/25 documents: Toileting hygiene: dependent. Section H (bladder and Bowel) documents: Urinary Continence: R5 was always incontinent. Care plan initiated 4/2/22 documents: R5 is incontinent of bladder and bowel function related to impaired mobility, weakness and other co-morbidities secondary to diagnosis of: hemiplegia, affecting left non-dominant side. Goal: staff will assist with toileting throughout the day. On 4/1/25 at 1:09pm, R5 was observed sitting in his wheelchair with wet soiled pants in his peri-area/between his legs. R17 (R5's roommate) who was assessed to be alert and oriented to person, place and time said, R5 was provide incontinence care around 9:30am this morning. A clock displaying the correct time was observed on the wall in the middle of R5/R17's bed area. R5 said, he was changed in the morning but was unable to report the time due not paying attention to the clock during incontinence care. R5 said, V12 (Certified Nursing Assistant/CNA) was his CNA and she provided his care. On 4/1/25 at 1:15pm, V12 (CNA) said, she provided incontinence care for R5 at 10:00am. V12 said, she will provide incontinence care for R5 again at 2:00pm. V12 was observed monitoring residents in the dining room. V12 said, she had to stay in the dining room until she was relieved. V12 said, sometimes R5 needs to be changed before 2pm. On 4/1/25 at 1:56pm, R5 was still observed sitting in his wheelchair, with the same wet pants on. R5 was wet in his peri-area/ between his legs with an irregular dry line on the outer portion of the wet spot on R5's pants. Incontinence Care policy dated 9/14 documents: Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode.

Based on observation, interview and record review, the facility failed to follow physician orders by not applying splint or braces for three residents (R5, R11 and R19) out of three residents reviewed for restoratives services. Findings include: 1. R19 was admitted to the facility on [DATE] with a diagnosis of hemiplegia affecting the left side. R19's brief interview for mental status score dated 3/5/25 documents a score of 15/15 which indicates cognitively intact. R19's physician order dated 6/10/24 documents: apply splint/brace to left upper extremities for 4-6 hours as tolerated. May remove during ADL care. R19's care plan dated 6/4/19 documents: R19 requires the use of splint to left hand/left knee related to diagnosis of hemiplegia/hemiparesis, contraction to left hand/left knee following Cerebral Vascular Accident, (CVA) affecting left dominant side. Interventions include: Splint to be on for at least 4-6 hours daily as tolerated. May remove when up to wheelchair per request. Help apply Splint to help maintain and/or improve current ROM status and prevent any further deterioration unless disease process causes unavoidable deterioration. On 4/1/25 at 12:00PM, R19 who was alert and oriented at time of interview said he doesn't know anything about a splint to his left hand. R19's left arm was contracted in a bent position with his hand towards his chest. His fingers were bent into a ball. R19 said he has limited mobility to his hand. No splint observed to his left hand. On 4/2/25 at 1:30PM, R19 was observed in bed. R19 said he had not had any splint on his left hand today and unsure where it was. On 4/2/25 at 1:34PM, V13 (Restorative Nurse) and V9 (Restorative Aide) said R19 did not have his splint on today because he was in bed. Both staff said that if the resident is in bed they do not wear splints. On 4/2/35 at 1:46PM, V9 (Restorative Aide) said she was unable to place splint or braces on the residents on 4/1/25 because she was doing weights for all the residents. V9 said she or V13 are the only staff that will apply the splints or braces. V9 confirmed that R19 splint was not applied on 4/1/25 or 4/2/25. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence. 2. R11 was admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting left side and aphasia. On 4/2/24 at 1:10PM, R11 who was alert and oriented a time of interview was able to communicate through typing on her phone. R11 said she has not had her left foot brace / orthotic for a long time a few months because it was too small. R11 was observed with brace or device to left foot. R11's foot observed turned inwards with limited mobility to joint. On 4/2/35 at 1:46PM, V9 (Restorative Aide) said R11 had a orthotic to left foot but it was not fitting right and she was waiting for anyone. V9 unsure how long R11 had been without it. On 4/3/25 at 3:30PM, V11 (Restorative Nurse) said she was not aware of R11 orthotic not being available or not fitting right until today. V11 said staff should let her know if there is a problem with device so they can get another one. R11's physician order dated 2/17/25 documents: left foot orthotic when out of bed and transfers every day. R11's care plan dated 6/5/19 documents left foot orthotics to be on 2-3 hours as tolerated. R11's restorative assessment dated [DATE] documents: left ankle severe loss/less than 50% of norm, resident currently using brace left foot orthotic. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence. 41758 3. R5 had the diagnosis of Hemiplegia. Restorative Nursing assessment dated [DATE] documents: Soft foam/sponge on left hand. Physician order sheet dated 4/2025 document: Order clarification. Soft foam/sponge to be applied on L hand when up 4-6hrs and as tolerated to prevent from further contractures. May remove during ADL care and skin checks. Care plan initiated 5/25/2018 documents: R5 has a soft foam/sponge on the left hand secondary to the diagnosis of hemiplegia. On 4/1/25 at 1:09pm, R5 was observed without a sponge/form in his left contracted hand. R5 said, he was supposed to have form in his hand. On 4/2/25 at 1:46pm, V9 (Restorative Aide) said, R5 did not have his form in his hand yesterday. V9 said, did not have time to put the form in R5's hand due to her getting facility weights. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence.

Based on interview and records review, the facility failed to notify the physician of a resident's decrease in blood pressure and decrease in oxygen saturation causing a further decline in condition. This affected one of three residents (R1) reviewed for notification of an acute change in condition. This failure resulted in R1 being sent to the hospital thirteen hours later emergently in respiratory distress, going in to cardiac arrest while in the emergency department, and expiring. Findings Include: R1 is a [AGE] year old with the following diagnosis: quadriplegia, encounter for gastrostomy, and acute respiratory failure. A Nursing note dated [DATE] at 11:32AM documents in the morning, R1 was noted resting in bed and left eye opened to name being called. At 11:20AM, V3 (Former Nurse) found R1 diaphoretic with cool/clammy skin, respiratory rate of 60 breaths per minute, and a heart rate of 96 beats per minute. A blood pressure was unable to be detected and the oxygen level was 85%. Lung sounds were coarse to the upper airway. 911 was called and on scene at 11:25AM. R1 was transferred to the hospital. A Nursing note that is struck out, dated [DATE] at 5:17PM, documents R1 was awake and looks around but is not verbal. R1's vital signs were 97.8 temperature, ,d+[DATE] blood pressure, 90 heart rate, respiratory rate 18, and oxygen level 90%. Monitor R1 for change of condition. This note was written by V7 (Nurse) and was the nurse that took care of R1 during the change of condition on [DATE]. The Fire Department Sheet dated [DATE] documents the fire department was called at 11:17AM, and they were on scene at 11:25 AM. The facility called 911 for R1 having breathing problems. Upon entering the room, R1 was unresponsive lying in the fetal position and was tachypneic at approximately 40 breaths per minute. Staff on scene stated they came to check on R1 and found R1 with an oxygen level of 84% on 5L of oxygen via nasal cannula. The crew noted R1 had shallow, rapid respirations. Staff did not provide any information regarding R1 feeling unwell or having any abnormal complaints or vital signs until just prior to contacting 911. The first set of vital signs were taken at 11:25 AM. The pulse was 164 bpm, the respirations were 60 breaths per minute, and the oxygen level was 94% after R1 was put on a nonrebreather mask at 15L. A blood pressure was unable to be obtained. During transport to the hospital, a manual blood pressure was able to be measured at 80/P. The diastolic number was unable to be obtained. The Hospital Records dated [DATE] document R1 presented to the emergency room for respiratory distress. Per the paramedics, the facility noted that R1 was unresponsive and tachypneic that morning. R1 was in acute distress, ill-appearing, and diaphoretic upon arrival. R1's carotid pulse was thready and the radial/dorsalis pedis pulses were not able to be felt. R1 is in respiratory distress, exhibits retractions with agonal breathing, and has diminished breath sounds throughout the lungs. The one set of vital signs upon R1's arrival were a pulse of 109 bpm, respirations of 45 breaths per minute, blood pressure at ,d+[DATE], and temperature of 109 F. All of the vital signs are abnormal. R1 arrived to the emergency room at 11:50AM and a code blue was called at 11:54AM. R1 became apneic and pulseless. R1 underwent multiple rounds of CPR in addition to an attempt to rapidly reduce R1's temperature with ice. R1 did not have return of spontaneous circulation and was pronounced dead at 12:42 PM. R1 did have laboratory bloodwork drawn during the code blue. The complete blood count showed that the white blood count was elevated to 13.73 K/uL (Kilo per microliter) (normal is 4XXX,d+[DATE].0 K/uL). This indicates R1 had an infection somewhere in the body. The Death certificate was requested, but a cause of death was still pending at the time of the investigation. A Nursing note dated [DATE] documents R1 expired while hospitalized . There are no progress notes documenting the change in R1's vital signs on [DATE] or any physician notification of the change in condition. On [DATE] at 1:47PM, V3 (Former Nurse) stated if something was abnormal then V3 would have talked to the doctor because R1 is nonverbal. V3 reported it is the nurse's responsibility to pick up little clues from residents' change in condition when they are unable to verbalize. V3 denied getting any report that R1 was having any issues overnight. V3 stated no one told V3 that R1 had a low blood pressure overnight. V3 reported if R1's blood pressure was normally in the 100's and hadn't had any medication to decrease it, then ,d+[DATE] points lower would be considered a change. V3 stated V3 would have contacted the physician for the blood pressure of ,d+[DATE] because it is considered a change and the physician need to give orders or tell staff what to do. On [DATE] at 2:55PM, V5 (Nurse) stated any abnormal vital signs for R1 then V5 would call the provider to see the next steps. V5 reported nurses can't decide what to do if a resident is having a change in condition and physicians have to tell staff what to do so that is why they have to notify the physician of the change. V5 reported nurses also have to document a phone call with a physician and say what the orders are. V5 stated if anything with R1 is off, even everything else is ok staff still needs to call the physician. V5 reported if vitals are slightly off for R1, the physician needs to be notified because R1 is nonverbal. V5 stated typically R1's baseline blood pressure was 100's or 110's but if R1 is in the 90's or 130's then V5 would definitely call to make the physician aware. On [DATE] at 1:36PM, V7 (Nurse) stated V7 was the one taking care of R1 on the overnight shift. V7 reported that the last blood pressure was lower than usual. V7 stated R1's blood pressure normally was over 100. V7 denied notifying a physician for that blood pressure. V7 reported a normal oxygen level is above 92%. V7 stated V7 didn't think 90% was abnormal for R1. V7 denied calling the doctor for the low oxygen level either. V7 reported V7 might have rechecked the vital signs and they were normal. V7 denied documenting the second set of vital signs because they were normal. On [DATE] at 1:59PM, V8 (Director of Nursing/DON) stated when there is any change in temperature or blood pressure, if they aren't responding the way they used to, or if they are sweating are things we watch for because R1 is nonverbal. V8 reported anything different from what a resident normally does is considered a change in condition. V8 stated a change in condition is specific for each resident and each resident has their own way of showing a change in condition. V8 stated any change in condition needs to be reported to the physician. V8 reported if the vitals aren't normal or a resident isn't responding how they normally respond then the physician should be called immediately. V8 stated the reason to call the physician is to get and orders or see what has to be done to help the resident. V8 reported staff should have called the doctor immediately when a change in R1's vital sings was noted. On [DATE] at 2:29PM, V9 (Nurse Practitioner) stated since R1 frequently had infections based on the chronic conditions R1 had, if anything was going on with R1 then R1 was sent to the hospital. V9 reported R1 had a communication barrier so with that and the chronic urinary catheter and G tube there was no hesitation to send R1 out. V9 stated when V3 did call V9 about R1's condition that V9 just said to send R1 out via 911 and not wait. V9 reported staff needs to be aware of resident's baseline so they know when something is different. V9 stated staff need to be rounding on residents and if anything is noted to be different then staff need to do a set of recent vitals and call the physician or nurse practitioner immediately. V9 reported R1's normal blood pressures were ,d+[DATE]. V9 stated if R1's blood pressure was around 90 then V9 would have wanted to be notified. V9 reported if the oxygen was at 90% then the physician/nurse practitioner should have been called. V9 stated if a resident is normally at 95% but drops down to 90%, it means there is a change and orders need to be put in to help the resident. The Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score cannot be performed due to R1 being nonverbal. Section J of the MDS documents R1 currently does not have a condition or chronic disease that may result in a life expectancy of less than six months. The Medication Administration Record dated ,d+[DATE] documents the last set of vital signs on [DATE] on the evening shift were as blood pressure ,d+[DATE] (R1's normal blood pressure ranged 100s/,d+[DATE]'s), temperature 98.5 degrees Fahrenheit, pulse 91(R1's normal pulse is documents in the 70's), respirations 18 breaths per minute, and oxygen level 90% on room air (R1's normal oxygen level is 95% or above). R1's vital signs for ,d+[DATE] were reviewed and does not document a blood pressure less than ,d+[DATE], a pulse greater than 78 beats per minute, or an oxygen level less than 95% on room air. The Care Plan dated [DATE] documents R1 is on enhanced barrier precautions for feeding tubes. An intervention documented is to assess for signs and symptoms of active infection and notify the physician. The policy titled, Change in Resident's Condition or Status, that is not dated documents, Purpose: To ensure that the resident's attending physician and representative is notified of changes in the resident's condition and/or status. Policy: 1. The Nurse will notify the resident's attending physician when: .there is a significant change in the resident's physical, mental, and psychosocial status .deemed necessary or appropriate by the resident .3. A significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident after experiencing a decrease in blood pressure and oxygen level and failed to reassess vital signs later in the shift. This affected one of three residents (R1) reviewed for comprehensive nursing assessments. This failure resulted in R1 being sent to the hospital in respiratory distress, going into cardiac arrest in the emergency room , and expiring. Findings Include: R1 is a [AGE] year old with the following diagnosis: quadriplegia, encounter for gastrostomy, and acute respiratory failure. A Nursing note dated [DATE] at 11:32AM documents in the morning, R1 was noted resting in bed and left eye opened to name being called. At 11:20AM, V3 (Former Nurse) found R1 diaphoretic with cool/clammy skin, respiratory rate of 60 breaths per minute, and a heart rate of 96 beats per minute. A blood pressure was unable to be detected and the oxygen level was 85%. Lung sounds were coarse to the upper airway. 911 was called and on scene at 11:25AM. R1 was transferred to the hospital. A Nursing note that is struck out, dated [DATE] at 5:17PM, documents R1 was awake and looks around but is not verbal. R1's vital signs were 97.8 temperature, ,d+[DATE] blood pressure, 90 heart rate, respiratory rate 18, and oxygen level 90%. Monitor R1 for change of condition. This note was documented by V7 (Nurse) who was the nurse taking care of R1 on [DATE] when R1 first had a change in vital signs. This note is dated [DATE], but R1 was no longer at the facility on [DATE] at this time. The Fire Department Sheet dated [DATE] documents the fire department was called at 11:17AM, and they were on scene at 11:25 AM. The facility called 911 for R1 having breathing problems. Upon entering the room, R1 was unresponsive lying in the fetal position and was tachypneic at approximately 40 breaths per minute. Staff on scene stated they came to check on R1 and found R1 with an oxygen level of 84% on 5L of oxygen via nasal cannula. The crew noted R1 had shallow, rapid respirations. Staff did not provide any information regarding R1 feeling unwell or having any abnormal complaints or vital signs until just prior to contacting 911. The first set of vital signs were taken at 11:25 AM. The pulse was 164 bpm, the respirations were 60 breaths per minute, and the oxygen level was 94% after R1 was put on a nonrebreather mask at 15L. A blood pressure was unable to be obtained. During transport to the hospital, a manual blood pressure was able to be measured at 80/P. The diastolic number was unable to be obtained. The Hospital Records dated [DATE] document R1 presented to the emergency room for respiratory distress. Per the paramedics, the facility noted that R1 was unresponsive and tachypneic that morning. R1 was in acute distress, ill-appearing, and diaphoretic upon arrival. R1's carotid pulse was thready and the radial/dorsalis pedis pulses were not able to be felt. R1 is in respiratory distress, exhibits retractions with agonal breathing, and has diminished breath sounds throughout the lungs. The one set of vital signs upon R1's arrival were a pulse of 109 bpm, respirations of 45 breaths per minute, blood pressure at ,d+[DATE], and temperature of 109 F. All of the vital signs are abnormal. R1 arrived to the emergency room at 11:50AM and a code blue was called at 11:54AM. R1 became apneic and pulseless. R1 underwent multiple rounds of CPR in addition to an attempt to rapidly reduce R1's temperature with ice. R1 did not have return of spontaneous circulation and was pronounced dead at 12:42 PM. R1 did have laboratory bloodwork drawn during the code blue. The complete blood count showed that the white blood count was elevated to 13.73 K/uL (Kilo per microliter) (normal is 4XXX,d+[DATE].0 K/uL). This indicates R1 had an infection somewhere in the body. The Death certificate was requested, but a cause of death was still pending at the time of the investigation. A Nursing note dated [DATE] documents R1 expired while hospitalized . There are no progress notes documenting the change in R1's vital signs on [DATE] or any follow up assessments/ vital signs that were performed to make sure there was no further decline in R1's condition. On [DATE] at 1:33PM, V2 (CNA) stated R1 was sleeping when V2 rounded on R1 around 7AM and 9AM. V2 reported R1 is usually awake at 9AM but V2 went and changed R1 at 9AM but R1 went back to sleep. V2 stated the only change noted with R1 the morning R1 went to the hospital was that R1 was more sleepy than usual. V2 reported R1 is nonverbal and unable to communicate R1's needs. On [DATE] at 1:47PM, V3 (Former Nurse) stated when V3 first rounded on R1 after getting report around 7:30AM R1 was sleeping. V3 reported rounding in R1 again around 9AM to check R1's Gtube (Gastrostomy tube) feed and R1 looked at V3 and smiled. V3 confirmed this was R1's only way to communicate with staff. V3 stated around 11AM R1 was diaphoretic and in respiratory distress breathing short and fast breaths. V3 denied being notified in report that R1 had a lower blood pressure and oxygen level the night before. V3 reported staff needs to monitor vital signs closely of residents that are not able to communicate their needs so changes can be picked up quickly and addressed. V3 stated V3 called 911 and R1 was sent to the hospital where R1 expired. On [DATE] at 2:55PM, V5 (Nurse) stated R1 did have a couple UTIs so staff would watch out for high temperature, foul smelling urine, and any other unstable vital signs that would indicate an infection. V5 reported if any vitals are abnormal, a physician should be notified to determine the next steps for the resident. V5 stated due to R1 being nonverbal a physician should be notified at even a slight difference in blood pressure such as a ,d+[DATE] number difference in blood pressure because the resident cannot tell staff any other ways they are feeling. V5 reported if the physician is not notified then a recheck of the vitals need to be performed to monitor the resident's condition. V5 said, As a nurse you need to either be rechecking the vitals or calling the physician for a resident like this. On [DATE] at 3:37PM, V6 (Certified Nursing Assistant/CNA) stated V6 took care of R1 the night before R1 went to the hospital. V6 denied anyone telling V6 R1 was having a low blood pressure or lower oxygen level. On [DATE] at 1:36PM, V7 (Nurse) stated R1 appeared healthy on the [DATE] overnight shift (11PM-7AM). V7 reported doing vital signs once on R1 and R1's blood pressure was lower than normal. V7 stated R1's blood pressure was normally over 100 and the oxygen level was also in the low 90s. V7 reported a normal oxygen level is 92% and above. V7 stated V7 did not document a recheck of any vital signs. V7 denied knowing why documenting a reassessment was important. V7 denied doing another assessment on R1 in the night and only would round on R1. V7 stated R1 was sleeping during the shift and V7 did not want to wake up R1 because R1 seemed ok. On [DATE] at 1:59PM, V8 (Director of Nursing/DON) stated staff called V8 right before R1 was sent out and notified V8 that R1 had a change in condition. V8 reported if a resident has an abnormal vital sign, then it must be reassessed by staff to make sure the resident is not getting worse. V8 stated the reassessment should be documented to show the vital sign has improved or stayed the same. V8 reported the physician should have been notified about R1's blood pressure to get orders on what to do next. On [DATE] at 2:29PM, V9 (Nurse Practitioner) stated R1 had a lot of chronic, challenging issues due to being a quadriplegic. V9 reported R1 had a lot of urinary tract infections with the chronic urinary catheter and R1 kept getting infections. V9 stated anything was going on with R1 then staff just sent R1 to the hospital. V9 reported due to R1's communication barrier and having chronic infections staff wouldn't hesitate to send R1 out. V9 reported R1 is at high risk for infection so staff just sends R1 to the hospital to not take any chances. V9 stated staff need to be aware of R1's baseline so they know when something is different. V9 reported if anything changes with a resident then the physician/nurse practitioner need to be notified immediately. V9 stated R1's normal blood pressures were ,d+[DATE] and if R1 had a blood pressure around 90, then the physician/ nurse practitioner would want to be notified. V9 reported the oxygen was at 90% then they also should have been called. V9 stated a resident normally has an oxygen level at 95% it means there is a change in condition and interventions need to be put in place. V9 was asked if a resident has a change to vital signs, what should staff do? V9 reported V9 would expect staff to be monitoring the resident to make sure there is no further change in condition or decline. V9 stated staff could monitoring the resident by more frequent rounding or additional vital signs to see what condition a resident is in. The Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score cannot be performed due to R1 being nonverbal. Section J of the MDS documents R1 currently does not have a condition or chronic disease that may result in a life expectancy of less than six months. The Medication Administration Record dated ,d+[DATE] documents the last set of vital signs on [DATE] as blood pressure ,d+[DATE] (R1's normal blood pressure ranged 100s/,d+[DATE]s), temperature 98.5 degrees Fahrenheit, pulse 91(R1's normal pulse is documents in the 70s), respirations 18 breaths per minute, and oxygen level 90% on room air (R1's normal oxygen level is 95% or above). R1's vital signs for ,d+[DATE] were reviewed and does not document a blood pressure less than ,d+[DATE], a pulse greater than 78 beats per minute, or an oxygen level less than 95% on room air. The policy titled, Standard Patient Monitoring Policy, dated [DATE] documents, Policy: To provide proactive interventions promoting enhanced physical, mental, and psychosocial well-being of residents. We will be proactive in anticipating needs of resident and aide in identifying issues or concerns. Procedure: .Any unusual occurrence or change in status of a resident will be reported to the charge nurse. The policy titled, Vital Signs, that is not dated documents, Frequency of Monitoring: Vital signs (temperature, pulse, respirations, and blood pressure) are usually checked at regular intervals, such as daily or weekly, depending on the resident's condition and physician's orders. These procedure help ensure that any changes in a resident's health are detected early, allowing for timely medical intervention.

Based on observation, interview, and record review, the facility failed to display in a public and accessible location, the [NAME] and [NAME] Retaliation Hotline poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation. The facility also failed to submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. This failure has the potential to affect all 42-residents residing in the facility. Findings Include: On 6/26/24 at 11:00am, the first-floor bulletin board observation was conducted with surveyor, V1 (Administrator) and V3(Admissions) for the [NAME] and [NAME] Retaliation poster. All parties verified that there was no visible poster of the mentioned advocacy group in the facility. On 6/26/24 at 11:30am, the dining and activity rooms were observed. There was no signage of [NAME] and [NAME] poster posted in these rooms. On 6/26/24 at 12:30pm V1 (Administrator), V3(Admissions) and V8 (Social Services) stated that they were not aware of a poster/signage that needs to be posted and visible to residents and family members in the facility. V1 stated I didn't know about this poster, but I will post it now on the facility's bulletin's board. On 6/26/24 at 1:00pm, V1 and V8 both stated that they are not aware that they must submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. V8 stated that an email is sent to the agency when residents request to be transferred into the community. There is no monthly list of residents on the program that is sent out. Facility document titled; Health Care Council of Illinois reads: Resident Admission Packet revised 12/2023. Statement of Resident Right. 5. The facility must post in a form and manner accessible and understandable to resident and resident representative: (i) A list of names addresses and telephone number of all pertinent state agencies and advocacy groups such as the state Survey Agency, the State licensure office, adult Protective Services where law provides for jurisdiction in long term care facility, the office of the State Long-Term Care on Ombudsman program, the protection and advocacy network, home and community-based services programs .

Based on observation, interview, and record review the facility failed to follow the Wound Care Plan by not implementing effective interventions to prevent further alteration in skin integrity. This failure affected 1 resident (R44) of 3 residents reviewed for wounds in a total sample of 15. Findings Include: On 6-25-24 at 8:03 AM, R44 was noted laying on a low air loss mattress with the mattress setting at static. On 6-27-24 at 11:00 AM, R44 was noted laying on a low air loss mattress with mattress set at static and verified with V11 (Assistant Director of Nursing/ADON). On 6-27-24 at 11:00 AM, V11 (ADON) said the low air loss mattress helps with wound healing by alternating pressure relief. V11 said the alternating pressure setting is based on the resident's weight. V11 said static setting is when all chambers are full and there is no alternating pressure relief for the resident. V11 said it is the nurse's responsibility to check the settings on the air mattress. On 6-27-24 at 11:28 AM, V2 (Director of Nursing) said the low air loss mattress can promote wound healing by alternating pressure relief for the resident. V2 said staff will use the static setting when changing position or providing care for a resident. V1 said static setting on the air mattress does not deliver the intended benefit of the air mattress. R44's wound care plan documents: Pressure reducing/relieving mattress and wheel chair (w/c) cushions as needed. Pressure Ulcer Prevention Protocol (no date) documents: Procedure: 4.C. Use of Pressure Reducing Devices, such as pressure reducing mattresses, mattress overlays, w/c cushioning devices, if needed. Manufacturer's Instructions (no date) documents: 2. Therapy Modes: A. Static - Redistribute body mass over a greater surface area at a constant low pressure. All of the air cells are equally inflated at lower pressures when compared to the respective comfort level in alternating mode. B. Alternate Pressure- 1 in 2 alternating cell cycle achieves period pressure relief. There are four selectable cycle time available. Caregivers can select one of the four cycle times based upon patient comfort and desired outcome.

Based on observation, interview, and record review the facility failed to follow the Medication Policy by not labeling medication bottles with the opened date. This failure affected 3 residents (R24, R34, and R18) of 15 residents reviewed for medications. Findings Include: On 6-26-24 at 1:10 PM surveyor found R24's Ketoconazole Shampoo 2%, R34's levocarnitine Oral Solution, and R18's liquid Ondansetron were opened without any opened date on the label. On 6-26-24 at 1:13 PM, V10 (Licensed Practical Nurse/LPN) said the opened date is important because staff can tell when it expires and how long the medication can last. V10 said the opened date lets staff know when to discard. On 6-26-24 at 1:45 PM, V9 (LPN) said when accessing medications she would label with the opened date and note the expiration date. On 6-26-24 at 9:00 AM, V2 (Director of Nursing) said nurses are responsible for labeling medication with the opened date. V2 said the opened date of medications is important to determine how long the medication can be used. V2 said the nurses will also honor the medication expiration date on the medication as well. Medication Policy (no date) documents: Procedure: 1. Each prescribe medication medication label includes: h. Date medication dispensed.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer treatments and/or prevention interventions were implemented and/or completed, as ordered, for 3 of 3 residents (R3, R6, and R8) reviewed for wounds in the sample of 13. The findings include: 1. On 3/22/24 at 9:54 AM, R8 was lying in bed on a regular mattress. No low air loss mattress was in place for R8. R8 said staff turn her when they change her pamper, but was not sure how often she is changed. R8 said she has a wound to her bottom, but doesn't know if there is a dressing. On 3/22/24 at 10:11 AM, R8 said, Tell them to come change me. On 3/22/24 at 10:05 AM, V4, Licensed Practical Nurse (LPN), said R8 has a pressure ulcer to her sacrum and R8's wound care is ordered daily on the night shift, and as needed, if it becomes soiled or removed. V4 said she rounds with the wound care physician each week. V4 assisted R8 to turn to her left side. R8 had a dressing in place to her sacrum which was dated 3/21/24 (the day prior to this investigation). V4 said she needs to change R8's dressing because it is soiled. R8's brief and dressing were both saturated. On 3/22/24 at 10:24 AM, V20, Certified Nursing Assistant (CNA), said R8 has not been changed since she began her shift at 7:00 AM. V20 said residents are supposed to be changed and repositioned every two hours. On 3/22/24 at 1:25 PM, V4 said she rounds with the wound care doctor and them puts the wound treatment orders in for the resident. V4 said she listens to and follows the wound care doctor's instructions from the Wound Evaluation and Management Summary. V4 said the nurse signs off on the Treatment Administration Record (TAR) when the wound care is completed. V4 said R8 is not on a low air loss mattress. V4 said a Group 2 Mattress is a low air loss mattress. V4 said R3 had a left foot wound she got due to her contractures causing her legs to turn inward and rub together. V4 said R3 did not have a special mattress while she was in the facility. R8's Admission Record dated 3/22/24 shows R8's diagnoses include, but are not limited to, right femur fracture, hypertensive heart disease, peripheral vascular disease, and Stage 3 pressure ulcers of the sacrum and left buttock. R8's Order Summary Report shows and order dated 3/5/24 for R3's sacral wound to be cleaned with Dakin's (wound cleanser) and betadine followed by the application of calcium alginate with silver, and medihoney, then covered with a border dressing every night and as needed. The same Order Summary Report does not include an order for a specialty mattress. R8's current Care Plan (undated) provided by the facility shows R8 is dependent on staff for bed mobility and toileting and is at high risk for further alterations in skin integrity related to impaired mobility and bowel and bladder incontinence. The same care plan also shows R8 has impaired cognitive function/dementia or impaired thought processes. R8's Initial Wound Evaluation and Management Summary dated 2/27/24 shows recommendations for a Group-2 mattress and for R8 to be turned side to side in bed every 1 to 2 hours. 2. R3's Admission Record dated 3/22/24 shows R3's diagnoses include, but are not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis, vascular dementia, and frontal lobe and executive function deficit. R3's Initial Wound Evaluation and Management Summary dated 12/19/23 and R3's Wound Evaluation & Management Summary from 1/5/24 show R3 has a Stage 3 Pressure Wound of the right foot (wound 1) and a Stage 3 Pressure Wound of the right dorsal foot (wound 2). The dressing treatment plan is as follows to Wound 1: Alginate calcium with silver apply once daily, Leptospermum honey apply once daily, wrap with a gauze roll daily and Wound 2: Alginate calcium with silver apply once daily, wrap with a gauze roll daily. Both summaries recommend turning R3 side to side in bed every 1 to 2 hours. R3's Order Summary Report dated 3/22/24 shows orders for R3's right anterior foot to cleanse with normal saline, pat dry, and apply medihoney with a border gauze every night shift from 9/10/23, an order for R3's right lateral foot as follows: cleanse with normal saline, pat dry, apply medihoney with a border gauze in the morning dated 12/17/23, and an order on 12/21/23 for Wound Care Right Foot- cleanse with betadine, apply calcium alginate with medihoney, wrap with gauze roll every night shift. On 12/27/23 there is are orders as follows: Cleanse with normal saline, apply medihoney to the wound bed and cover with dry dressing daily and as needed. Alginate calcium with silver is never ordered for R3's wound care. R3's Treatment Administration Record (TAR) for January 2024 shows R3 did not receive any wound care on 1/1/24, 1/5/24, 1/6/24, and 1/7/24. R3's Care Plan (closed on 1/23/24) provided by the facility shows R3 is dependent on staff for bed mobility. R3's Care Plan did not include any interventions to treat or prevent alterations in R3's skin. The facility's Pressure Ulcer Recommended Treatment Protocols (dated 11/14) shows, All residents with pressure ulcers will be treated with consistent treatment protocols to aid in the healing process. 34117 3. On 3/22/24 at 9:51 AM, R6 was observed lying in bed. A gauze dressing was observed to his sacrum. R6's Wound Physician Progress note dated 3/12/24 documents a stage 4 pressure wound to the sacrum measuring 2.1 cm x 2.0 cm x 0.2cm. Treatment orders include apply calcium alginate with silver and foam dressing daily. Peri-wound treatment apply antifungal and zinc daily. R6's Treatment Administration Record (T.A.R.) dated March 2024 shows orders to clean with dakins and betadine, apply calcium alginate with santyl anchor with 4x4 gauze, apply zinc around wound, apply border patch every night shift. A second treatment order wound care: cleanse with 1/4 dakins solution cover with leptospermum honey soaked with calcium alginate, gauze island with border foam daily and apply zinc around peri wound daily at 5:00 AM. The T.A.R. shows two different treatments and both do not show the prescribed treatment as ordered. The T.A.R. shows both treatments are signed off daily.

Based on interview and record review the facility failed to have a Registered Nurse working 8 hours a day, 7 days a week. This failure has the potential to affect all 37 the residents currently residing in the facility. Findings include: A review of the facilities resident roster on 10.1.23 indicates there are 37 residents residing in the facility. Review of facility schedules, timecards, and assignments sheets for September 2023 and PBJ (payroll-based journal) reporting record for 8.27.23 through 9.23.23 there was not a Registered nurse working on 9.5.23, 9.9.23, 9.14.23, 9.16.23, 9.22.23, 9.23.23, 9.24.23, 9.26.23, 9.29.23, and 9.30.23. On 10.2.23 at 11:15am V3 (Administrator) stated she did not have a registered nurse on duty working eight hours a day 7 days a week for the month of September 2023. V3 stated she does not have a staffing waiver for RN hours. V3 reviewed timecards, schedules, and assignment sheets, V3 confirmed there was not a Registered Nurse working on 9.5.23, 9.9.23, 9.14.23, 9.16.23, 9.22.23, 9.23.23, 9.24.23, 9.26.23, 9.29.23, and 9.30.23.

Based on observation, interview, and record review the facility failed to have sufficient nursing staff on duty to meet resident needs of providing assistance with ADLs (activities of daily living). This failure applied to four (R2, R6, R7, and R12) of four residents reviewed for ADLs and has the potential to affect all 37 residents currently in the facility. Findings include: Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 27 out of 37 residents in the facility who are occasionally or frequently incontinent of bowel and bladder. During initial rounds in the facility on 7/28/23 at 9:22AM, V2 (LPN) confirmed that she was the only nurse on duty and that there is currently no director of nursing. On 7-29-2023 6:00am V4- (Licensed Practical Nurse) observed to be in R6's room telling the patient, I am the only one here, you will need to wait for the morning shift to come and they will help you with morning care. V4 came out of the room and said, I did not have any Certified Nurse Assistant working with me last night, I was by myself. I did the best I could to keep the patients safe and I was not able to change them all. I called V1 (Administrator) to let her know. I know we need to make rounds at least every two hours and provide incontinence care, but I was not able to do it last night, I was alone for 37 residents. At 6:10am, R6 said I am soak and wet, I need help, I do not want to get another urinary infection, I am soak and wet. Last night no one was available to change me, this happens frequently, that I am urinated for long periods of time, for the nurses to come and change the undergarments. I do not like to feel dirty; I was always a well-kept person. At 6:25am V5 (Certified nurse assistant) said, I am the morning Certified Nurse Assistant, I come to work early because I like to get things done and ready as early as possible. We are supposed to make rounds every two hours and as needed, no patient should be left wet for long period of time, they can develop bed sores. I am going to take care of R6. V5 added that she comes in early when there are only two CNA's scheduled so that she can get prepared for the day because it is hard to do so when there are only two CNA's working for the day. After R6 was cleaned V5 went to make R6's bed and said, I had to wait for the mattress to be clean/ disinfected by housekeeping because the urine penetrated all the linen up to the mattress and has a strong smell of concentrated urine. At 7:00am V4 (licensed practical nurse) told V5 (CNA) to clean R2 as soon as possible. R2 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: nontraumatic intracerebral hemorrhage, anxiety and hemiplegia and hemiparesis. R2 is nonverbal but can follow simple commands answering by nodding his head yes or no. MDS dated [DATE] reads; BIMS unable to be complete. MDS; dated 6-14-2023 reads R2 needs extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene. At 7:20am V5 went in to R2's room to provide incontinence care. R2 observed to have a brown substance in his hands all over the linen and in the mattress. V5 said, I know I need another person with me to perform the care on R2, but I am they only one here, I am going to do it by myself. V5 explained to R2 what she was going to do and R2 nodded his head in agreement. Incontinent care observation done. V5 said, I did not realize R2 was in such a bad shape, he has feces all over, all the bed linen are soiled. I must change everything from his bed. 7/29/23 at 7:08AM, V5 (CNA) was observed telling V17 that R12 had to get ready to go to dialysis and that V5 was tied up with another resident and asked V17 to please help R12. V5 notified V17 that R12 needed one person assist because she is blind. V17 (LPN) agreed and then proceeded to R12's room to provide R12 assistance with ADL's (Activities of Daily Living). R12 asked V17 to please provide incontinence care because no one had changed her since yesterday. Surveyor observed that incontinence brief was soaked with urine and feces. Surveyor asked R12 if anyone had provided incontinence care to her overnight and R12 said, No, the last time I was changed was yesterday morning. All day yesterday no one changed me. At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Surveyor asked permission to enter R7's room and R7's mother said, yes, look at my son. He is soaked and dirty. Someone better get in here right now and clean him up. R7's mother was visibly upset, using foul language, and walked out of the room to get staff assistance. R7 was noted to be in bed, with incontinence brief visibly soiled and sheets soaked and stained. R7 has communication deficits and could not respond to questions. Surveyor noted V18 (CNA) in the hall and asked if she had provided any care for R7 today and V18 said, no, that's not my side; I think that side belongs to V5 (CNA), but she is in with another resident right now. 7/29/23 at 7:27AM Surveyor asked V1 (Administrator) why there were no CNA's in the building last night and why V4 (LPN) was the only staff on duty to care for all 37 residents. V1 said that she thought there were two CNA's scheduled to work last night; one CNA called and said she would be late but then never showed up and the other CNA apparently was not scheduled to work. V1 added that the former Director of Nursing had made the July schedule before resigning and that V1 would be responsible for making the August schedule and was planning to start working on it. V1 was asked if the facility ever uses a staffing agency and V1 responded that she had actually looked into yesterday (7/28/23) and showed surveyor a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, We had constant problems with staffing because the administration and the owner refused to get agency. My last straw, why I left is because I was the only nurse on the floor. Even though the administrator is clinical she wouldn't help. I had to leave because I felt it was a dangerous situation. It was just me and one other staff that were RN's. I had to work almost every day to make sure that we had an RN in the building. Sometimes we would only have one nurse at night even though there are supposed to be two nurses in the building at night. Every shift I had some issue with staffing, at least 80% of the time. I went to the administrator and owner repeatedly and they would not open up the facility to get agency staff. I felt we needed two nurses during the most active times during the day and all times residents are active. One nurse at night is adequate because most residents are sleeping. I was told that one nurse was adequate enough for the whole building. I found CNA's to cover most of the time but there were events when I only had one CNA in the building. V1 provided policy and procedure titled, Direct Care Staffing (dated 9/8/2014), which reads: Policy The number of staff who provides direct care who is needed at any time in the facility shall be based on the needs of the residents and shall be determined by figuring the number of hours of direct care each resident needs on each shift of the say. [sic] The facility shall provide minimum care staff by determining the amount of direct staffing to meet the needs of the residents and meeting the minimum direct care staff ratios set forth in the Administrative Code 77. For the purpose of computing staff to resident ratios, direct staff shall Include registered nurse, licensed practical nurse, certified nursing assistants, rehabilitative and therapy aides, 50% of DON time, 30% of Social Service Director time and licensed physical, occupational, and speech therapists. Procedure To determine the numbers of direct care personnel needed to staff the facility, the following procedures shall be used: 1. The facility shall determine the number of residents needing skilled or intermediate care. 2. The number of residents in each category shall be multiplied by the overall hours of direct care needed each day for each category. 3. Adding the hours of direct care needed for the residents in each category will give that total hours of direct care needed by all residents of the facility. 4. Multiplying the total minimum hours of direct care needed by 25% will give the minimum amount of licensed nurse time that shall be provided during a 24-hour period. Multiplying the total minimum hours of direct care needed by 10% will give the minimum amount of registered nurse time that shall be provided during a 24-hour period. Registered nurses and licensed practical nurses employed by the facility in excess of the requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. 5. Additional Direct Care Hours Equal to at least 75% of the Minimum Required. The remaining 75% of the minimum required direct care hours may be fulfilled by other staff identified above as long as it can be documented that they provided direct care. 6. The amount of time determined is expressed in hours. Dividing the total number of hours needed by the number of hours each person works per shift will give the number of persons needed to staff each shift. Calculations shall not include time for scheduled breaks or scheduled in-service training. The number of residents used to calculate staff ratios shall be based on the facility's midnight census. 7. Minimum staffing ratios will reflect the January 1, 2014 requirement. of 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.

Based on observation, interview, and record review the facility failed to provide the services of a registered nurse in the building for at least 8 consecutive hours a day, 7 days a week and failed to have a designated registered nurse serving as a full-time director of nursing. This failure has the potential to affect all 37 residents currently in the facility. Findings include: Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 37 residents in the facility. During initial rounds in the facility on 7/28/23 at 9:22AM, V2 (LPN) confirmed that she was the only nurse on duty and that there is currently no DON (Director of Nursing). V2 added that she thought the DON just resigned. Interview with V1 (Administrator) on 7/28/23 at 12:40PM, V1 confirmed that the facility currently does not have a director of nursing. V1 said, She left yesterday. She was here about a week and a half. The one before that was here about a month. I have two RN's on staff, and they are going to be helping me fill in, in the meantime and I am in the process of hiring. The previous DON was V8 (Former DON), I believe she worked here about [DATE] - May 2023. I started February 2023. Up until today I have not had an issue with no RN coverage. I have not had a chance to look at the schedule. There are no RN's on duty today, those scheduled currently are both LPN's. V1 was asked to provide a facility assessment and stated that she was asked for that before but does not have one. At 6am on 7/29/23 and confirmed that there was no RN on duty. At this time, V4 (Licensed Practical Nurse) was observed to be the only nurse in the building and confirmed that she worked alone last night (night of 7/28/23) and that she is not an RN. V4 added that she just started working at the facility and was visibly upset that she was the only nurse on duty and stated that she does not like working under these conditions. Reviewed nursing schedule provided for June and July and identified concerns. V1 (Administrator) was asked to provide documentation of payroll for all registered nurses for the months of June and July. 7/29/23 at 1:15PM, V1 provided payroll documentation for RN staffing for June and July and stated, Our week starts on Sunday; if it's not listed on there, then they didn't work. Review of payroll information provided documented that there was no RN on duty in the facility on 6/23, 6/30, 7/7, 7/16 - 7/21, and 7/26 - 7/28, 2023. 7/29/23 at 7:27AM, V1 (Administrator) said that she had actually looked into contracting with a staffing agency yesterday (7/28/23) and showed a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, It was just me and one other staff that were RN's. I had to work almost every day to make sure that we had an RN in the building. Sometimes we would only have one nurse at night even though there are supposed to be two nurses in the building at night. V1 provided policy and procedure titled, Direct Care Staffing (dated 9/8/2014), which reads: Policy The number of staff who provides direct care who is needed at any time in the facility shall be based on the needs of the residents and shall be determined by figuring the number of hours of direct care each resident needs on each shift of the say. [sic] The facility shall provide minimum care staff by determining the amount of direct staffing to meet the needs of the residents and meeting the minimum direct care staff ratios set forth in the Administrative Code 77. For the purpose of computing staff to resident ratios, direct staff shall Include registered nurse, licensed practical nurse, certified nursing assistants, rehabilitative and therapy aides, 50% of DON time, 30% of Social Service Director time and licensed physical, occupational, and speech therapists. Procedure To determine the numbers of direct care personnel needed to staff the facility, the following procedures shall be used: 1. The facility shall determine the number of residents needing skilled or intermediate care. 2. The number of residents in each category shall be multiplied by the overall hours of direct care needed each day for each category. 3. Adding the hours of direct care needed for the residents in each category will give that total hours of direct care needed by all residents of the facility. 4. Multiplying the total minimum hours of direct care needed by 25% will give the minimum amount of licensed nurse time that shall be provided during a 24-hour period. Multiplying the total minimum hours of direct care needed by 10% will give the minimum amount of registered nurse time that shall be provided during a 24-hour period. Registered nurses and licensed practical nurses employed by the facility in excess of the requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. 5. Additional Direct Care Hours Equal to at least 75% of the Minimum Required. The remaining 75% of the minimum required direct care hours may be fulfilled by other staff identified above as long as it can be documented that they provided direct care. 6. The amount of time determined is expressed in hours. Dividing the total number of hours needed by the number of hours each person works per shift will give the number of persons needed to staff each shift. Calculations shall not include time for scheduled breaks or scheduled in-service training. The number of residents used to calculate staff ratios shall be based on the facility's midnight census. 7. Minimum staffing ratios will reflect the January 1, 2014 requirement. of 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.

Based on observation, interview, and record review, the facility failed to ensure that incontinence care was provided for four (R2, R6, R7 and R12) of four residents reviewed for activities of daily living this failure has the potential to affect all 37 residents currently residing at the facility. Findings include: 7/29/23 at 7:08AM, V5 (CNA) was observed telling V17 that R12 had to get ready to go to dialysis and that V5 was tied up with another resident and asked V17 to please help R12. V5 notified V17 that R12 needed one person assist because she is blind. V17 (LPN) agreed and then proceeded to R12's room to provide R12 assistance with ADL's (Activities of Daily Living). R12 asked V17 to please provide incontinence care because no one had changed her since yesterday. Surveyor observed that incontinence brief was soaked with urine and feces. Surveyor asked R12 if anyone had provided incontinence care to her overnight and R12 said, No, the last time I was changed was yesterday morning. All day yesterday no one changed me. 7/29/23 at 7:27AM Surveyor asked V1 (Administrator) why there were no CNA's in the building last night and why V4 (LPN) was the only staff on duty to care for all 37 residents. V1 said that she thought there were two CNA's scheduled to work last night; one CNA called and said she would be late but then never showed up and the other CNA apparently was not scheduled to work. V1 added that the former Director of Nursing had made the July schedule before resigning and that V1 would be responsible for making the August schedule and was planning to start working on it. V1 was asked if the facility ever uses a staffing agency and V1 responded that she had actually looked into yesterday (7/28/23) and showed surveyor a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Surveyor asked permission to enter R7's room and R7's mother said, yes, look at my son. He is soaked and dirty. Someone better get in here right now and clean him up. R7's mother was visibly upset, using foul language and walked out of the room to get staff assistance. R7 was noted to be in bed, with incontinence brief visibly soiled and sheets soaked and stained. R7 has communication deficits and could not respond to questions. Surveyor noted V18 (CNA) in the hall and asked if she had provided any care for R7 today and V18 said, no, that's not my side; I think that side belongs to V5 (CNA) but she is in with another resident right now. 41692 On 7-29-2023 6:00am V4- (Licensed Practical Nurse) observed to be in R6's room telling the patient, I am the only one here, you will need to wait for the morning shift to come and they will help you with morning care. V4 came out of the room and said, I did not have any Certified Nurse Assistant working with me last night, I was by myself. I did the best I could to keep the patients safe and I was not able to change them all. I called V1 (administrator) to let her know. I know we need to make rounds at least every two hours and provide incontinence care, but I was not able to do it last night, I was alone for 37 residents. R6 is a [AGE] year-old female originally admitted on [DATE] with medical diagnosis that include hypertension, major depressive disorder and personal urinary tract infections. Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) score of 9/15 (Impaired cognition). MDS dated : 5-13-2023 reads: R6 needs extensive assistance of one-person physical help for transfers, walking, dressing, and toileting. At 6:10am, R6 said I am soak and wet, I need help, I do not want to get another urinary infection, I am soak and wet. Last night no one was available to change me, this happens frequently, that I am urinated for long periods of time, for the nurses to come and change the undergarments. I do not like to feel dirty; I was always a well-kept person. At 6:25am V5 (Certified nurse assistant) said, I am the morning Certified Nurse Assistant, I come to work early because I like to get things done and ready as early as possible. We are supposed to make rounds every two hours and as needed, no patent should be let wet for long period of time, they can develop bed sores. I am going to take care of R6. At 6:30am incontinence care observation done, V5 (C.N.A) assisted R6 from the bed to the wheelchair and transported the R6 to the toilet, R6 observed to be able to stand and pivot to the toilet. V5 removed the incontinent brief that appeared to be soiled, V5 said is very heavy and soaked. R6 said please clean me well I smelled like urine. After R6 was cleaned V5 went to make R6's bed and said, I had to wait for the mattress to be clean/ disinfected by housekeeping because the urine penetrated all the linen up to the mattress and has a strong smell of concentrated urine. At 7:00am V4 (licensed practical nurse) told V5 (C.N.A) to clean R2 as soon as possible. R2 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: nontraumatic intracerebral hemorrhage, anxiety and hemiplegia and hemiparesis. R2 is nonverbal but can follow simple commands answering by nodding his head yes or no. MDS dated [DATE] reads; BIMS unable to be complete. MDS; dated 6-14-2023 reads R2 needs extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene. At 7:20am V5 went in to R2's room to provide incontinence care. R2 observed to have a brown substance in his hands all over the linen and in the mattress. V5 said, I know I need another person with me to perform the care on R2 but I am they only one here, I am going to do it by myself. V5 explained to R2 what she was going to do and R2 nodded his head in agreement. Incontinent care observation done. V5 said, I did not realize R2 was in such a bad shape, he has feces all over, all the bed linen are soiled. I must change everything from his bed. On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, We do have a big problem with staffing. We do not use any agency. We do not always have a Registered Nurse in the building for a 24-hour period. V8 added that she asked the Administrator and the owner multiple times to please consider using agency staff but they refused every time and assisted that the staffing was sufficient, even though V8 did not agree that the staffing was adequate to meet resident needs. On 7-30-2023 at 2:30pm V1 (Administrator) said, the floor nurse needs to make sure to pass the medications that are ordered, assist the residents as needed, answer the call, the nurse can provide incontinence care to all the residents that need to be change. Part of nursing is to provide incontinence care. The staff needs to be made rounds at least every 2 hours, and as needed, no resident should be soiled for extended period. V1 presented undated policy titled: Incontinent Management Program Guidelines, reads: the purpose is to: prevent skin problems such as pressure areas and excoriation, improve the morale of the resident and restore the resident's dignity. Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 27 out of 37 residents in the facility who are occasionally or frequently incontinent of bowel and bladder.

Based on observation, interview, and record review, the facility failed to follow physician orders in the administration of tube feedings for four (R1, R2, R7, and R11) residents and failed to administer IV antibiotic medication as ordered for one (R1) resident out of four residents reviewed for physician orders. Findings include: R1's most recent re-admission to the facility, after hospitalization , was on 4/17/23. R1 physician orders included: Nothing by Mouth (NPO) diet, NPO texture Start Date 4/17/23 Jevity 1.5 at 270 ml bolus QID Start Date 4/17/23 Jevity is therapeutic nutrition for tube feeding. Review of medication administration record for April 2023 include no documentation that Jevity feeding was provided on the following dates/times: 4/19/23 0800 and 1200 4/20/23 1200 4/26/23 0800 Nursing Progress Note written by V8 (Former Director of Nursing) written on 4/26/23 12:46 reads: Note Text: writer went into residents' room to give afternoon feeding and Iv medication. Noted that resident was holding g-tube in her hand, it was dislodged from G-tube site. Daughter was notified. Daughter gave me the number to the intervention radiologist (named); Dr was paged waiting on a return call. No other documentation provided in medical record to show reason for missed doses of Jevity. Review of R1's physician orders include the following: Order Date 4/17/23, Start Date 4/17/23 Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously three times a day for bacterial infection until 05/09/2023 23:59 CBC/ CMP weekly faxed to (physician name and fax number provided) while on abx Review of R1's MAR (Medication Administration Record) documentation includes the following: 4/17/23 2200, 4/18/23 0600, 1400, and 4/19/23 0600 indicate that medication was not given; marked code 9 which means 9=Other / See Nurse Notes 4/18/23 2200, 4/19/23 1400, and 4/20/23 1400 are blank with no code documenting reason not given Review of nursing progress notes for R1 include the following documentation: 4/19/2023 00:05 Nursing Progress Note written by V19 (LPN) reads: Note Text: Writer reached out to pharmacy regarding IV tubing, DON notified, and also reached out to pharmacy regarding IV tubing, awaiting response from pharmacy. 4/28/2023 14:08 Nursing Progress Note written by V8 (Former Director of Nursing) reads: Note Text: 4/18/23@ 9:30 pm Writer was made aware by the pm nurse that the facility was out of IV tubing. Resident did not receive Iv medication for 10pm dose. The nurse stated that she was told by pharmacy that they would need a pre-authorization signed by facilityrepresentee to receive tubing. Called the pharmacy consultant to expedite delivery. Tubing was received on 4/19/23 am. Iv medication was started at 12pm. Tolerated medication well. [sic] Interview with V8 (Former Director of Nursing) 7/29/23 at 12:00PM, V8 stated that R1's antibiotics got called in by the nurse when we admitted (R1). We couldn't get it from the pharmacy, and we didn't have it in the lock box. I told the daughter we didn't have it. I had to call the pharmacy to get tubing and supplies but she was very irate. I had to place a call to our representative at the pharmacy and she rushed it right over. When we received it, we gave it. When it was documented is when it was given. R2 was also reviewed for physician orders and the following was noted: Enteral Feed Order four times a day 200 cc FWF Phone Active 06/26/2023 Jevity 1.5 Cal @ 55ml/hr start time (12pm) Off time (8am) Start Date 6/17/23 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5/23, 7/7/23, 7/10/23, and 7/24/23 - no 0800 or 1200 feedings were documented as given 7/17/23, 7/21/23, and 7/22/23 - no 1600 or 2000 feedings were documented as given Observation of R2 on 7/28/23 at 1:52PM noted that tube feeding was running at 55ml/hr with approximately 900ml remaining in bag; bag was dated 7/28 with no time. Observation of R2 on 7/29/23 at 6:31AM noted that tube feeding was running at 55ml/hr with approximately 700ml remaining in bag; bag was dated 7/28 with no time. 7/29/23 at 8:05AM, V4 (LPN) was asked if the tube feeding bag had been changed for R2 and also how long the feeding had been running since there was still about 700ml in the bag. V4 responded that she was the only person in the building last night and didn't have time, she remembered just pouring some more of the feeding in the bag around 12 o'clock or 1AM last night. V4 was asked how they keep track of how long the resident's feeding has been running or how much they are getting, and she stated that she was the only one working and didn't have time for any of that. V4 was also asked why R11 had orders for tube feeding but there was no set up in the room, nor was he set up for feeding based on observation this morning and V4 said, he only gets a bolus, and I gave it to him. Review of physician orders for R11 include: Nothing by Mouth (NPO) diet, NPO texture, NPO consistency Diet Active 6/15/2023 09:22 Enteral Feed Order every shift Give 350 ml every shift, free water flush ORDER START DATE 06/23/2023 Enteral Feed Order every 18 hours on at 6 am and off at 11:59p ORDER START DATE 06/16/2023 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/24 - day shift 7/17, 7/21, and 7/22 - evening shift 7/3 and 7/22 - night shift Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/2, 7/3, 7/4, 7/6, 7/7, 7/24, 7/27, 7/28 - not documented as given with code 9 (see nurses notes). Review of nurse progress notes does not include any documentation as to why tube feeding was not given. Multiple observations of R11 at various times on 7/28/23 and 7/29/23 noted that resident was not receiving tube feeding as ordered; there was no tube feeding set up in R11's room. V17 (LPN) was interviewed on 7/29/23 at 1:38PM and asked if R11 has been receiving his tube feedings per physician orders. V17 replied that this was her first day and she was not familiar with the resident but would check the electronic medical record and his orders. V17 proceeded to check orders with surveyor present and confirmed the order in the system. V17 stated that she would have to call the physician to confirm the orders because she wasn't sure what R11 should be receiving and was unclear as to how long the tube feeding should be running for based on how the order was written. V17 confirmed that up to this time she had not administered any tube feedings to R11. 7/31/23 at 3:55PM V1 (Administrator) was asked if she was aware of the order clarification V17 was going to get regarding R11's tube feeding and V1 said that she was not sure and would get back to surveyor. At 4:55PM V1 confirmed that she was not able to locate the tube feeding order for R11. R7 was reviewed for tube feedings and the following orders were included in current physician orders: Nothing by Mouth (NPO) diet NPO texture, NPO consistency with Active date of 06/01/2023 Jevity 1.5) @(60) ML/HR Start Time: (12pm ) off Time: (8 am) Give Via G-tube. every shift for Dysphagia Active 06/01/2023 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/13, 7/24, and 7/28 - day shift 7/21, 7/22 - evening shift 7/14, 7/22 - night shift Review of nurse progress notes does not include any documentation as to why tube feeding was not given. Facility provided Physician Order policy (dated February 2017), which reads: Policy: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. Procedure: Elements of the Medication Order: 1. Medication orders specify the following: a. Name of medication b. Strength of medication, c. Dosage. d. Time or frequency of administration. e. Route of administration, if other than oral. f. Quantity or duration (length) of therapy. If not specified by prescriber on a new order, the duration is limited by automatic stop order policy. g. Diagnosis or indication for h. Medication Allergy. 1. Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician. 2. PRN (as needed) orders also specify the condition for which they are being administered, c.g, as needed for pain, as needed for sleep Documentation of the Medication Order: 1. The physician's new orders may be received on the Admission Physician's Order form, by telephone or handwritten on the Physician Order Sheet. All drug orders received via transfer sheet must be verified by the attending physician and transcribed onto the Physician Order Sheet. 2. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheet if it is a verbal order, and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 3. The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders on the medication order and fax the medication order to the provider pharmacy. c. Transcribed newly prescribed medications on the MAR or TAR. If a new order changes the dosage of a previously prescribed medication, discontinue precious entry by writing DC's and the date. 4. After completion, document each medication order noted on the physician's order form with date, time, and signature. Example Noted I:15 p.m., 3/28/16.

Based on observation, interview, and record review, the facility failed to follow their policy for tube feedings by not administering tube feedings per physician orders; failed to document that physician was notified of missed feedings; failed to follow nutrition recommendations per nutrition assessments; and failed to document tube feeding intake and/or administration for two (R7 and R11) of four residents reviewed for tube feedings. Findings include: R7 and R11 were reviewed for feeding tube care during this survey. Review of physician orders for R11 include: Nothing by Mouth (NPO) diet, NPO texture, NPO consistency Diet Active 6/15/2023 09:22 Enteral Feed Order every shift Give 350 ml every shift, free water flush ORDER START DATE 06/23/2023 Enteral Feed Order every 18 hours on at 6 am and off at 11:59p (Jevity) ORDER START DATE 06/16/2023 Observations of R11 lying in bed in his room throughout the course of this survey and there was no feeding tube running nor any feeding tube set up in the room. Observations were made on 7/28/23 at 1:57PM, 7/29/23 at 6:42AM, 7:03AM, and 1:24PM. 7/29/23 at 8:05AM, V4 (LPN) was asked how they (nurses) keep track of how long the resident's feeding has been running or how much they are getting, and she stated that she was the only one working and didn't have time for any of that. V4 was also asked why R11 had orders for tube feeding but there was no set up in the room, nor was he set up for feeding based on observation this morning and V4 said, he only gets a bolus, and I gave it to him. Review of R11's medication administration record for July 2023 does not include documentation that enteral feed order (free water flush) given as ordered on the following dates/times: 7/5, 7/7, 7/10, 7/24 - day shift 7/17, 7/21, and 7/22 - evening shift 7/3 and 7/22 - night shift Review of R11's medication administration record for July 2023 does not include documentation that enteral feed order (Jevity) given as ordered on the following dates/times: 7/2, 7/3, 7/4, 7/6, 7/7, 7/24, 7/27, 7/28 - not documented as given with code 9 (see nurses notes). Review of nurse progress notes does not include any documentation as to why tube feeding was not given. V17 (LPN) was interviewed on 7/29/23 at 1:38PM and asked if R11 has been receiving his tube feedings per physician orders. V17 replied that this was her first day and she was not familiar with the resident but would check the electronic medical record and his orders. V17 proceeded to check orders with surveyor present and confirmed the order in the system. V17 stated that she would have to call the physician to confirm the orders because she wasn't sure what R11 should be receiving and was unclear as to how long the tube feeding should be running for based on how the order was written. V17 confirmed that up to this time she had not administered any tube feedings to R11. 7/31/23 at 3:55PM V1 (Administrator) was asked if she was aware of the order clarification V17 was going to get regarding R11's tube feeding and V1 said that she was not sure and would get back to surveyor. At 4:55PM V1 confirmed that she was not able to locate the tube feeding order for R11. R11's Nutrition Assessment - Enteral/Parenteral dated 7/7/23 reads: 1. Nutrition Diagnosis: Inadequate oral intake 2. Etiology (related to): decreased ability to orally consume sufficient energy 3. Symptoms (as evidenced by): the inability to maintain weight w/o use of enteral tube feeding 4. Plan: NUTRITION: TF/WT REVIEW WTS: 115.2/64in/BMI 19.8. Noted sig 9.6% wt gain x 1 mo. Res under hospice care, no wt goal at this time. DIET/TF: NPO. Jevity 1.5 @ 70mL/hr x 18 hrs to TV of 1260mL in 24 hrs. FWF 350mL TID. SKIN: no known areas of pressure REVIEW: Res under hospice care at this time r/t progression of disease. Res non verbal and TF is sole source of nutrition. No recent reports of vomiting or intolerance at this time. No reports of d/c. On 18 hour feed at this time as opposed to bolus. Res now with hx of wt gain, could be r/t switching from bolus to continuous and better tolerance. No edema reported. No new recommendations at this time. PLAN: Continue to follow with RD available for consult PRN. R7 was reviewed for tube feedings and the following orders were included in current physician orders: Nothing by Mouth (NPO) diet NPO texture, NPO consistency with Active date of 06/01/2023 Jevity 1.5) @(60) ML/HR Start Time: (12pm ) off Time: (8 am) Give Via G-tube. every shift for Dysphagia Active 06/01/2023 Observations of R7 lying in bed in his room throughout the course of this survey and the following was observed: 7/29/23 at 6:29AM and at 7:01AM, feeding tube was connected but not running; bag was not labeled (no date, time, or name of the type of formula). At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Review of R7's MAR (medication administration record) for July 2023 does not include documentation that enteral feed order for Jevity was given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/13, 7/24, and 7/28 - day shift 7/21, 7/22 - evening shift 7/14, 7/22 - night shift Review of nurse progress notes does not include any documentation as to why tube feedings were missed on dates indicated on the MAR. R7's Nutrition Assessment - Enteral/Parenteral dated 7/13/23 reads: 1. Nutrition Diagnosis: Inadequate oral intake 2. Etiology (related to): decreased ability to orally consume sufficient energy 3. Symptoms (as evidenced by): the inability to maintain weight w/o use of enteral tube feeding 4. Plan: NUTRITION: RD TF review PMH: quadriplegia, neuromuscular dysfunction, gastrostomy, MDD, anxiety WEIGHTS: 130.3#/67in/BMI 20.4. No sig wt changes noted. Res w/ slight insidious wt loss could be d/t previous hospitalization . DIET/TF: NPO. Jevity 1.5 @ 60mL/hr x 20 hrs to TV of 1200mL in 24 hrs. FWF 250mL q 6 hrs. SKIN: intact REVIEW: Resident reviewed for quarterly. Noted slight insidious wt loss. Wt loss likely r/t previous hospitalization UTI and fever, res likely hypermetabolic and burning excess kcals. No issues with TF toleration reported. Skin intact. No edema noted. No reports of n/v/d/c at this time. On meds PRN for constipation. No new recommendations at this time. Current TF regimen meets estimated needs along with med pass for additional fluid intake PLAN/Monitoring: Continue to follow with RD available for consult PRN. Facility provided policy titled, Tube Feeding (dated 5/2014), which reads: GENERAL: Nasogastric, gastrostomy and jejunostomy tubes are used when an alternate method of nutrition is needed. RESPONSIBLE PARTY: RN, LPN POLICY: 1. Continuous tube feedings are based upon a 22 hour consumption period or other time frame tased on individual resident need per Registered Dietician assessment and delivered over a 24 hour period. There is no set hours for the tube feeding to be off. 2. Tube feedings are documented on the MAR and intake record. 3. Tube feedit gs are hang times are based on manufactures guidelines. 4. Feeding tube is flushed andelamped when not in use. 5. An order by the physician or nurse practitioner contains the type of formula and rate. 6. Documentation in the chart should support the use of a feeding tube. 7. Head of the bed should be elevated 30-45 degrees unless ordered differently by the physician. 8. The physician or nurse practitioner should be notified if tube feeding amount not infused as ordered. BOLUS FEEDING: 1. Ensure head of bed is 30-45 degrees. 2. Explain procedure, provide privacy, wash hands and done gloves. 3. Check tube placement by aspiration or air insertion. 4. Instill formula and run over appropriate time frame, monitoring resident for signs and sympfoms of aspiration. 5. Flush tube with amount of water ordered at end of tube feeding. 6. When feeding complete, disconnect and cover the end of the feeding set. 7. Document feeding and alert physician or nurse practitioner of any issues or problems. FEEDING PUMP: 1. Use feed in [sic] set for pump and assemble per manufacturer instructions. 2. Turn on pump 3. Flush tube with water as ordered. 4. Check residual as ordered and alert physician if there is more than 100cc or other order. 5. Pump should be cleared at the end of each shift. 6. Document tube feeding delivered. 7. Alert physician or nurse practitioner of any issues or concerns.

Based on observation, interview, and record review, the facility failed to implement effective pain management for one resident's (R139) with severe pain of one resident reviewed for pain in a sample of 12. This failure resulted in R139 becoming extremely anxious in anticipation of pain, crying and saying she wanted to die because the pain was so bad. Findings include: On 05/23/23 at 8:30 AM R139 was observed lying in bed, soft spoken, and V16 (LPN) at bedside. V16 asked how R139 was doing and R139 states her neck hurts. V16 states oh your neck is still hurting. V16 then leaves the room without asking R139 her pain level. R139's [NAME] is to her chest and the resident looks uncomfortable. Surveyor asked R139's pain level from 1-10. R139 states her pain level is 9/10. R139 states the nurse gave her extra strength acetaminophen medication. R139 states she is waiting for it to work, and states she has been in pain since she had a stent/surgery. On 05/23/23 10:30 AM R139 states pain is still 7/10. R139 states she only had the extra strength acetaminophen earlier and nothing else. On 05/24/23 09:54 AM R139 states her pain is 10/10. R139 states she doesn't remember seeing a nurse today. On 05/24/23 at 9:56 AM V2 (DON) standing in the hall at the medication cart states she is working the floor today. V2 states she saw the resident at about 8 am. R139 states R139 has a narcotic pain medication for high levels of pain. V2 states residents can have narcotics if they request it and for pain level of 5 or above. On 05/24/23 09:58 AM R139 is observed lying in bed with her [NAME] to her chest and looking uncomfortable. R139 states she is in pain and the staff doesn't believe her when she tells them. R139 states because I'm not screaming and hollering they don't believe me. I'm a person and this is my body. I wouldn't lie about that. R139's arms observed visibly shaking. R139 states she is not sure if shaking is because of pain or something else. R139 states she can get confused because of the pain. R139 states they tell her You are okay. R139 states, My head, neck and shoulders hurt. My neck on the right side is worse than the left side. I scream when they turn me over to the left side to change me. At 10:03 AM V2 comes into the room and says to R139 do you want the strong stuff, for pain. R139 states yes, to the offer of a stronger pain medication. V2 starts to leave the room. Surveyor asks do you ask what the pain level is? V1 says, yes, and comes back to ask pain level. R139 states pain is 10. R139 says, I cried in my sleep because pain was so bad. V2 states, I don't want you to cry, and she would get R139 some pain medication. At 10:05 AM V2 leaves the room, then Resident starts crying and says Thank you. While crying R139 states I want to die. R139 states, I want to die because it hurts so bad. I love to be alive, but this pain is so stressful. R139 states she was in pain all night. On 5/24/23 at 10:08 AM V2 at medication cart and surveyor tells V2 that R139 was crying and said she wants to die because of the pain. V2 states she will let the doctor/social services know. R139's progress note by V2 dated 5/24/2023 at 10:50 AM documents the following: Resident complaining of generalized pain to body. Stated it was 10 out of 10. Resident only had Tylenol ordered. Given as ordered. Called V22 (Dr.) ordered to refer to palliative care for evaluation and management of pain. On 5/24/2023 at 11:08 Am R139 states her pain is 10/10. On 5/24/2023 at 11:10 AM V10 CNA states R139 gets real scared a lot when you are going to turn her. I tell her to take a deep breath. On 5/24/23 at 11:15 AM V21 (Therapy) states she is working with R139. V21 states V21 had complained of head and neck pain on Monday. On 05/24/23 11:30 AM V6 (CNA) states on Saturday R139 said her right leg and right side was hurting and then her stomach was hurting. She said whole right side of her head and neck was hurting on Saturday. V6 states she told V9 (nurse) on Saturday about R139's pain. On 05/24/23 02:18 PM R139 states her pain is a little better and is 7/10. R139 states she would like pain relief. On 5/24/2023 at 2:57 PM with V6 (CNA), V10 (CNA) and V13 (PTA) to observe ADL care. Surveyor asked R139 her pain level. R139 states it is a 5/10. R139 is anxious while they cleaned the front of her. V13 states resident is anticipating pain and gets apprehensive. R139 gets very anxious starts saying oh and breathing fast and rolling her eyes, shaking, and quivering more intensely. V10 states she has seen her do this before. R139 calms down and says be careful before they were going to turn her. When they turned R139 on her left side, R139 screamed Ohhhh! and kept saying oh. No one asked R139 if she was in pain. Surveyor then asked staff has she ever screamed like that before when you turned her. V6 and V10 both said yes, all the time. V10 states she always does that. V10 said she considered that a moan. V6 and V13 were in agreement. Surveyor asks R139 if she was in pain and R139 said yes, it hurts. My neck is hurting. On 5/25/2023 at 9:16 AM surveyor asks R139 how she is doing. R139 states, I'm still hurting. Pain is still the same. When asked what number on scale of 1-10, R139 states 10. On 5/25/2023 at 9:18 AM surveyor informed V16 (LPN) that R139's pain was 10/10. V16 states she will go see her. V16 states she gave R139 pain medicine on Tuesday 5/23/2023 and when she rechecked R139's pain level she was still in pain. R139 states she then asked V14 (APN) to see her because R139 was still in pain after the Tylenol. On 5/25/2023 at 9:33 AM V14 (APN) states she saw R139 on Tuesday and R139 said she is having neck pain and pain on the side of the Peripherally Inserted Central Catheter (PICC) line. V14 states she doesn't remember her pain level and she didn't chart it because she was not billing R139. V14 states she ordered PICC line be taken out. V14 (APN) states V16 (nurse) told her to see R139 today because of pain. On 5/25/2023 at 10:19 AM V14 (APN) states she saw resident and she has pain of 10/10 consisting of a headache, neck pain, and right chest pain that radiates to the left side. V14 states she is going to send R139 out to the hospital because R139 said her head pain is the worst she has ever had. On 5/25/2023 at 2:33 PM V22 (Primary Care Provider) states the nurse called him regarding R139's pain. V22 states the nurse stated that R139's pain was uncontrolled and nothing was working and they (facility) had tried everything. V22 states, had he known that R139 only had acetaminophen on board for pain, he would have tried to add something else like Naproxen, or Neurontin. V22 states kidney problems and R139's history is no reason not to treat R139's pain. V22 states when routine things are not helping pain then he would recommend palliative care for pain control. V22 states he ordered palliative care for the resident because the nurse said they had tried everything. On 5/26/2023 at 12:22 PM V2 (DON) states the nurse should ask about pain every shift minimally or if you have someone always complaining, then they should ask more often. V2 states the facility should ask pain level, what kind of pain, look at vital signs, facial expressions, if guarded, moaning, screaming, or grimacing, fearful, don't want you to touch them; these are all signs of pain. V2 states they use different interventions to relieve pain. In general, we should write a note about what a resident said and what intervention provided and how the resident received the pain management intervention. If it was effective or ineffective. V2 states, if you don't document on the Medication Administration Record (MAR) the pain level, the reminder to reassess pain doesn't pop up. V2 states for uncontrolled pain they try to see what's working and try to alleviate pain and should call doctor and let the doctor know. R139's Therapy note by V21 (Occupational Therapist Aide) dated 5/19/2023 documents pain present on assessment. Pain limits patient's functional activity. R139's Therapy note by V23 (Occupational Therapist) dated 5/23/2023 documents R139 reports pain on neck. Review of R139's pain assessments, is empty of any documented pain level. Review of R139's care plan is absent of a care plan for pain. Review of R139's medication administration record is absent of any documentation that any pain medication was given. The facility's Pain management policy documents the following: Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents to means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain Monitoring treatment efficacy and side effects. Preventing and minimizing anticipated pain when possible. B. The licensed nurse will repeat the comprehensive pain assessment under any of the following circumstances: * Resident is on routine pain medication and pain is not controlled, persistent, or worsening.

Based on observation, interview and record the facility failed to avoid an accident by not ensuring that the window safety latch was engaged to prevent a window from opening no greater than the 1 ,d+[DATE] inch in height. This failure affects one of three residents (R9) reviewed for accidents. R9 room window observed open at its highest and R9 observed outside on the ground, and unresponsive, R9 subsequently noted cold to touch, with rigor in the jaw and with obvious signs of death, R9 pronounced deceased at 5:49am on [DATE]. This was identified as an immediate jeopardy which began on [DATE] when R9 was found outside the facility on the ground below his room window. The immediacy was removed on [DATE]. V7 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on [DATE] at 10:32 am. The facility provided an acceptable removal plan on [DATE]. On [DATE] the surveyor was onsite to confirm the removal plan was implemented. Although the immediacy was removed, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of removal plan. Findings include: R9 face sheet shows R9 was admitted to the facility on [DATE]. R9's care plan shows R9 had diagnosis of major depressive disorder, metabolic encephalopathy, asthma, chronic kidney disease, long term use of aspirin, personal history of other venous thrombus and embolism, history of falling, psychotic disorder with delusions due to known physiological condition, hypertension, heart disease, unspecified atrial fibrillation, sarcoidosis, other obesity, type 2 diabetes, vascular dementia, other seizures, benign paroxysmal vertigo unspecified ear, cerebral ischemia, other speech and language deficits following cerebral infraction, osteophyte right hip, facial weakness, acquired absence of eye, and presence of artificial eye. R9's MDS dated [DATE] denotes in part section C for BIMS (brief mental status) denotes a score of 9 (cognitive impairments), R1 has disorganized thinking- 1. Behavior continuously present, does not fluctuate. Section D for mood shows for ,d+[DATE] days R9 has trouble falling or staying asleep or sleeping too much , section E for behavior denotes behavioral symptoms presence or frequency, other behavioral symptoms not directed toward others; number 1 is denoted for behavior of this type occurred 1 to 3 days, E0500 denotes did any of the identified symptoms put the resident at significant risk for physical illness or injury; number 1 is denoted for yes, significantly interferes with resident care; number 1 is denoted for yes, E1100 for changes in behavior or other symptoms; how does resident current behavior status, care rejection, or wandering compare to prior assessments (OBRA or scheduled PPS) - 0 denoted for same. Section G for functional status denotes for bed mobility- R9 requires extensive assistance with two-person physical assist, transfer- R9 requires extensive assistance with two-person physical assist, walk in room / corridor - activity did not occur. Facility initial incident report to the department dated [DATE] denotes in-part, resident name (R9), date of incident: [DATE], time of incident: 4:45am, location of incident: facility. Description of incident: resident (R9) accessed the window to his room and was found by staff on the ground. The facility is ground level and all one floor. The staff immediately brought the resident back in the building via wheelchair. The resident was alert at that time and the nurse was speaking to him trying to get information on what occurred. The CNAs put the resident to bed while the nurse initiated a call to 911, the nurse went to the room to assess the resident he became unresponsive and immediately CPR was initiated. Shortly after CPR was initiated, the paramedics arrived and continued resuscitation efforts. The resident was pronounced deceased by paramedics at 5:49am. Investigation initiated. Final will be sent per protocol. Type of incident; other box is checked. Type of injury; nothing is checked, environmental; nothing is checked. Notification denotes, physician on [DATE] at 6:30am, family on [DATE] at 630am and police on [DATE] at 4:45am. hospitalization ; no box is checked, 24-hour preliminary report box is checked. Signature box denotes V25 (DON- Director of Nursing). Facility incident report titled other dated [DATE] completed by V24 (Nurse) at 10:30am completed by V24 (Nurse) denotes in-part incident location- outside, resident found on ground outside below window, resident unable to give description, 911 called, no injuries observed at time of incident, no injuries observed post incident, predisposing environment factors- other is checked, predisposing physiological factors; confused, predisposing situation factors; other is checked, agencies, people notified; DON on [DATE] at 10:36am. R9 Fire Department report dated [DATE] denotes in-part Medics 612 and 602 were dispatched to the above location for the heat/cold emergency. Upon our arrival crew found a [AGE] year-old male laying supine in bed, apneic and pulseless. Patient nurse stated, we found him hanging out the window next to his bed. At this time, an assessment was performed from head to toe. Crew found the patient to be cold to touch, fixed pupils, and rigor to the jaw. Patient was placed on the cardiac monitor and showed asystole. Patient nurse was asked by crew the last known normal of the patient and she stated we saw him at 4:00am LUMC (hospital initials) was contacted for medical control and time of death was given of 0549 by nurse 8067 and Doctor (physician name noted). Patient was left in the hands of police, and they were given TOD (time of death) and Doc (Doctor) name. Patient was laying supine in bed apneic and pulseless. Patient was cold to the touch and rigor to the jaw. Chief complaint hot/cold exposure, patient nurse stated, we found him hanging out the window. Arrest present; yes prior to any EMS arrival, who witness; not witness, etiology; presumed cardiac, initial rhythm; asystole, CPR (Cardiopulmonary resuscitation) provided prior to EMS arrival: no, CPR started; 00:00, CPR by first responder, resuscitation; not attempted- considered futile, AED uses: no, Defib type: N/A. Impression/diagnosis; system cardiovascular, symptoms death, impression: obvious death, initial patient acuity: dead without resuscitation efforts (black). Cardiac monitor performed: role performing paramedic. Patient was placed on the pads to conform asystole, size pads, successful. Complication: none. Authorization: Via protocol. Patient response: unchanged. Paramedic consulted with (physician name noted) via radio, attempts 1; successful. Response factors affecting care; none. Scene factors affecting care: none. Transportation factors affecting care: not applicable. Dispatch factors: none. Turn around factors: none. Electronically signed by V26 (Fire department medic) at 6:43am. On [DATE] at 12:50p.m during observation of R9's room identified via facility census with V6 (Maintenance Supervisor), V6 identified the bed by the window as the bed that R9 was assigned to, the bed was observed pushed up against the window, bed frame touching the wall where window is located. The window locks were pointing outward (V6 said the window was unlocked), the window screen was observed missing, V6 identified the window screen that was observed outside the window on the ground to belong to R9's room window. The window screen was observed outside the window next to the bushes, portion of the metal frame was observed bent. The window blinds were observed to be missing, there was an additional mattress noted leaning on the wall. V6 said the blinds are missing because R9 pulled the blinds down, V6 did not have time frame of when R9 pulled the blinds down. Window measurements conducted with V6, when the bottom window was open to its highest the window opening was observed to measure at 27 inches in high, V6 said a resident can fall out the window when it's open to its highest. The measurement from the floor to the window seal was 13.75 inches (measured by V6). The measurement from the floor to the top of R9's mattress was observed to be 19.25 inches (measured by V6). At 5:10pm during observation of the facility widows to determine if they have locks, several room windows were observed with screws in them. V6 said the screws are there so that the window does not open too far. On [DATE] at 10:43am during follow up observation of the window in R9's room, there were 2 white apparatus on the top window (left and right side), V6 identified the apparatus to be a safety latch, V6 said the latch is to prevent the bottom window from opening too far. V6 moved the latch to the out position, V6 opened the window with the latch engaged, the window opening was observed to open no greater than 1.25 inches (measured by V6). V6 said the safety latch should always be in the out position, V6 said the last time he checked the window safety latch was 2 weeks ago, V6 said he checks the safety latch whenever, V6 said there is no frequency as to how often the windows should be checked to ensure that the latches are in the out position. V6 said when the latches are in the out position, it prevents the window from opening too high. V6 said when the safety latch is in the out position the window will not open wide enough for the resident to fall out. V6 said it is his responsibility to check the window safety latches to ensure they are in the out position. During the tour of the other residents' rooms to observe if there were safety latches in place and in the out position, there were 11 windows noted with the safety latch not in the out position thus allowing the window to open greater than 1.25 inches and or at its highest. During the tour V6 did not position the safety latches in the out position to prevent the windows opening greater than 1.25 inches. On [DATE] at 1:45 pm V24 (Nurse) said she was passing medication when V17 (CNA- Certified Nursing Aide) reported to her that R9 was outside on the ground. V24 said she looked out R9's room window and saw R9 on the ground, no one else was out there. V24 said they went outside, R9 was groaning, R9 had on a gown, no socks, no shoes, and she was not sure if R9 had on a brief. V24 said she asked R9 what he trying to do and R9 just looked at her and did not respond. V24 said they picked R9 up off the ground, R9 was not able to stand. V24 said they went and got a wheelchair and brought R9 back inside the facility. V24 said they put R9 in the bed, R9 was moaning, and she went to call 911 and get the blood pressure cuff. V24 said when she came back to R9's room that's when R9 stopped breathing. V24 said she initiated CPR- chest compressions. V24 said she stopped CPR and came out the room to allow for the medics to go in R9's room. V24 said the aide last saw R9 at 4:00am. V24 said R9 bed was in the low position. V24 said R9 bed is by the window. V24 said sometimes R9 sleeps at night and sometimes R9 is busy tossing and turning. V24 said she's sure R9 opened the window. V24 said R9 has confusion and is a fall risk. V24 said R9 never had any exit seeking behavior, and R9 did not have any bed alarms. V24 said when she called 911, she informed them that R9 was outside the window on the ground. V24 said she does not know how R9 got outside the window, she does not know how long R9 was outside on the ground. V24 said R9 room window was open pretty high. V24 said R9 was a full code. V24, said she did an assessment and R9 was not breathing, and she initiated CPR. V24 said the medics came and took over. V24 said the medics worked on R9 for 45minutes to an hour. V24 said R9 not revived. V24 said she notified the family and the physician. During a follow up interview with V24 on [DATE] at 3:12pm, V24 denied telling the police that R9 was hanging out the window. V24, she doesn't remember what she told the 911 dispatcher when she called for emergency services. On [DATE] at 7:47a.m during a follow up interview, V24 said she was in the hallway getting her things together to start medication administration. V24 said that's when V17 informed her that R9 was outside on the ground below the window, V24 said she went to the room and looked first then her and V17 went outside immediately, V24 said she saw R9 on the ground. V24 said R9 was moaning, V24 said she checked R9 to make sure he was not bleeding, and she looked at his limbs and head. V24 said she told V17 to go and get V18 to help pick R9 up. V24 said V17 walked toward the front of the building to get V18. V24 said V18 arrived with the wheelchair, they picked R9 up, V24 said they picked R9 up on the first attempt. V24 said her and V17 had R9 legs and V18 had R9 upper body. V24 said they was outside with R9 for about 10 minutes. V24 said V18 pushed the wheelchair with R9 in and her and V17 held R9 legs. V24 said they put R9 in the bed, R9 continued to moan. V24 said after they put R9 in the bed, she left the room to call 911 because there was not a phone in the R9 room. V24 said she got the blood pressure cuff from the medicine cart also. V24 said her cell phone was at the nurse station and she used her cell phone to call 911. V24 said she reported to the 911 dispatcher that R9 was on the ground by his window, V24 said she believes that's what she said. V24 said she reported to the 911 dispatcher that R9 was breathing, and she reported that the CNA was with R9, and she believes that's all she reported. V24 said when she got back to the room, she told the CNA to get blankets for R9. V24 said when she got back to the room R9 had stopped breathing, R9 chest was not rising and falling, R9 did not have a pulse, she checked his carotid artery. V24 said she yelled out for someone to bring the backboard that was hanging on the crash cart, so that she could do CPR on R9. V24 said she don't know who she yelled out to. V24 said V17 was in the room with her but it was not V17 that went and got the backboard. V24 said she don't know who it was that brought her the back board. V24 said by the time she started CPR (chest compressions) the medics came. V24 said she saw the medics lights when they pulled up to the facility, V24 said she could see outside of R9's room window. V24 said she saw the medics get out the vehicle and approach the ramp to come inside the facility. V24 said that's when she stopped doing chest compressions on R9. V24 said she may have done 30 compressions. V24 said she should have not stopped doing chest compressions on R9 before the Emergency Medics took over CPR efforts for R9. V24 said she did not used the Ambu-bag on R9. V24 said when she saw medics pull up to the facility, she also told V17 to go and let them inside the facility. When asked V24 if she called 911 immediately, V24 replied I believe I called 911 immediately. V24 said she did not tell the 911 dispatcher that R9 got naked and was hanging out the window. V24 reviewed her phone log and said she called 911 at 5:30am. V24 said she don't know why 911 was not called until 5:30am. V24 said she don't remember what R9 pulse rate was, she did not write it down, V24 said she know that R9 was breathing because R9 was moaning, V24 said R9 respiratory rate was 16. V24 said she don't know when R9 respiratory rate was 16. V24 said she did not call code blue because she was the only nurse there (in the facility) and when you call a code blue, that's to get assistance from another Nurse. When asked can the CNA assist you during a code blue, V24 said everyone, the Nurse and CNA should respond to a code blue. V24 said she don't know why she didn't call a code blue, V24 said it was a very frustrating night. V24 said she last saw R9 around 3:00am or 4:00am and R9 was laying in his bed awake. V24 said she don't recall the window being open. V24 said she was not aware that R9 could open the window in his room. On [DATE] at 4:25p.m V17 (CNA) said she was the aide responsible for R9 care on [DATE] for the 11:00pm-7:00am shift. V17 said she checked on R9 at 3:30am, and at 440am when she went to check on R9, she went in the room, she did not see R9 in the bed, and she went further and saw R9 outside the window on the ground. V17 said she went and got the nurse V24, and she went and told V18 (CNA) to get a wheelchair for R9. V17 said R9 was outside laying in a fetal position, naked with his gown on his arm. V17 said her and V24 had R9 by the arms and V18 had R9's legs and they picked R9 up and put him in the wheelchair and brought him back inside the facility, V17 said they put R9 in the bed. V17 said R9 was cold so she got blankets to try and warm R9 up, V17 said she stayed with R9 until V24 came back. V17 said she left R9 room to wait for the paramedic at the entrance door with the ramp. V17 said she did not see V24 do CPR on R9. V17 said she saw R9 snoring, V17 said R9 was not talking. V17 said she did not do CPR on R9. V17 said she does not know how long R9 had been outside on the ground. During a follow up call with V17 on [DATE] at 3:41pm, V17 denied telling the police that she saw R9 hanging out the window. On [DATE] at 7:00am during a follow up call V17 said the police misquoted her statement in the police report, V17 said she read and reviewed the report. V17 said she told the police that she was hanging out the window and saw R9 on the ground, V24 said she did not say R9 kicked out the screen, she did not say she pulled R9 back inside the window. V17 said on [DATE] at 4:50am, V17 said she knew it was 4:50am because she always looks at her clock, V17 said she was going into R9's room to get him up, V17 said she was not preparing her cart at 4:50am, she was at R9's room at 4:50am. V17 said R9's room door was open a little. V17 said when she went inside the room she felt a burst of air, V17 said she didn't see R9 in the bed, V17 said she looked out the window, and when she looked down, R9 was on the ground. V17 said she ran and told the nurse (V24), that's when her and V24 went outside where R9 was. V17 said they went out the exit the building at the east door (where the ramp is). V17 said the nurse was looking R9 over calling R9's name, trying to get him to respond. V17 said the nurse lift R9 left arm, trying to bring R9 to a position so that he was on his back. V17 said the nurse asked her to go and get V18. V17 said at that time V18 was on his break and was sitting in his car, the car was parked down the street a little pass the main entrance door. V17 said she went and got V18, and they came back to where R9 and V24 was, V24 informed V18 to go and get a wheelchair for R9. V17 said V18 came back with the wheelchair, they picked R9 up and put him in the wheelchair, V17 said it took at two attempts to get R9 up. V17 said her and V24 had R9 legs while V18 had R9 by the arms. V17 said they was outside with R9 for about 10 minutes. V17 said V18 pushed R9 inside the facility, V17 said all three of them put R9 back in the bed. V17 said once R9 was in the bed, R9 was still making snoring sounds. V17 said after R9 was in the bed, V24 (Nurse) left the room, V17 said she assume V24 was going to call 911, but V24 did not say she was calling 911. V17 said when V24 came back to the room she had the blood pressure cuff and she heard V24 on the phone with 911. V17 once V24 came back to the room she went to her cart and got blankets for R9 (cart at room door). V17 said she saw the nurse put the blood pressure cuff on R9's left arm. V17 said she saw V24 put two fingers on R9 wrist and neck to check R9 pulse, and V24 was calling R9's name. V17 said she stayed in the room with V24 and R9 until she had to leave the room to let Medics in. V17 said she could see from R9 room window when the medics/911 pulled up, V17 said when she saw the lights flash, she went to let them inside the facility at the east exit door (door with the ramp). V17 said when she was in the room with V24 she did not see V24 do CPR on R9, V27 said she did not see V24 do chest compressions on R9. V17 said code blue was not called. V17 said she did not call 911. V17 said V28 (CNA) did not help them with R9. V17 said her CPR certification was expired that's why she renewed it on [DATE]. V17 said she do remember having her CPR certification within the last two years. On [DATE] at 11:05am V28 (CNA) said she was working on [DATE] on the 11:00pm to 7:00am shift, V28 said she was not assigned to R9's care, V28 said she held the door open for the staff to bring R9 into the facility. V28 said R9 did not have a gown on, R9's gown was wrapped around his arm. V28 said V24 and V17 took R9 back to his room. V28 said she is not aware of whatever else happened after that because she went to finish getting up her assigned residents. V28 said she did not hear an announcement for code blue. V28 said she did not open any windows for R9 that night or early morning. On [DATE] at 3:41p.m V18 (CNA) said he was working on [DATE] on the 11:00pm to 7:00am shift, V28 said he was not assigned to R9's care. V18 said he was providing patient care when V17 came and got him to assist with R9, V18 this was around 5:00am or 5:30am. V18 said he dropped everything and ran outside to see. V18 said he saw V24 and V17 holding R9 up, the window was wide open, the screen was on the ground. V18 said R9 was awake, his eyes were open and R9 was not saying anything. V18 said he called R9's name but he did not respond and R9 would usually respond. V18 said R9 only had on a diaper, and it was not really on him. V18 said he ran and got a wheelchair, and they placed R9 in the wheelchair. V18 said he thinks V17 came and got him because they could not lift R9. V18 said they was waiting for him to come and help them lift R9. V18 said he does not know how long R9 was outside. V18 said he rolled R9 inside and all of them put R9 in the bed. V18 said R9 did not assist them with getting him in the bed. V18 said R9 was breathing, blinking his eyes, and making a sound like a smokers cough, growling and R9 was not responding. V18 said R9 skin was cool. V18 said when he felt R9 skin, it wasn't enough to say R9 was freezing, it seemed like he could have been out there for 20 minutes. V18 said he did not see R9 20 minutes prior to R9 being found either. V18 said after he assisted with getting R9 in the bed he left and went back to his assignment. V18 said he does not know how R9's room window got open. V18 said the last time he saw R9 was at 11:15pm in the bed, R9 was sleeping, and the room window was closed. V18 said if the window was open at that time, he would have felt the cold air. V18 said he don't know if V24 or V17 did CPR. V18 said code Blue was not called. V18 said if a code blue is called, they announce it over the PA system and all staff come, and you grab the crash cart. On [DATE] at 11:19am V26 (Fire Department Medic) said he was the responding medic for the emergency call for R9. V26 said when he arrived to R9 bedside, there were no staff observed implementing CPR to R9, V26 said he did not take over CPR efforts from any staff member at the facility, V26 said he initiated CPR for R9. V26 said R9 was laying in the bed in supine position. V26 said on his assessment R9 body was cold to touch, R9 upper body temperature felt the same as his lower body temperature, R9 was pulseless and there were no respirations observed. V26 said R9 had obvious signs of death when he got to him. V26 said rigor mortis was noted in R9 jaw, V26 said rigor mortis is stiffing of the body when some has died , V26 said rigor starts to set in with 30 minutes to 2 hours of death. V26 said R9 was placed on a cardiac monitor, and it shows asystole: meaning no electrical activity in the heart. V26 said he does not recall seeing a back board under R9. V26 said V24 (Nurse) reported to him that R9 was hanging out of his window, V26 said it was cold that night/ early morning hours. V26 said he saw a heat vent near R9 bed. (V26 said he thought it was strange that R9 was hanging out the window next to the heat vent and the lower part of his body was the same temperature as the upper part). V26 said V24 said R9 was last seen by staff at 4:00am and everything was okay with R9. V26 said V24 reported that R9 had dementia but he didn't see the diagnosis listed in the records that was presented to him, V26 said the documents did show that R9 had a stroke with right-side paralysis. V26 said he did not observe any alarms or sensors on R9 room window. V26 said when he arrived, he observed several windows that appeared to be open. V26 said R9 case was turned over to the police department, and he did not have any details from the police department. V26 said the fire department medics report to (LMC-hospital name given) and the medical Doctor gave the time of death, of 5:49am. V26 said the cardiac monitor did not suggest shocking R9, V26 said the resuscitation was minimal because R9 had obvious signs of death. V26 said he was concerned about the supervision of R9. V26 said in his experience as a fire department medic, if a resident or a person is found on the ground, that person should not be moved, V26 said there could be an injury to the neck or any trauma and or moving them without knowing if theres a serious injury would not be appriopriate. V26 said this is not routine for the nurse and CNA to move a resident and bring them back inside the facility after finding the residnet on the ground. V26 said R9 should have remained there for the emergency team to assess R9 where he was. On [DATE] at 11:34p.m V27 (Responding Officer) said he was the responding officer to the emergency call for R9, V27 said he interviewed V17 and V17 statement is in his report, V27 said the statement is not verbatim but that's what was reported to him. V27 said he spoke to V24 briefly and V24 statement was the same as V17, and so he didn't put V24 statement in his report. V27 said he contact the medical examiner's office and he was informed that it was not a medical examiners case, V27 said he notified the facility and he contacted R9's family for notification. Review of the 911 call on [DATE] at 0530 hours, V24 is heard telling the 911 dispatcher that the location of the emergency was 5909 west North avenue, on the oak park side, V24 is heard saying to the dispatcher that I have a patient here that got naked and hanging out the window and now he's hyperthermia when asked what number she was calling from V24 said this is my personal number and gave the dispatcher the phone number, after 1 minute and 51 seconds V24 told the 911 dispatcher that she was not with R9 and she was walking back there now V24 is heard saying she was getting the paper work together for the ambulance. At 2 minutes and 13 seconds 911 dispatcher asked V24 if the resident was awake, V24 said he was but it don't look like it now, V24 said she don't know if R9 was sleeping or not. At 2 minutes and 34 seconds V24 said it looks like he is snoring. V24 is heard saying where's that thing for the blood pressure, when the dispatcher asked was the resident snoring like he was sleep or like he was having trouble breathing, V24 responded like he went back to sleep, V24 said R9 was breathing, no concern for covid 19, at 3minutes and 28 seconds V24 is heard saying R9 breathing was completely normal, At 3 minutes and 48 seconds when the dispatcher asked V24 if R9 was conscious and alert , V24 is heard saying he was snoring but, V24 denied that R9 was responding normally when he was awake, V24 denied that R9 had any issues with heart problems, at 4 minutes and 23 seconds V24 denied having a defibrillator. 911 called ended after 4 minutes and 57 seconds. Review of the ambulance run report it denotes that 911 call received at 531, dispatch at 532, enroute at 534, at reference at 538, at patient at 539, leave reference at 605, available at 610. On [DATE] at 12:46p.m V29 (Physician) said he was notified of the incident/accident with R9 on [DATE] around 6:30am by the facility. Survey findings was reviewed with V29, V29 said the incident is an unfortunate situation, V29 was made aware that the nurse and aides said R9 was snoring, V29 said in his opinion because he was not there, but there's no was that R9 was snoring. V29 said maybe the Nurse was not able to recognize when someone is having difficulty breathing. V29 said he does not know the cause of R9 death but if R9 was outside for an unknow period, no clothes on and the staff said R9 body was cold it is likely that R9 was dealing with hypothermia. V29 said any person will be cold with clothes on within 10 minutes of being outside in 26-degree Fahrenheit weather. V29 said situation of R9 accessing the window would not have occurred if the safety latches were engaged to prevent the window from opening to high and R9 climbing out. V29 said safety is important. V29 said the facility needs to take measures to prevent this from happening again. V29 said if the staff observed R9 outside on the ground at 4:50am the nurse should have called 911 right away. V29 said the nurse should have initiated basic CPR, i.e., check the airway, do chest compressions as appropriate. V29 said calling 911 after 40minutes of finding R9 was a lot of time. V29 said he wish the nurse would have called sooner. V29 said in his career he has seen rigor mortis start to set in within 1 to hours of death, depending on the environmental factors. Review of the national weather report it shows that the temperature in Oak Park, Il on [DATE] between the hours of 3:30am to 4:50am, the temperature ranged 25 to 26 degrees Fahrenheit and the wind chill ranged between 16 to 21 (MPH), making the outside temperature feel like 11 to 13 degrees Fahrenheit. The windchill chart denotes that at a temperature of 25 to 26 degrees and a wind chill of 16 to 21 mph, will produce frostbite in humans in 30 minutes. Request was made to review facility video recording for [DATE] for the hours of 1:30am to 6:00am. On [DATE] at 445pm V7 (Administrator) said the video was not available due to the internet connection being out at that time. The surveyor on [DATE] via observation, interview and record review confirmed the following removal plan was implemented by the facility: [NAME] Nursing and Rehab Removal/Abatement Plan 1. The facility has taken the following actions concerning the IJ component a. The facility maintenance director has started working on all the windows in the facility to ensure that all safety latches on all window are engaged and will not permit anyone to go through the window. These checks and any adjustments will be completed on or before the end of day [DATE]. An additional screw was added to all windows to enhance safety, that cannot be removed without a tool. b. The facility has reviewed the floor plan to ensure all room windows are secured with safety latches have been inspected and verified to have the safety latch engaged with no room window missed. 2. Statement regarding how the facility identify other residents having potential to be affected by the same preliminary fact analysis of the IJ component? a. All residents in the facility have been identified to have potential of being affected by the alleged preliminary fact of the IJ component 3. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a. The facility has initiated repairs to secure all windows in the facility with safety latches to prevent individual from going through the window. Check initiated on [DATE] and will be completed before the end of the day [DATE]. An additional permanent screw was added to all windows to enhance safety, that cannot be removed without a tool. b. The facility has initiated a q-30mins checks on all resident to ensure residents are accounted for and to ensure no resident is loitering around the windows. Safety checks initiated on [DATE]. 1. The facility will continue procedures for monitoring and supervising all residents during all shifts. This procedure is temporary and in place to ensure that all staff is trained and educated on safety and monitoring of the residents. Once the training has been completed the facility will refer to its procedures on safety and monitoring going forward. c. The facility has initiated an educational in-service on m [TRUNCATED]

Based on interview and record review the facility failed to follow their Code Blue policy and practice by not announcing a code blue, not immediately starting Cardiopulmonary Resuscitation (CPR) and by stopping CPR before emergency team implemented efforts when a resident was observed unresponsive, irregular breathing, breathless and pulseless. This affects 1 of 3 residents (R9) reviewed for CPR. This failure resulted in a delay in emergency medical attention, Resident was found outside at 4:50am, 911 was called at 5:31am. The EMS team arrived to the resident at 5:39am and found R9 was pulseless, not breathing, rigor to jaw, with obvious signs of death, and no staff performing CPR, R9 was pronounced deceased at 5:49am. Findings include: R9 face sheet shows R9 was admitted to the facility on [DATE]. R9 POLST for dated [DATE] denotes attempt resuscitation/CPR. R9 POS (physician Order sheet) dated [DATE] shows orders for full code. R1 care plan shows R9 had diagnosis of major depressive disorder, metabolic encephalopathy, asthma, chronic kidney disease, long term use of aspirin, personal history of other venous thrombus and embolism, history of falling, psychotic disorder with delusions due to known physiological condition, hypertension, heart disease, unspecified atrial fibrillation, sarcoidosis, other obesity, type 2 diabetes, vascular dementia, other seizures, benign paroxysmal vertigo unspecified ear, cerebral ischemia, other speech and language deficits following cerebral infraction, osteophyte right hip, facial weakness, acquired absence of eye, presence of artificial eye. R9 MDS dated [DATE] denotes in part section C for BIMS (brief mental status) denotes a score of 9 (cognitive impairments), R1 has disorganized thinking- 1. Behavior continuously present, does not fluctuate. Section D for mood shows , section E for behavior denotes behavioral symptoms presence or frequency, other behavioral symptoms not directed toward others: number 1 is denoted for behavior of this type occurred 1 to 3 days, E0500 denotes did any of the identified symptoms put the resident at significant risk for physical illness or injury; number 1 is denoted for yes, significantly interferes with resident care; number 1 is denoted for yes, E1100 for changes in behavior or other symptoms; how does resident current behavior status, care rejection, or wandering compare to prior assessments (OBRA or scheduled PPS) - 0 denoted for same. Section G for functional status denotes for bed mobility- R9 require extensive assistance with two-person physical assist, transfer- R9 require extensive assistance with two-person physical assist, walk in room / corridor - activity did not occur. Facility initial incident report to the department dated [DATE] denotes in-part, resident name (R9), date of incident: [DATE], time of incident: 4:45am, location of incident: facility. Description of incident: resident (R9) accessed the window to his room and was found by staff on the ground. The facility is ground level and all one floor. The staff immediately brought the resident back in the building via wheelchair. The resident was alert at that time and the nurse was speaking to him trying to get information on what occurred. The CNAs put the resident to bed while the nurse initiated a call to 911, the nurse went to the room to assess the resident he became unresponsive and immediately CPR was initiated. Shortly after CPR was initiated, the paramedics arrived and continued resuscitation efforts. The resident was pronounced deceased by paramedics at 5:49am. Investigation initiated. Final will be sent per protocol. Type of incident; other box is checked. Type of injury; nothing is checked, environmental; nothing is checked. Notification denotes, physician on [DATE] at 6:30am, family on [DATE] at 630am and police on [DATE] at 4:45am. hospitalization ; no box is checked, 24-hour preliminary report box is checked. Signature box denotes V25 (DON- Director of Nursing). Facility incident report titled other dated [DATE] completed by V24 (Nurse) at 10:30am completed by V24 (Nurse) denotes in-part incident location- outside, resident found on ground outside below window, resident unable to give description, 911 called, no injuries observed at time of incident, no injuries observed post incident, predisposing environment factors- other is checked, predisposing physiological factors; confused, predisposing situation factors; other is checked, agencies, people notified; DON on [DATE] at 10:36am. R9 fire department report dated [DATE] denotes in-part Medics 612 and 602 were dispatched to the above location for the heat/cold emergency. Upon our arrival crew found a [AGE] year-old male laying supine in bed, apneic and pulseless. Patient nurse stated, we found him hanging out the window next to his bed. At this time, an assessment was performed from head to toe. Crew found the patient to be cold to touch, fixed pupils, and rigor to the jaw. Patient was placed on the cardiac monitor and showed asystole. Patient nurse was asked by crew the last known normal of the patient and she stated we saw him at 4:00am LUMC was contacted for medical control and time of death was given of 0549 by nurse 8067 and Doctor (physician name noted). Patient was left in the hands of police, and they were given TOD (time of death) and Doc (Doctor) name. Patient was laying supine in bed apneic and pulseless. Patient was cold to the touch and rigor to the jaw. Chief complaint hot/cold exposure, patient nurse stated, we found him hanging out the window. Arrest present; yes prior to any EMS arrival, who witness; not witness, etiology; presumed cardiac, initial rhythm; asystole, CPR (Cardiopulmonary resuscitation) provided prior to EMS arrival: no, CPR started; 00:00, CPR by first responder, resuscitation; not attempted- considered futile, AED uses: no, Defib type: N/A. Impression/diagnosis; system cardiovascular, symptoms death, impression: obvious death, initial patient acuity: dead without resuscitation efforts (black). Cardiac monitor performed: role performing paramedic. Patient was placed on the pads to conform asystole, size pads, successful. Complication: none. Authorization: Via protocol. Patient response: unchanged. Paramedic consulted with (physician name noted) via radio, attempts 1; successful. Response factors affecting care; none. Scene factors affecting care: none. Transportation factors affecting care: not applicable. Dispatch factors: none. Turn around factors: none. Electronically signed by V26 (Fire department medic) at 6:43am. On [DATE] at 1:45 pm V24 (Nurse) said she was passing medication when V17 (CNA- Certified Nursing Aide) reported to her that R9 was outside on the ground. V24 said she looked out R9's room window and saw R9 on the ground, no one else was out there. V24 said they went outside, R9 was groaning, R9 had on a gown, no socks, no shoes, and she was not sure if R9 had on a brief. V24 said she asked R9 what he trying to do and R9 just looked at her and did not respond. V24 said they picked R9 up off the ground, R9 was not able to stand. V24 said they went and got a wheelchair and brought R9 back inside the facility. V24 said they put R9 in the bed, R9 was moaning, and she went to call 911 and get the blood pressure cuff. V24 said when she came back to R9's room that's when R9 stopped breathing. V24 said she initiated CPR- chest compressions. V24 said she stopped CPR and came out the room to allow for the medics to go in R9's room. V24 said the aide last saw R9 at 4:00am. V24 said R9 bed was in the low position. V24 said R9 bed is by the window. V24 said sometimes R9 sleeps at night and sometimes R9 is busy tossing and turning. V24 said she's sure R9 opened the window. V24 said R9 has confusion and is a fall risk. V24 said R9 never had any exit seeking behavior, and R9 did not have any bed alarms. V24 said when she called 911, she informed them that R9 was outside the window on the ground. V24 said she does not know how R9 got outside the window, she does not know how long R9 was outside on the ground. V24 said R9 room window was open pretty high. V24 said R9 was a full code. V24, said she did an assessment and R9 was not breathing, and she initiated CPR. V24 said the medics came and took over. V24 said the medics worked on R9 for 45minutes to an hour. V24 said R9 not revived. V24 said she notified the family and the physician. During a follow up interview with V24 on [DATE] at 3:12pm, V24 denied telling the police that R9 was hanging out the window. V24, she doesn't remember what she told the 911 dispatcher when she called for emergency services. On [DATE] at 7:47a.m during a follow up interview, V24 said she was in the hallway getting her things together to start medication administration. V24 said that's when V17 informed her that R9 was outside on the ground below the window, V24 said she went to the room and looked first then her and V17 went outside immediately, V24 said she saw R9 on the ground. V24 said R9 was moaning, V24 said she checked R9 to make sure he was not bleeding, and she looked at his limbs and head. V24 said she told V17 to go and get V18 to help pick R9 up. V24 said V17 walked toward the front of the building to get V18. V24 said V18 arrived with the wheelchair, they picked R9 up, V24 said they picked R9 up on the first attempt. V24 said her and V17 had R9 legs and V18 had R9 upper body. V24 said they was outside with R9 for about 10 minutes. V24 said V18 pushed the wheelchair with R9 in and her and V17 held R9 legs. V24 said they put R9 in the bed, R9 continued to moan. V24 said after they put R9 in the bed, she left the room to call 911 because there was not a phone in the R9 room. V24 said she got the blood pressure cuff from the medicine cart also. V24 said her cell phone was at the nurse station and she used her cell phone to call 911. V24 said she reported to the 911 dispatcher that R9 was on the ground by his window, V24 said she believes that's what she said. V24 said she reported to the 911 dispatcher that R9 was breathing, and she reported that the CNA was with R9, and she believes that's all she reported. V24 said when she got back to the room, she told the CNA to get blankets for R9. V24 said when she got back to the room R9 had stopped breathing, R9 chest was not rising and falling, R9 did not have a pulse, she checked his carotid artery. V24 said she yelled out for someone to bring the backboard that was hanging on the crash cart, so that she could do CPR on R9. V24 said she don't know who she yelled out to. V24 said V17 was in the room with her but it was not V17 that went and got the backboard. V24 said she don't know who it was that brought her the back board. V24 said by the time she started CPR (chest compressions) the medics came. V24 said she saw the medics lights when they pulled up to the facility, V24 said she could see outside of R9's room window. V24 said she saw the medics get out the vehicle and approach the ramp to come inside the facility. V24 said that's when she stopped doing chest compressions on R9. V24 said she may have done 30 compressions. V24 said she should have not stopped doing chest compressions on R9 before the Emergency Medics took over CPR efforts for R9. V24 said she did not used the Ambu-bag on R9. V24 said when she saw medics pull up to the facility, she also told V17 to go and let them inside the facility. When asked V24 if she called 911 immediately, V24 replied I believe I called 911 immediately. V24 said she did not tell the 911 dispatcher that R9 got naked and was hanging out the window. V24 reviewed her phone log and said she called 911 at 5:30am. V24 said she don't know why 911 was not called until 5:30am. V24 said she don't remember what R9 pulse rate was, she did not write it down, V24 said she know that R9 was breathing because R9 was moaning, V24 said R9 respiratory rate was 16. V24 said she don't know when R9 respiratory rate was 16. V24 said she did not call code blue because she was the only nurse there ( in the facility) and when you call a code blue, that's to get assistance from another Nurse. When asked can the CNA assist you during a code blue, V24 said everyone, the Nurse and CNA should respond to a code blue. V24 said she don't know why she didn't call a code blue, V24 said it was a very frustrating night. V24 said she last saw R9 around 3:00am or 4:00am and R9 was laying in his bed awake. V24 said she don't recall the window being open. V24 said she was not aware that R9 could open the window in his room. On [DATE] at 4:25p.m V17 (CNA) said she was the aide responsible for R9 care on [DATE] for the 11:00pm-7:00am shift. V17 said she checked on R9 at 3:30am, and at 440am when she went to check on R9, she went in the room, she did not see R9 in the bed, and she went further and saw R9 outside the window on the ground. V17 said she went and got the nurse V24, and she went and told V18 (CNA) to get a wheelchair for R9, V17 said R9 was outside laying in a fetal position, naked with his gown on his arm. V17 said her and V24 had R9 by the arms and V18 had R9's legs and they picked R9 up and put him in the wheelchair and brought him back inside the facility, V17 said they put R9 in the bed. V17 said R9 was cold so she got blankets to try and warm R9 up, V17 said she stayed with R9 until V24 came back, V17 said she left R9 room to wait for the paramedic at the entrance door with the ramp. V17 said she did not see V24 do CPR on R9. V17 said she saw R9 snoring, V17 said R9 was not talking. V17 said she did not do CPR on R9. V17 said she does not know how long R9 had been outside on the ground. During a follow up call with V17 on [DATE] at 3:41pm, V17 denied telling the police that she saw R9 hanging out the window. On [DATE] at 7:00am during a follow up call V17 said the police misquoted her statement in the police report, V17 said she read and reviewed the report. V17 said she told the police that she was hanging out the window and saw R9 on the ground, V24 said she did not say R9 kicked out the screen, she did not saw she pulled R9 back inside the window. V17 said on [DATE] at 450am, V17 said she knew it was 4:50am because she always look at her clock, V17 said she going into R9's room to get him up, V17 said she was not preparing her cart at 450am, she was at R9 room at 450am. V17 said R9 room door was open a little, V17 said when she went inside the room she felt a burst of air, V17 said she didn't see R9 in the bed, V17 said she looked out the window, and when she looked down, R9 was on the ground, V17 said she ran and told the nurse (V24), that's when her and V24 went outside where R9 was, V17 said the exit the building at the east door ( where the ramp is). V17 said the nurse was looking R9 over calling R9's name, trying to get him to respond, V17 said the nurse left R9 left arm, trying to bring R9 to a position so that he was on his back. V17 said the nurse asked her to go and get V18, V17 said at that time V18 was on his break and was sitting in his car, the car was parked down the street a little pass the main entrance door. V17 said she went and got V18, and we they came back to where R9 and the V24 was, V24 informed V18 to go and get a wheelchair for R9. V17 said V18 came back with the wheelchair, they picked R9 up and put him in the wheelchair, V17 said it took at two attempts to get R9 up. V17 said her and V24 had R9 legs while V18 had R9 by the arms. V17 said they was outside with R9 for about 10 minutes. V17 said V18 pushed R9 inside the facility, V17 said all three of them put R9 back in the bed. V17 said once R9 was in the bed, R9 was still making snoring sounds. V17 said after R9 was in the bed, V24 (Nurse) left the room, V17 said she assume V24 was going to call 911, but V24 did not say she was calling 911. V17 said when V24 came back to the room she had the blood pressure cuff and she heard V24 on the phone with 911. V17 once V24 came back to the room she went to her cart and got blankets for R9 (cart at room door). V17 said she saw the nurse put the blood pressure cuff on R9's left arm. V17 said she saw V24 put two fingers on R9 wrist and neck to check R9 pulse, and V24 was calling R9's name. V17 said she stayed in the room with V24 and R9 until she had to leave the room to let Medics in. V17 said she could see from R9 room window when the medics/911 pulled up, V17 said when she saw the lights flash, she went to let them inside the facility at the east exit door (door with the ramp). V17 said when she was in the room with V24 she did not see V24 do CPR on R9, V27 said she did not see V24 do chest compressions on R9. V17 said code blue was not called. V17 said she did not call 911. V17 said V28 (CNA) did not help them with R9. V17 said her CPR certification was expired that's why she renewed it on [DATE]. V17 said she do remember having her CPR certification within the last two years. On [DATE] at 11:05am V28 (CNA) said she was working on [DATE] on the 11:00pm to 7:00am shift, V28 said she was not assigned to R9's care, V28 said she held the door open for the staff to bring R9 into the facility. V28 said R9 did not have a gown on, R9's gown was wrapped around his arm. V28 said V24 and V17 took R9 back to his room. V28 said she is not aware of whatever else happened after that because she went to finish getting up her assigned residents. V28 said she did not hear an announcement for code blue. V28 said she did not open any windows for R9 that night or early morning. V28 said she did not give V24 a backboard. On [DATE] at 3:41p.m V18 (CNA) said he was working on [DATE] on the 11:00pm to 7:00am shift, V28 said he was not assigned to R9's care. V18 said he was providing patient care when V17 came and got him to assist with R9, V18 this was around 5:00am or 5:30am. V18 said he dropped everything and ran outside to see. V18 said he saw the V24 and V17 holding R9 up, the window was wide open, the screen was on the ground. V18 said R9 was awake, his eyes were open and R9 was not saying anything. V18 said he called R9's name but he did not respond and R9 would usually respond. V18 said R9 only had on a diaper, and it was not really on him. V18 said he ran and got a wheelchair, and they placed R9 in the wheelchair. V18 said he thinks V17 came and got him because they could not lift R9. V18 said they was waiting for him to come and help them lift R9. V18 said he does not know how long R9 was outside. V18 said he rolled R9 inside and all of them put R9 in the bed. V18 said R9 did not assist them with getting him in the bed. V18 said R9 was breathing, blinking his eyes, and making a sound like a smokers cough, growling and R9 was not responding. V18 said R9 skin was cool. V18 said when he felt R9 skin, it wasn't enough to say R9 was freezing, it seemed like he could have been out there for 20 minutes. V18 said he did not see R9 minutes prior. V18 said he did not see R9 20 minutes prior to R9 being found either. V18 said after he assisted with getting R9 in the bed he left and went back to his assignment. V18 said he does not know how R9's room got open. V18 said the last time he saw R9 was at 11:15pm in the bed, R9 was sleeping, and the room window was closed, V18 said if the window was open at that time, he would have felt the cold air. V18 said he don't know if V24 or V17 did CPR. V18 said code Blue was not called. V18 said if a code blue is called, the announce it over the PA system and all staff come, and you grab the crash cart. V18 said he did not give V24 a backboard. On [DATE] at 11:19am V26 (Fire Department Medic) said he was the responding medic for the emergency call for R9. V26 said when he arrived to R9 bedside, there were no staff observed implementing CPR to R9, V26 said he did not take over CPR efforts from any staff member at the facility, V26 said he initiated CPR for R9. V26 said R9 was laying in the bed in supine position. V26 said on his assessment R9 body was cold to touch, R9 upper body temperature felt the same as his lower body temperature, R9 was pulseless and there were no respirations observed. V26 said R9 had obvious signs of death when he got to him. V26 said rigor mortis was noted in R9 jaw, V26 said rigor mortis is stiffing of the body when some has died , V26 said rigor starts to set in with 30 minutes to 2 hours of death. V26 said R9 was placed on a cardiac monitor, and it shows asystole: meaning no electrical activity in the heart. V26 said he does not recall seeing a back board under R9. V26 said V24 (Nurse) reported to him that R9 was hanging out of his window, V26 said it was cold that night/ early morning hours. V26 said he saw a heat vent near R9 bed. (V26 said he thought it was strange that R9 was hanging out the window next to the heat vent and the lower part of his body was the same temperature as the upper part). V26 said V24 said R9 was last seen by staff at 4:00am and everything was okay with R9. V26 said V24 reported that R9 had dementia but he didn't see the diagnosis listed in the records that was presented to him, V26 said the documents did show that R9 had a stroke with right-side paralysis. V26 said he did not observe any alarms or sensors on R9 room window. V26 said when he arrived, he observed several windows that appeared to be open. V26 said R9 case was turned over to the police department, and he did not have any details from the police department. V26 said the fire department medics report to (LMC-hospital name given) and the medical Doctor gave the time of death, of 5:49am. V26 said the cardiac monitor did not suggest shocking R9, V26 said the resuscitation was minimal because R9 had obvious signs of death. V26 said he was concerned about the supervision of R9. V26 said in his experience as a fire department medic, if a resident or a person is found on the ground, that person should not be moved, V26 said there could be an injury to the neck or any trauma and or moving them without knowing if theres a serious injury would not be appriopriate. V26 said this is not routine for the nurse and CNA to move a resident and bring them back inside the facility after finding the residnet on the ground. V26 said R9 should have remained there for the emergency team to assess R9 where he was. On [DATE] at 11:34p.m V27 (Responding Officer) said he was the responding officer to the emergency call for R9, V27 said he interviewed V17 and V17 statement is in his report, V27 said the statement is not verbatim but that's what was reported to him. V27 said he spoke to V24 briefly and V24 statement was the same as V17, and so he didn't put V24 statement in his report. V27 said he contact the medical examiner's office and he was informed that it was not a medical examiners case, V27 said he notified the facility and he contact R9's family for notification. Review of the 911 call on [DATE] at 0530 hours, V24 is heard telling the 911 dispatcher that the location of the emergency was 5909 west North avenue, on the oak park side, V24 is heard saying to the dispatcher that I have a patient her that got naked and hanging out the window and now he's hyperthermia when asked what number she was calling from V24 said this is my personal number and gave the dispatcher the phone number, after 1 minute and 51 seconds V24 told the 911 dispatcher that she was not with R9 and she was walking back there now V24 is heard saying she was getting the paper work together for the ambulance. At 2minutes at 13 seconds 911 dispatcher asked V24 if the resident was awake, V24 said he was but it don't look like it now, V24 said she don't know if R9 was sleeping or. At 2 minutes at 34 seconds V24 said it looks like he is snoring. V24 is heard saying where's that thing for the blood pressure, when the dispatcher asked was the resident snoring like he was sleep or like he was having trouble breathing, V24 responded like he went back to sleep, V24 said R9 was breathing, no concern for covid 19, at 3minutes at 28 seconds V24 is heard saying R9 breathing was completely normal. At 3 minutes and 48 seconds when the dispatcher asked V24 if R9 was conscious and alert, V24 is heard saying he was snoring but, V24 denied that R9 was responding normally when he was awake, V24 denied that R9 had any issues with heart problems, at 4 minutes and 23 seconds V24 denied having a defibrillator. 911 called ended after 4 minutes and 57 seconds. Review of the ambulance run report it denotes that 911 call received at 531, dispatch at 532, enroute at 534, at reference at 538, at patient at 539, leave reference at 605, available at 610. On [DATE] at 12:46p.m V29 (Physician) said he was notified of the incident/accident with R9 on [DATE] around 6:30am by the facility. Survey findings was reviewed with V29, V29 said the incident is an unfortunate situation, V29 was made aware that the nurse and aides said R9 was snoring, V29 said in his opinion because he was not there, but there's no was that R9 was snoring, V29 said maybe the Nurse was not able to recognize when someone is having difficulty breathing, V29 said he does not know the cause of R9 death but if R9 was outside for an unknow period of time, no clothes on and the staff said R9 body was cold it is likely that R9 was dealing with hypothermia, V29 said any person will be cold with clothes on within 10 minutes of being outside in 26 degree weather. V29 said situation of R9 accessing the window would not have occurred if the safety latches were engaged to prevent the window from opening to high and R9 climbing out. V29 said safety is important. V29 said the facility needs to take measures to prevent this from happening again. V29 said if the staff observed R9 outside on the ground at 4:50am the nurse should have called 911 right away. V29 said the nurse should have initiated basic CPR, i.e., check the airway, do chest compressions as appropriate. V29 said calling 911 after 40 minutes of finding R9 was a lot of time. V29 said he wish the nurse would have called 911 sooner. V29 said in his career he has seen rigor mortis start to set in within 1 to 2 hours of death, depending on the environmental factors. On [DATE] at 10:16am V25 (DON) said the nurse should not stop CPR efforts before the nurse hand the patient over to the medics. V25 said the nurse should follow the facility code blue policy when a resident is unresponsive. V25 said the nurse should report exactly what occurred when calling 911. V25 said she will check to see if the facility has a defibrillator. At 2:17pm surveyor was informed that the facility did not have a CPR policy or pamphlets with instructions on how to perform CPR. During this survey V25 did not report if the facility had a defibrillator or not. During this survey V24 said R9 was not responsive when she went back to his room to assess him. V24 called 911 at 5:30am. V24 is heard on the 911 call at 1 minute and 51 seconds saying she was going to R9 room now, and she was getting paperwork together for the ambulance. V24 was not heard telling the 911 dispatcher that R9 needed CPR. V24 was not heard telling the 911 dispatcher that she had to initiate CPR for R9. V24 told the 911 dispatcher at 3 minutes and 48 seconds into the emergency call that R9 was snoring but. Using the responsible person concept, it is reasonable to believe that V24 failed to give the 911 dispatcher all the details of R9 condition. At 3 minutes and 48 seconds V24 was not heard telling the 911 dispatcher that R9 needed CPR. V24 was not heard telling the 911 dispatcher that she had to initiate CPR for R9. V24 was on the phone with the 911 dispatcher for 4 minutes and 51 seconds. V24 was not heard telling the 911 dispatcher that R9 needed CPR. V24 was not heard telling the 911 dispatcher that she had to initiate CPR for R9. During this survey V24 said she did CPR (30 compressions) on R9, V17 said she did not witness V24 doing CPR on R9. V17 and V24 said V17 stayed with V24 and R9 until she went to open the door for the medics who arrived on the scene at 5:38am. V26 (Fire department Medic) said when he arrived to R9 bedside, he did not see anyone doing CPR on R9. Review of the facility code blue policy dated ,d+[DATE], revision date ,d+[DATE] and review date of ,d+[DATE] denotes in-part a code is initiated for all residents requiring emergency medical attention. Upon finding a person without respirations and/or pulse, call for help and confirm presence/absence of advanced directives/code status. If the resident is not a DNR (Do Not Resuscitate), a code blue should be announced and start CPR. When announcing code blue, state the area of the code. As staff arrive the DON (Director of Nursing) or designee should assign staff to the following items: someone to call 911, someone to assist with CPR, someone notify the physician and family, someone to start the transfer form, get the paperwork together and notify the hospital, someone to hold the elevator on the first floor if applicable, someone to remove other residents from and ensure there is a clear path for the paramedics. The American Heart Association denotes what to do if, sudden cardiac arrest: for adults, check for responsiveness then shout for nearby help. Next, call 911 to activate emergency medical services. Then call for, or get, an automated external defibrillator if one is available and use it as soon as it arrives. Begin high-quality CPR immediately and continue until professional emergency medical services arrive. If two people are available to help, one should begin CPR immediately while the other calls 911 and finds an AED.

Based on interview and record the facility failed to immediately conduct a comprehensive assessment and immediately activate 911 for a resident found unresponsive on the ground outside of the facility at approximately 4:50am. This affected 1 of 3 (R9) residents reviewed for comprehnsive assessment. This failure resulted in R9 a 6ft 8 inch male over 240 pounds being carried into the facility by staff without conducting a comprhensive assessment to include vital signs. and not activating 911 until 5:31am. The EMS team arrived to the resident at 5:39am and found R9 was pulseless, not breathing, rigor to jaw, with obvious signs of death, and no staff performing CPR, R9 was pronounced deceased at 5:49am. Findings include: R9 face sheet shows R9 was admitted to the facility on [DATE]. R9 face sheet shows R9 had diagnosis of vascular dementia, hemiplegia/hemiparesis, history of falling, metabolic encephalopathy, brain damage, diabetes, heart failure, asthma, type 2 diabetes, atrial fibrillation. R9 care plan shows R9 had diagnosis of major depressive disorder, metabolic encephalopathy, asthma, chronic kidney disease, long term use of aspirin, personal history of other venous thrombus and embolism, history of falling, psychotic disorder with delusions due to known physiological condition, hypertension, heart disease, unspecified atrial fibrillation, sarcoidosis, other obesity, type 2 diabetes, vascular dementia, other seizures, benign paroxysmal vertigo unspecified ear, cerebral ischemia, other speech and language deficits following cerebral infraction, osteophyte right hip, facial weakness, acquired absence of eye, presence of artificial eye. R9 MDS dated [DATE] denotes in part section C for BIMS (brief mental status) denotes a score of 9 (cognitive impairments), R1 has disorganized thinking- 1. Behavior continuously present, does not fluctuate. Section D for mood shows , section E for behavior denotes behavioral symptoms presence or frequency, other behavioral symptoms not directed toward others, number 1 is denoted for behavior of this type occurred 1 to 3 days, E0500 denotes did any of the identified symptoms put the resident at significant risk for physical illness or injury; number 1 is denoted for yes, significantly interferes with resident care; number 1 is denoted for yes, E1100 for changes in behavior or other symptoms; how does resident current behavior status, care rejection, or wandering compare to prior assessments (OBRA or scheduled PPS) - 0 denoted for same. Section G for functional status denotes for bed mobility- R9 require extensive assistance with two-person physical assist, transfer- R9 require extensive assistance with two-person physical assist, walk in room / corridor - activity did not occur. R9 progress note dated [DATE] documented by V24 (Nurse) at 10:37a.m. denotes this writer was informed by CNA- (Certified Nursing Aide) that during rounding she noted the resident was on the ground outside below the window of room. This writer and the CNA staff assisted the resident into wheelchair the resident was moaning, and this writer asked him what was he trying to do? The resident looked at me (V24) but did not respond to the question. As the CNA were putting resident in bed this writer called 911. When I (V24) entered the resident room to assess him he was noted with no pulse or respirations so I Initiated CPR efforts. The resident expired 5:45 per the paramedics. The police also was present and had no concerns and stated that the facility could notify the family to have the funeral home of their choice pick up the resident. The DON (Director of Nursing), Administrator and family, V29 (physician) notified. Facility initial incident report to the department dated [DATE] denotes in-part, resident name (R9), date of incident: [DATE], time of incident: 4:45am, location of incident: facility. Description of incident: resident (R9) accessed the window to his room and was found by staff on the ground. The facility is ground level and all one floor. The staff immediately brought the resident back in the building via wheelchair. The resident was alert at that time and the nurse was speaking to him trying to get information on what occurred. The CNAs put the resident to bed while the nurse initiated a call to 911, the nurse went to the room to assess the resident he became unresponsive and immediately CPR was initiated. Shortly after CPR was initiated, the paramedics arrived and continued resuscitation efforts. The resident was pronounced deceased by paramedics at 5:49am. Investigation initiated. Final will be sent per protocol. Type of incident; other box is checked. Type of injury; nothing is checked, environmental; nothing is checked. Notification denotes, physician on [DATE] at 6:30am, family on [DATE] at 630am and police on [DATE] at 4:45am. hospitalization ; no box is checked, 24-hour preliminary report box is checked. Signature box denotes V25 (DON- Director of Nursing). Facility incident report titled other dated [DATE] completed by V24 (Nurse) at 10:30am completed by V24 (Nurse) denotes in-part incident location- outside, resident found on ground outside below window, resident unable to give description, 911 called, no injuries observed at time of incident, no injuries observed post incident, predisposing environment factors- other is checked, predisposing physiological factors; confused, predisposing situation factors; other is checked, agencies, people notified; DON ( Director of Nursing) on [DATE] at 10:36am. R9 fire department report dated [DATE] denotes in-part Medics 612 (Medic1) and 602 (Medic 2) were dispatched to the above location for the heat/cold emergency. Report shows the dispatch time was 5:31am, medics arrived at the facility 5:38am and at the patient at 5:39am. What time was the team dispatched to the facility ? What time was the 911 called? Upon our arrival crew found a [AGE] year-old male laying supine in bed, apneic and pulseless. Patient nurse stated, we found him hanging out the window next to his bed. At this time, an assessment was performed from head to toe. Crew found the patient to be cold to touch, fixed pupils, and rigor to the jaw. Patient was placed on the cardiac monitor and showed asystole. Patient nurse was asked by crew the last known normal of the patient and she stated we saw him at 4:00am LUMC was contacted for medical control and time of death was given of 0549 by nurse 8067 and Doctor (physician name noted). Patient was left in the hands of police, and they were given TOD (time of death) and Doc (Doctor) name. Patient was laying supine in bed apneic and pulseless. Patient was cold to the touch and rigor to the jaw. Chief complaint hot/cold exposure, patient nurse stated, we found him hanging out the window. Arrest present; yes prior to any EMS arrival, who witness; not witness, etiology; presumed cardiac, initial rhythm; asystole, CPR (Cardiopulmonary resuscitation) provided prior to EMS arrival: no, CPR started; 00:00, CPR by first responder, resuscitation; not attempted- considered futile, AED uses: no, Defib type: N/A. Impression/diagnosis; system cardiovascular, symptoms death, impression: obvious death, initial patient acuity: dead without resuscitation efforts (black). Cardiac monitor performed: role performing paramedic. Patient was placed on the pads to conform asystole, size pads, successful. Complication: none. Authorization: Via protocol. Patient response: unchanged. Paramedic consulted with (physician name noted) via radio, attempts 1; successful. Response factors affecting care; none. Scene factors affecting care: none. Transportation factors affecting care: not applicable. Dispatch factors: none. Turn around factors: none. Electronically signed by V26 (Fire department medic) at 6:43am. On [DATE] at 1:45 pm V24 (Nurse) said she was passing medication when V17 (CNA- Certified Nursing Aide) reported to her that R9 was outside on the ground. V24 said she looked out R9's room window and saw R9 on the ground, no one else was out there. V24 said they went outside, R9 was groaning, R9 had on a gown, no socks, no shoes, and she was not sure if R9 had on a brief. V24 said she asked R9 what he trying to do and R9 just looked at her and did not respond. V24 said they picked R9 up off the ground, R9 was not able to stand. V24 said they went and got a wheelchair and brought R9 back inside the facility. V24 said they put R9 in the bed, R9 was moaning, and she went to call 911 and get the blood pressure cuff. V24 said when she came back to R9's room that's when R9 stopped breathing. V24 said she initiated CPR- chest compressions. V24 said she stopped CPR and came out the room to allow for the medics to go in R9's room. V24 said the aide last saw R9 at 4:00am. V24 said R9 bed was in the low position. V24 said R9 bed is by the window. V24 said sometimes R9 sleeps at night and sometimes R9 is busy tossing and turning. V24 said she's sure R9 opened the window. V24 said R9 has confusion and is a fall risk. V24 said R9 never had any exit seeking behavior, and R9 did not have any bed alarms. V24 said when she called 911, she informed them that R9 was outside the window on the ground. V24 said she does not know how R9 got outside the window, she does not know how long R9 was outside on the ground. V24 said R9 room window was open pretty high. V24 said R9 was a full code. V24, said she did an assessment and R9 was not breathing, and she initiated CPR. V24 said the medics came and took over. V24 said the medics worked on R9 for 45minutes to an hour. V24 said R9 not revived. V24 said she notified the family and the physician. During a follow up interview with V24 on [DATE] at 3:12pm, V24 denied telling the police that R9 was hanging out the window. V24, she doesn't remember what she told the 911 dispatcher when she called for emergency services. On [DATE] at 7:47a.m during a follow up interview, V24 said she was in the hallway getting her things together to start medication administration. V24 said that's when V17 informed her that R9 was outside on the ground below the window, V24 said she went to the room and looked first then her and V17 went outside immediately, V24 said she saw R9 on the ground. V24 said R9 was moaning, V24 said she checked R9 to make sure he was not bleeding, and she looked at his limbs and head. V24 said she told V17 to go and get V18 to help pick R9 up. V24 said V17 walked toward the front of the building to get V18. V24 said V18 arrived with the wheelchair, they picked R9 up, V24 said they picked R9 up on the first attempt. V24 said her and V17 had R9 legs and V18 had R9 upper body. V24 said they was outside with R9 for about 10 minutes. V24 said V18 pushed the wheelchair with R9 in and her and V17 held R9 legs. V24 said they put R9 in the bed, R9 continued to moan. V24 said after they put R9 in the bed, she left the room to call 911 because there was not a phone in the R9 room. V24 said she got the blood pressure cuff from the medicine cart also. V24 said her cell phone was at the nurse station and she used her cell phone to call 911. V24 said she reported to the 911 dispatcher that R9 was on the ground by his window, V24 said she believes that's what she said. V24 said she reported to the 911 dispatcher that R9 was breathing, and she reported that the CNA was with R9, and she believes that's all she reported. V24 said when she got back to the room, she told the CNA to get blankets for R9. V24 said when she got back to the room R9 had stopped breathing, R9 chest was not rising and falling, R9 did not have a pulse, she checked his carotid artery. V24 said she yelled out for someone to bring the backboard that was hanging on the crash cart, so that she could do CPR on R9. V24 said she don't know who she yelled out to. V24 said V17 was in the room with her but it was not V17 that went and got the backboard. V24 said she don't know who it was that brought her the back board. V24 said by the time she started CPR (chest compressions) the medics came. V24 said she saw the medics lights when they pulled up to the facility, V24 said she could see outside of R9's room window. V24 said she saw the medics get out the vehicle and approach the ramp to come inside the facility. V24 said that's when she stopped doing chest compressions on R9. V24 said she may have done 30 compressions. V24 said she should have not stopped doing chest compressions on R9 before the Emergency Medics took over CPR efforts for R9. V24 said she did not used the Ambu-bag on R9. V24 said when she saw medics pull up to the facility, she also told V17 to go and let them inside the facility. When asked V24 if she called 911 immediately, V24 replied I believe I called 911 immediately. V24 said she did not tell the 911 dispatcher that R9 got naked and was hanging out the window. V24 reviewed her phone log and said she called 911 at 5:30am. V24 said she don't know why 911 was not called until 5:30am. V24 said she don't remember what R9 pulse rate was, she did not write it down, V24 said she know that R9 was breathing because R9 was moaning, V24 said R9 respiratory rate was 16. V24 said she don't know when R9 respiratory rate was 16. V24 said she did not call code blue because she was the only nurse there ( in the facility) and when you call a code blue, that's to get assistance from another Nurse. When asked can the CNA assist you during a code blue, V24 said everyone, the Nurse and CNA should respond to a code blue. V24 said she don't know why she didn't call a code blue, V24 said it was a very frustrating night. V24 said she last saw R9 around 3:00am or 4:00am and R9 was laying in his bed awake. V24 said she don't recall the window being open. V24 said she was not aware that R9 could open the window in his room. On [DATE] at 4:25p.m V17 (CNA) said she was the aide responsible for R9 care on [DATE] for the 11:00pm-7:00am shift. V17 said she checked on R9 at 3:30am, and at 440am when she went to check on R9, she went in the room, she did not see R9 in the bed, and she went further and saw R9 outside the window on the ground. V17 said she went and got the nurse V24, and she went and told V18 (CNA) to get a wheelchair for R9, V17 said R9 was outside laying in a fetal position, naked with his gown on his arm. V17 said her and V24 had R9 by the arms and V18 had R9's legs and they picked R9 up and put him in the wheelchair and brought him back inside the facility, V17 said they put R9 in the bed. V17 said R9 was cold so she got blankets to try and warm R9 up, V17 said she stayed with R9 until V24 came back, V17 said she left R9 room to wait for the paramedic at the entrance door with the ramp. V17 said she did not see V24 do CPR on R9. V17 said she saw R9 snoring, V17 said R9 was not talking. V17 said she did not do CPR on R9. V17 said she does not know how long R9 had been outside on the ground. During a follow up call with V17 on [DATE] at 3:41pm, V17 denied telling the police that she saw R9 hanging out the window. On [DATE] at 7:00am during a follow up call V17 said the police misquoted her statement in the police report, V17 said she read and reviewed the report. V17 said she told the police that she was hanging out the window and saw R9 on the ground, V24 said she did not say R9 kicked out the screen, she did not saw she pulled R9 back inside the window. V17 said on [DATE] at 450am, V17 said she knew it was 4:50am because she always look at her clock, V17 said she going into R9's room to get him up, V17 said she was not preparing her cart at 450am, she was at R9 room at 450am. V17 said R9 room door was open a little, V17 said when she went inside the room she felt a burst of air, V17 said she didn't see R9 in the bed, V17 said she looked out the window, and when she looked down, R9 was on the ground, V17 said she ran and told the nurse (V24), that's when her and V24 went outside where R9 was, V17 said the exit the building at the east door ( where the ramp is). V17 said the nurse was looking R9 over calling R9's name, trying to get him to respond, V17 said the nurse left R9 left arm, trying to bring R9 to a position so that he was on his back. V17 said the nurse asked her to go and get V18, V17 said at that time V18 was on his break and was sitting in his car, the car was parked down the street a little pass the main entrance door. V17 said she went and got V18, and we they came back to where R9 and the V24 was, V24 informed V18 to go and get a wheelchair for R9. V17 said V18 came back with the wheelchair, they picked R9 up and put him in the wheelchair, V17 said it took at two attempts to get R9 up. V17 said her and V24 had R9 legs while V18 had R9 by the arms. V17 said they was outside with R9 for about 10 minutes. V17 said V18 pushed R9 inside the facility, V17 said all three of them put R9 back in the bed. V17 said once R9 was in the bed, R9 was still making snoring sounds. V17 said after R9 was in the bed, V24 (Nurse) left the room, V17 said she assume V24 was going to call 911, but V24 did not say she was calling 911. V17 said when V24 came back to the room she had the blood pressure cuff and she heard V24 on the phone with 911. V17 once V24 came back to the room she went to her cart and got blankets for R9 (cart at room door). V17 said she saw the nurse put the blood pressure cuff on R9's left arm. V17 said she saw V24 put two fingers on R9 wrist and neck to check R9 pulse, and V24 was calling R9's name. V17 said she stayed in the room with V24 and R9 until she had to leave the room to let Medics in. V17 said she could see from R9 room window when the medics/911 pulled up, V17 said when she saw the lights flash, she went to let them inside the facility at the east exit door (door with the ramp). V17 said when she was in the room with V24 she did not see V24 do CPR on R9, V27 said she did not see V24 do chest compressions on R9. V17 said code blue was not called. V17 said she did not call 911. V17 said V28 (CNA) did not help them with R9. V17 said her CPR certification was expired that's why she renewed it on [DATE]. V17 said she do remember having her CPR certification within the last two years. On [DATE] at 11:19am V26 (Fire Department Medic) said he was the responding medic for the emergency call for R9. V26 said when he arrived to R9 bedside, there were no staff observed implementing CPR to R9, V26 said he did not take over CPR efforts from any staff member at the facility, V26 said he initiated CPR for R9. V26 said R9 was laying in the bed in supine position. V26 said on his assessment R9 body was cold to touch, R9 upper body temperature felt the same as his lower body temperature, R9 was pulseless and there were no respirations observed. V26 said R9 had obvious signs of death when he got to him. V26 said rigor mortis was noted in R9 jaw, V26 said rigor mortis is stiffing of the body when some has died , V26 said rigor starts to set in with 30 minutes to 2 hours of death. V26 said R9 was placed on a cardiac monitor, and it shows asystole: meaning no electrical activity in the heart. V26 said he does not recall seeing a back board under R9. V26 said V24 (Nurse) reported to him that R9 was hanging out of his window, V26 said it was cold that night/ early morning hours. V26 said he saw a heat vent near R9 bed. (V26 said he thought it was strange that R9 was hanging out the window next to the heat vent and the lower part of his body was the same temperature as the upper part). V26 said V24 said R9 was last seen by staff at 4:00am and everything was okay with R9. V26 said V24 reported that R9 had dementia but he didn't see the diagnosis listed in the records that was presented to him, V26 said the documents did show that R9 had a stroke with right-side paralysis. V26 said he did not observe any alarms or sensors on R9 room window. V26 said when he arrived, he observed several windows that appeared to be open. V26 said R9 case was turned over to the police department, and he did not have any details from the police department. V26 said the fire department medics report to (LMC-hospital name given) and the medical Doctor gave the time of death, of 5:49am. V26 said the cardiac monitor did not suggest shocking R9, V26 said the resuscitation was minimal because R9 had obvious signs of death. V26 said he was concerned about the supervision of R9. V26 said in his experience as a fire department medic, if a resident or a person is found on the ground, that person should not be moved, V26 said there could be an injury to the neck or any trauma and or moving them without knowing if theres a serious injury would not be appriopriate. V26 said this is not routine for the nurse and CNA to move a resident and bring them back inside the facility after finding the residnet on the ground. V26 said R9 should have remained there for the emergency team to assess R9 where he was. Review of the 911 call on [DATE] at 0530 hours, V24 is heard telling the 911 dispatcher that the location of the emergency was 5909 west North avenue, on the oak park side, V24 is heard saying to the dispatcher that I have a patient here; that got naked and hanging out the window and now he's hyperthermia dispatcher when what number she was calling from V24 said this is my personal number and gave the dispatcher the phone number, after 1 minute and 51 seconds V24 told the 911 dispatcher that she was not with R9 and she was walking back there now V24 is heard saying she was getting the paper work together for the ambulance. At 2minutes at 13 seconds the 911 dispatcher asked V24 if the resident was awake, V24 said he was but it don't look like it now, V24 said she don't know if R9 was sleeping or. At 2 minutes at 34 seconds V24 said it looks like he is snoring. V24 is heard saying where's that thing for the blood pressure, when the dispatcher asked was the resident snoring like he was sleep or like he was having trouble breathing, V24 responded like he went back to sleep, V24 said R9 was breathing, and no concern for covid 19, at 3minutes at 28 seconds V24 is heard agreeing that R9 breathing was completely normal, At 3 minutes and 48 seconds when the dispatcher asked V24 if R9 was conscious and alert , V24 is heard saying he was snoring but, V24 denied that R9 was responding normally when he was awake, V24 denied that R9 had any issues with heart problems, at 4 minutes and 23 seconds V24 denied having a defibrillator . 911 called ended after 4 minutes and 57 seconds. Review of the ambulance run report it denotes that 911 call received at 5:31am, dispatch at 5:32am, enroute at 5:34am, at reference at 538am, at patient at 5:39am, R9 pronounced deceased at 5:49am, leave reference at 6:05am, available at 610am. On [DATE] at 12:46p.m V29 (Physician) said he was notified of the incident/accident with R9 on [DATE] around 6:30am by the facility. Survey findings was reviewed with V29, V29 said the incident is an unfortunate situation, V29 was made aware that the nurse and aides said R9 was snoring, V29 said in his opinion because he was not there, but there's no was that R9 was snoring, V29 said maybe the Nurse was not able to recognize when someone is having difficulty breathing, V29 said he does not know the cause of R9 death but if R9 was outside for an unknow period of time, no clothes on and the staff said R9 body was cold it is likely that R9 was dealing with hypothermia, V29 said any person will be cold with clothes on within 10 minutes of being outside in 26 degree weather. V29 said situation of R9 accessing the window would not have occurred if the safety latches were engaged to prevent the window from opening to high and R9 climbing out. V29 said safety is important. V29 said the facility needs to take measures to prevent this from happening again. V29 said if the staff observed R9 outside on the ground at 4:50am the nurse should have called 911 right away. V29 said the nurse should have initiated basic CPR, i.e., check the airway, do chest compressions as appropriate. V29 said calling 911 after 40minutes of finding R9 was a lot of time. V29 said he wish the nurse would have called sooner. V29 said in his career he has seen rigor mortis start to set in within 1 to hours of death, depending on the environmental factors. On [DATE] during a phone interview V25 (Director of Nursing) said she has only been with the facility for maybe a week, and she has not reviewed the facility policies, V25 said her expectation is that the nurse follows the standards of nursing practice, or the facility change in condition policy when a resident has a change in condition. V25 made aware that the facility change in condition policy was reviewed and it does not address physicial assessments of a resident observed with a physicial change in condition. V25 said she will not answer questions about frequency of assessing a resident with a physicial change in condition. Review of the national weather report it shows that the temperature in Oak Park, Il on [DATE] between the hours of 3:30am to 4:50am, the temperature ranged 25 to 26 degrees Fahrenheit and the wind chill ranged between 16 to 21 (MPH), making the outside temperature feel like 11 to 13 degrees Fahrenheit. The windchill chart denotes that at a temperature of 25 to 26 degrees and a wind chill of 16 to 21 mph, will produce frostbite in humans in 30 minutes. Review of the incident report, there are no assessments documented and there is no vital sign assessment document. Review of the nurse progress notes, there are no assessments documented and there is no vital sign assessment documented. During this investigation V17 said R9 was observed on the ground at 4:50am (V17 said she looked at the time), V24 and V17 said they was outside with R9 for about 10 minutes; that puts the time roughly around 5:00am when they got R9 inside the facility into the bed. V24 made the 911 call at 5:30am: 30 minutes after getting R9 back inside the facility. V24 is heard on the 911 call at 1 minute and 51 second saying she was going back there with R9 now and she was getting the paperwork together for the ambulance. Using the reasonable person concept V24 failed to conduct a comprehensive assessment on R9 for 30 minutes after observing R9 unresponsive on the ground outside. V24 failed to call 911 for 40 minutes after observing R9 on the ground outside. The Illinois Nurse Practice Act, Article 50 general provisions (225 ILCS ,d+[DATE]-35) Sec. ,d+[DATE]. RN (Registered Nurse) scope of practice. The RN scope of nursing practice is the protection, promotion, and optimization of health and abilities, the prevention of illness and injury, the development and implementation of the nursing plan of care, the facilitation of nursing interventions to alleviate suffering, care coordination, and advocacy in the care of individuals, families, groups, communities, and populations. Practice as a registered professional nurse means this full scope of nursing, with or without compensation, that incorporates caring for all patients in all settings, through nursing standards of practice and professional performance for coordination of care, and may include, but is not limited to, all of the following: Collecting pertinent data and information relative to the patient heath or the situation on an ongoing basis through the comprehensive nursing assessment. Analyzing comprehensive nursing assessment data to determine actual or potential diagnosis, problems, and issues. Identifying expected outcomes for a plan individualized to the patient or the situation that prescribes strategies to attain expected, measurable outcomes. Implementing the identified plan, coordinating care delivery, employing strategies to promote healthy and safe environments, and administrating or delegating medicating administration according to section ,d+[DATE] of this act. Evaluating patient progress toward attainment of goals and outcomes. Delegating nursing interventions to implement the plan of care. Providing health education and counseling. Advocating for the patient. Practice ethically according to the American Nurse Association Code of Ethics. Practicing in a manner that recognize cultural diversity. Communicating effectively in all areas of practice. Collaborating with patients and other key stakeholders in the conduct of nursing practice. Participating in continuous professional development. Teaching the theory and practice of nursing student nurse. Leading within the professional practice setting and the profession. Contributing to quality nursing practice. Integrating evidence and research findings into practice. Utilizing appropriate resources to plan, provide and sustain evidence- based nursing services that are safe and effective. Facility policy accident and incident policy reports dated ,d+[DATE] denotes in part an incident/ accident report is to be completed and shall include date and time of incident/ accident. Description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties.

Based on observations, interviews and record reviews, the facility failed to follow standards of practice and physician's orders for wound care for R2. This failure caused the pressure ulcer wound to increase in size and deteriorate to a Stage IV wound with slough and necrotic tissue. This applies to 1 of 3 residents (R2) reviewed for pressure ulcer development and treatment. Findings include: R2 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on R2's admission skin assessment dated [DATE] document no sacral skin issue and skin has been assessed as being intact with no breakdown. R2 was transferred to the hospital on January 14, 2022 for a change in condition. A review of R2's electronic medical record indicates that the facility did not document any pressure sores for R2. R2's care plan addresses R2's risk for skin breakdown with a goal for no skin breakdown. A shower sheet dated January 12, 2022 documents only a skin tear on the perineal frontal area but no pressure ulcer. Record review on hospital record dated 1/14/22 document a full-thickness stage 3 pressure wound (5.7 x 4.6 x 0.3 cm) on R2's sacrum upon admission on 1/14/22. On 1/29/22 at 1:20 PM, V2 (Director of Nursing - DON) stated, R2 was sent out to hospital on 1/14/22 for altered mental status. We didn't notice any sacral wound before her transfer to the hospital on 1/14/22. She was readmitted with a right buttock wound. The nursing skin assessment upon readmitted d 1/18/22 document right buttocks wound (4.5 x 2.5 cm) with 80% of wound bed necrosis, 10% slough, and 10% granulation and with foul order. On January 30, 2022 at 12:25PM, R2 was observed during wound care. R2's wound care orders upon readmission are to: Normal Saline Cleanse, apply santyl ointment and calcium alginate and dry dressing daily. V2(Director of Nursing), V 3 (Nurse) and V 6 (Certified Nurse Aide) were observed to provide the treatment to R2. R2 was not assessed for pain prior to the procedure. R2's wound was assessed at this time to be Stage IV measuring 5 by 4 by 2 centimeters with slough and necrotic tissue. This measures documents an increase in size for the wound from the re-admission assessment of January 18, 2022. V2 was observed to cleanse R2's wound with wet gauze and not irrigate the wound with saline. V2 attempted to obtain an adequate amount of Santyl ointment to treat R2's wounds from what appeared to be an empty tube of santyl on treatment tray V2 was only able to get about 1/2 inch of ointment that did not cover the entire area and was not enough to treat the entire wound bed. V2 then proceeded to cover the wound with calcium alginate pad about 4 inches by 6 inches. The wound was not packed with calcium alginate. On 1/30/22 at 12:50 PM, V2 stated, The Santyl ointment is expensive, and we don't have any Santyl available now. It's reordered from the pharmacy. The order doesn't say to irrigate the wound, and that's why I used wet gauze to clean the wound. The order also says to apply calcium alginate. It doesn't say to pack it with the wound. On 1/31/22 at 10:30 AM, V7 (wound care physician) stated, Santyl ointment is an enzymatic [MEDICATION(S)] agent to loosen up slough/necrotic tissue and must be applied to the wound bed. Calcium alginate (absorber) must be packed inside the wound to absorb that loosened necrotic tissue by the Santyl ointment. It's pretty basic nursing to irrigate the wound instead of cleaning with wet gauze. It doesn't need to be in the physician order. R2's plan of care for skin updated January 18, 2022 documents to monitor wound care and wound care as ordered. Facility presented Policy and Procedure for the Treatment and Prevention of Skin Breakdown (dated 9/2021) document: 12. Use safe and effective ulcer irrigation pressures ranging from 4 to 15 psi (Pound per Square Inch - a unit of pressure). High pressure not exceeding 15 psi is needed for wounds with adherent material in the wound bed.

Based on observation, interview, and record review, the facility failed to assess and address pain before wound care to a resident. This failure has caused severe pain of 10/10 for 1 of 3 residents (R2) reviewed for pressure ulcer and pain management in a sample of 3. Findings include: R2 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on R2's admission skin assessment on 12/2/21 document no sacral skin issue. Shower sheet dated 1/12/22 document a skin tear to the front (perineal) and no skin breakdown with sacral/buttocks. On 1/29/22 at 1:20 PM, V2 (Director of Nursing - DON) stated, R2 was sent out to hospital on 1/14/22 for altered mental status. We didn't notice any sacral wound before her transfer to the hospital on 1/14/22. She was readmitted on [DATE] with a right buttock wound. Record review on hospital record dated 1/14/22 document a full-thickness stage 3 pressure wound (5.7 x 4.6 x 0.3 cm) with R2's sacrum upon admission on 1/14/22. Skin assessment upon readmitted d 1/18/22 document right buttocks wound (4.5 x 2.5 cm) with 80% of wound bed necrosis, 10% slough, and 10% granulation and with foul order. On 1/30/22 at 12:35 PM, observed V2 (DON) providing wound care to R1's right buttocks wound along with V3 (Nurse) and V6 (certified nursing assistant - CNA) without assessing for pain. Observed a stage 4 sacral wound (5 x 4 x 2 cm) with slough/necrotic tissue with drainage with R2's sacrum. R2 was observed screaming throughout the wound care due to pain and was saying, 'make it quick make it quick .'. R2 replied, My dressing change is painful in response to the surveyor's inquiry. My pain is 10/10. Observed V2 continued dressing change to finish it up by applying dry gauze dressing over calcium alginate covering the wound opening. On 1/30/22 at 12:50 PM, V2 stated, R2 was given pain medication (Tylenol 500 mg at 10:44 AM) before the wound care, and that's why I didn't assess her for pain. On 1/31/22 at 10:30 AM, V7 (wound care physician) stated, The facility should have followed the standard of practice in assessing for pain before they start wound care. They should have stopped the wound care when R2 reported pain 10/10 to address her pain. They could have used [MEDICATION(S)] spray to numb the area before wound care. Facility presented Policy and Procedure for the Treatment and Prevention of Skin Breakdown (dated 9/2021) document: Assess the resident for pain related to the pressure ulcer or its treatment. Avoid assuming that because a resident can't express or respond to pain, it does not exist.

Based on interviews and record reviews, the facility failed to administer anti-[CONDITION(S)] medications as ordered for one (R1) of three residents reviewed for medication administration. This failure resulted in R1 sustaining multiple episodes of [CONDITION(S)] activities and subsequent emergent transfers to the emergency room . Findings include: R1 is a [AGE] year old, female, originally admitted in the facility on 12/07/2007 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] tablet Delayed Release (Divalproex Sodium) 500 mg (milligrams) give one tablet by mouth two times a day and [MEDICATION(S)] tablet 1000mg, give 1000 mg by mouth two times a day. Per MAR, the following dates do not contain nurses' signatures: 09/29/20 at 5PM; 10/27/20 at 5PM; 10/28/20 at 5PM; 10/31/20 at 5PM; 11/05/20 at 9AM and 11/27/20 at 5PM. [MEDICATION(S)] 100 mg (Lacosamide) give one tablet by mouth two times a day. Per MAR, there were no signatures indicated on 11/20/20 at 9AM; and on 11/27/20 at 5PM. [MEDICATION(S)] 50mg (Lacosamide) give 100 mg by mouth every 12 hours. Again, there were missing nurses' signatures on 09/29/20 at 9PM; 10/02/20 at 9PM; 10/22/20 at 9PM; 10/27/20 at 9PM; 10/28/20 at 9PM; 10/31/20 at 9PM; and 11/05/20 at 9AM. According to R1's laboratory test dated 11/10/20, her [MEDICATION(S)] ([MEDICATION(S)]) level was 41.3, which means low. Progress notes dated 11/28/20 documented that R1 was observed having seizures and was sent to the hospital and was admitted . She was readmitted back in the facility on 11/30/21. Hospital records dated 11/28/20 indicated that R1 was admitted for seizures. 2. [MEDICATION(S)] 500mg. 1.5 tablets by mouth two times a day and [MEDICATION(S)] 1000mg by mouth two times a day. MAR indicated missing signatures on 12/01/20 at 9AM and 5PM; 12/04/20 at 9AM; 12/08/20 at 9AM; 12/25/20 at 5PM; 12/31/20 at 5PM; 01/05/21 at 5PM; and 02/07/21 at 5PM. [MEDICATION(S)] 100mg. give one tablet by mouth two times a day. MAR also indicated that there were no signatures indicating that this medication was administered on 12/01/20 at 9AM and 5PM; 12/04/20 at 9AM; 12/08/20 at 9AM; 12/25/20 at 5PM; 12/30/20 at 5PM; 12/31/20 at 5PM; 01/05/21 at 5PM; and 02/07/21 at 5PM. Her (R1) laboratory results dated [DATE] documented that her [MEDICATION(S)] level was 42.9 meaning low; 02/09/21 of [MEDICATION(S)] level of 46.8 which means low and 03/09/21 of [MEDICATION(S)] level of 40.2 which also means low. Progress notes dated 03/10/21 showed that she was sent to the hospital due to [CONDITION(S)]. She came back in the facility on 03/18/21. Hospital records dated 03/10/21 recorded a chief complaint of R1 experiencing a witnessed [CONDITION(S)] in the facility. 3. Further review of R1's MAR also revealed that [MEDICATION(S)] and [MEDICATION(S)] was not signed off on the following dates: 03/20/21 at 9AM and 5PM; 03/21/21 at 9AM; 03/22/21 at 9AM; 03/24/21 at 9AM; and 03/25/21 at 5PM. There were also missing signatures on 03/20/21 at 9AM and 5PM; 03/21/21 at 9AM; 03/22/21 at 9AM; 03/24/21 at 9AM; 03/25/21 at 5PM for [MEDICATION(S)] medication. She was again sent to the hospital on 04/01/21 due to seizures and came back in the facility on 04/06/21. Her hospital records dated 04/01/21 indicated her final hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/26/21 at 11:43 AM, V2 (Director of Nursing) was asked regarding R1 and anti [CONDITION(S)] medications. V2 stated, She does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her [MEDICATION(S)] levels and [MEDICATION(S)] levels are checked monthly. I have spoken to V4 (Physician) about her having seizures, said he (V4) would not change the dosage because he felt it was adequate. To my knowledge, she (R1) was getting her medications on a regular basis. Based on the MAR from September 2020 to April 2021, there were missing signatures. I can't answer why it was blank. But per policy, if it is not signed off, then it was not given. There were no issues with her medication availability, appeared given and nothing was left in the cart. According to progress notes dated 03/19/21, 03/23/21, 03/27/21 and 03/28/21, R1's [MEDICATION(S)] was not available in the facility. On 04/26/21 at 1:48PM, V5 (Licensed Practical Nurse, LPN) was interviewed regarding R1's anti [CONDITION(S)] medications. V5 stated, Regarding her anti [CONDITION(S)] medications, not that I remember that I miss giving doses. Once I give the medications, I sign it off. If the medication is not available, I will document it. I usually sign off the medications once it is administered. If it is not signed off, then it was not given. V5 was the scheduled licensed staff on 03/20/21 when medications were not signed off. On 04/26/21 at 1:37PM, V6 (LPN) was also asked regarding R1's medications. V6 stated, On medication administration, once I administered the medications, I signed it off. If its not signed off, I usually put a code why resident did not take it. 04/26/21 at 3:33PM, V8 (LPN) was also interviewed regarding R1. V8 stated, I don't have any issues. She always take it when I give it, then I sign the MAR. When I give it, I sign it, if I don't, I chart it in the progress notes and use codes in MAR. V8 was the scheduled licensed staff on 03/24/21. R1's care plan on [CONDITION(S)] disorder dated 03/13/2019 documented: Intervention - give [CONDITION(S)] medication as ordered by doctor. Monitor/document side effects and effectiveness. On 04/26/21 at 2:25PM, V4 (Physician) was interviewed regarding R1 and anti-[CONDITION(S)] medications. V4 stated, In order to prevent recurrence of seizures is making sure the resident is under the care of a neurology specialist who adjust [CONDITION(S)] medications. Medications in controlling seizures should be taken regularly as ordered. On R1, she has significant seizures. Medications in controlling seizures is important. If a resident is not getting the medications on a regular basis, she can have seizures. It is the duty of the physician to prescribe medications. It is the duty of the nurses to give it as ordered. Nurses will have to make a follow-up with Pharmacy to make sure medications are available for resident. Facility's policy titled, Medication Administration, revised date 04/26/21 documented in part but not limited to the following: General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve symptoms and help in diagnosis. Guideline: 18. Document as each medication is prepared on the MAR. 20. Explain procedure to resident and give the medications. 32. Sign MAR after administration.

Based on interview and record review, the facility failed to follow physician orders for wound care and treatment for one resident (R58) reviewed for pressure ulcers. This failure resulted in R58 developing an unstageable (deteriorated from Stage 2) sacral wound, which also became infected. 10/20/20 at 3:57 PM, V6 (Wound Care Nurse/Nursing Supervisor) stated that V15 (Wound Care Doctor) assessed R58 on 9/16/20 and noted her wound was infected and deteriorated. She ordered antibiotics and labs but on 9/18/20, R58 was sent to the hospital due to the wound on her sacrum. V15's note on 9/16/20 stated that wound on sacrum was there for 27 days and unstageable. The wound was black (necrosis), had an odor, a moderate amount of purulent drainage and was deteriorating. Upon review of weekly wound evaluation, on 8/10/20, there was documentation stating that R58 had 2 skin tears on sacrum. 2 days later, on 8/12/20, skin note stated that she developed to stage 2 pressure sore on sacrum. A [MEDICATION NAME] dressing was applied until waiting wound care doctor evaluation. Review of progress notes, physician orders and treatment administration record notes there was no wound care administered from 8/12/20-8/19/20. Progress notes also show there is no documentation of turning and repositioning during this time frame. V6 went on to state that R58 was seen by V15 (Wound Care Doctor) on 8/19/20 and dressing was changed to Calcium alginate every 72 hours and as needed for stage 2 pressure ulcer of sacrum. Interventions recommended by V15 included turning and repositioning every 2 hours. On 9/2/20 (2 weeks later), R58's wound was now unstageable (100% dead tissue), was larger in size and showed a yellow and brown color. V15 removed the damaged tissue (debrided) the wound this day and changed the treatment and dressing to santyl ([MEDICATION NAME] medication) to be changed daily. Review of progress notes from 9/6/20-9/16/20 do not state intervention of repositioning being followed. V6 went then on to state that my note on 9/16/20,notes unstageable ulcer still, a moderate amount of thick drainage and is foul smelling. V15 debrided the wound again and changed the treatment orders to dakins solution and to change daily and as needed. Interventions still include turning and repositioning every 2 hours. 10/20/20 at 4:46 PM, V3 (Nursing Supervisor) stated that there should be an order to turn and reposition every 2 hours so it alerts the CNA's (Certified Nursing Assistants) when caring for her. This was an oversight. I see that the bed mobility section the CNA's document on, notes once that she was repositioned once a shift and that there are several days and times with no documentation of turning, so there is no proof. R58 required total assistance for turning in bed and repositioning from staff and she was incontinent of bowel and bladder. There were days when I did her wound care and she did not have a dressing on. I would just go ahead and put the dressing on. I do not know how long it was off or what happened. I see on the treatment administration record from 8/19/20-9/2/20 that it is blank. When a nurse changes a dressing, it should be documented. In September, On 9/5/20-9/13/20 the treatment for the wound care was santyl to sacrum once a day. This was not documented as done. When I was here during the week, I did the dressing change. On the weekends or when I was not here, a nurse should do the dressing and chart it. V3 went on to state that the CNA's were supposed to chart turning and reposition at least every shift and that was not done. If there was an order for [REDACTED]. 10/21/20 at 11:46 AM, V15 (Wound Care Physician) stated that R58's wound deteriorated quickly in a week or two. I did a deep debridement the week before she went to the hospital since it had an odor and showed signs of infection in the wound. She was immobile, contracted, incontinent and confused, I ordered labs and antibiotics but she did not get better and she was sent to the hospital. If the dressing was not done or recommendations not followed, it could make the wound worse. My recommendations including turning every 2 hours in addition to the wound care. V15's note on 9/16/20 R58 has an unstageable wound to sacrum that is necrotic and has moderate amount of purulent (thick drainage associated with infection). It is deteriorating and has an odor. Recommendations include to off-load the wound, reposition per facility protocol and add antibiotics. Review of ADL report from 8/18/20-9/16/20 shows lack of documentation for turning and repositioning on 19 of 30 days. Review of Physician orders and progress notes from 8/12/20 to 8/19/20, after the stage 2 wound was identified did not show any treatment orders or dressing completed. Review of Treatment Administration record from 8/19/20 to 9/16/20 note treatment was only charted as completed on 4 of 13 days. R58's care plan initiated 9/4/20 states she has an alteration in skin integrity as evidenced by a unstageable pressure ulcer to her sacrum and is at risk for additional and or worsening of skin related to impaired cognition, incontinence of bowel and bladder and impaired mobility. Interventions include: Reposition resident frequently, monitor for signs and symptoms of infection, administer wound care treatments as physician orders. R58's care plan dated 9/16/20 states she is receiving antibiotics related to unstageable, infected pressure ulcer to sacrum. R58's functional status on 7/30/20 notes she requires extensive assistance for bed mobility and is incontinent of bowel and bladder. Facility skin care and prevention policy states to establish an individualized turning and reposition schedule if the resident is immobile. While in bed, not to exceed 2 hours and while in sitting position not to exceed 1 hour.

Based on observation, interview and record review, the facility failed to follow care plan interventions for two residents (R36 and R48) assessed as high risk for falls and with a history of falls. This failure resulted in both R36 and R48 sustaining fractures which required hospitlization and surgery. Findings include: R36 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R36's care plan dated 3/17/20 includes (but not limited to): The resident is high risk for falls related to [DIAGNOSES REDACTED]. Actual fall on 5/21/20-Resident tripped on bedside table. Interventions: After each meal while clearing the meal tray, aides on duty will move bedside table to a safe area to prevent further falls; Room will be cluter free; Call light will be placed within easy reach at all times; Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Ensure that the resident is wearing appropriate footwear. Observations conducted on 10/19/20 at 11:40 AM show R36 in her room with two other residents cohabitating the same room. The room was arranged with two beds lined up parallel to the wall and the third bed parallel to the back window. The room appeared cluttered with wheelchairs, clothing hampers, and furniture arranged against the adjacent wall. R36 was observed sitting on her bed that was placed parallel to the wall while her nearest roommate was sitting in her wheelchair in the center of the room with a rolling tray table placed in front of her. There was a wet area in between R36 and her closest room mate. A rolling tray table was placed in front of R36 and call light was hanging against the wall but not near R36 to reach. R36 was sitting watching television at the edge of the bed fully dressed with feet dangling on the edge of the bed but wearing only socks and no shoes. Surveyor asked how she was doing, R36 stated, I'm ok, who are you. Surveyor asked R36 if she was able to use the call light to ask for assistance, R36 turned around to view the call light and stated, I guess not. It's all the way over there. Surveyor asked about her latest fall, R36 stated, Oh yes, I had a cast on for awhile but I can't remember anymore how it happened but I do remember I was taken to the hospital and my arm hurt for awhile. 10/19/20 at 1:20 PM, R36 was lying in bed with call light in the center of the room that was not within her reach and with rolling tray table adjacent to her bed. 10/19/20 at 1:45 PM, V8 (Certified Nurses Aide) stated, What about her? She (R36) can do stuff on her own. We don't help her much. Why do you ask? Is everything okay? Surveyor asked V8 when was the last time she saw R36 and V8 responded, I went in there and cleared her lunch tray when she finished. Asked if she did anything else for R36, V8 stated, No, she can do things pretty much herself. 10/20/20 at 9:50 AM, R36 was observed in her room lying in bed with a rolling meal tray table placed against the bed. The call light was hanging against the wall and had fallen to the floor behind the bed. Review of R36's medical records document the following: 5/22/20 at 1:24 PM written by V7 (LPN), Resident observed on the floor in her room lying on the left side of her body denies claims tripping over the bedside table while walking to the bathroom. Xray result dated 5/21/20 show impacted distal radial fracture, acute to subacute. 5/22/20 at 09:16 written by V19 (LPN), Resident Left forearm demonstrates impacted distal radial fracture, acute/subacute. Resident left forearm feels warm, swollen, and bruised. MD notified with orders to send resident to hospital for evaluation. 6/2/20 at 7:31 PM witten by V20 (LPN), Resident readmitted to facility from hospital, alert, forgetful and verbally responsive. Diagnosis: [REDACTED]. Skin: Per hospital record incision Left wrist ORIF (Open Reduction Internal Fixation) surgery 5/29, observed covered by cast, sling in place, resident placed on contact, droplet isolation. Resident requires assistance with adls (activities of daily living), will continue to monitor. Prior to aforementioned fall, R36 required limited asistance with physical functioning related to bed mobility and transfers per MDS (Minimum Data Set) assessment dated [DATE]. After R36's fall, bed mobility and transfer functioning declined to requiring extensive assistance from staff per MDS assessments dated 6/9/20 and most current MDS dated [DATE]. 10/22/20 at 12:10 PM R36 stated, It took a long time to recover from that fall because I had a cast on. I couldn't unwrap things, or make my bed but thankfully I'm right handed or else it would have been really difficult. To this day, it's still a challenge to do things myself and you can see I still have a bandage on my wrist and I get aches on it. Asked if she uses the call light to ask for assistance, R36 stated, I used to use it but it's hard enough getting help so I try to do it myself. R48 is a [AGE] year old resident listed in part but not limited to [DIAGNOSES REDACTED]. R48's care plan dated 4/1/20 documents: Falls: :High risk for more falls. Has history of repeated falls related to [DIAGNOSES REDACTED]. Actual fall on 3/22/20 in the bathroom. Fall on 5/21/20-Slipped while coming out of the bathroom while getting water. Fall on 6/9/2020-Transfer without assist in room,wheel chair unlocked. Fall on 7/19/2020-fell out of bed while trying to go to bathroom. Interventions: Call light within reach at all times; Resident will be reminded to call staff when she has urge to use the bathroom; Staff will provide extensive x 2 assist with toileting needs due to lack of coordination, muscle weakness; Resident will have helment/hipster on at all times except while in bed as ordered; Floor mat at bedside,with bed in lowest position.Staff will anticipate needs and provide frequent roundings;Staff will continue to remind resident to lock wheelchair before transferring. R48's medical record includes note written by V3 (MDS Coordinator), which reads: Resident had a fall with injury on 7/19/2020 (Closed fracture of distal end of right radius) and laceration to right eye brow with 5 steri-strip in place. Right side of face with bruising. Has a soft cast in place. Has other [DIAGNOSES REDACTED].Requires extensive assist with all adls at this time,due to presence of soft cast.Resident has poor impulse control with decreased safety awareness Related to [DIAGNOSES REDACTED]. Resident requires increased monitoring,reminders to use call light for assistance.Resident is currently on restorative toileting program.Plan of care at this time is to place her in restorative Transfer and bed mobility program for safe surface-surface transfer and on ROM exercises to LUE and BLE for flexibility,strength and to prevent loss of functional ability. Bed booster will be placed on mattress for safety. Resident has order for helmet on during the day and off at Hs. Due to recurrent falls and injury to head resident will wear helmet at all times,per Dr.s order .Staff will continue to monitor right hand for circulation,motion and sensitivity. 10/19/20 at 11:45 AM R48 was observed in her room that was located at the end of the hall furthest from the nursing station. She was seated in her wheelchair, fully dressed wearing tube socks but no helmet to protect her from a head injury per her plan of care. R48 appeared pleasantly confused and could not respond to any questions. R48's bed was placed parellel to the wall and she was sitting in her wheelchair with the call light hanging behind her bed against the wall far from her reach. 10/20/20 at 10:20 AM, R48 was observed in bed, with no fall mats on the floor while she was in the bed as per her care plan. 10/21/20 at 9:20 AM, R48 was observed in her room beside her bed sitting in her wheelchair with no helmet on as per her care plan. 10/22/20 at 12:40 PM, V6 (LPN) was asked if R48 was able to use her call light or follow direction, V6 stated, (R48) is very confused; I don't think she can follow directions.

Based on observation, interview, and record review the facility failed to provide medically necessary social services to assist a resident in addressing mental and behavioral health needs for one resident (R47) reviewed for social services. This failure resulted in agitation of mood and behavior for R47; R47 subsequently obtained alcohol while in the facility and was sent to local hospital due to [MEDICAL CONDITION]. Findings include: R47 is a [AGE] year old male admitted to the facility 07/01/20. R47 has a [DIAGNOSES REDACTED]. 10/21/20 09:29 AM V10 (Activities /Admissions Director) stated there has been no social services worker since September 17th approximately. V10 stated the facility uses a social services consultant in place of a social worker. 10/21/20 12:09 PM V21 (Office Manager) stated the administrator wanted her to fill the role of a social service worker because they don't currently have one but she is not qualified to perform those duties. V21 stated that V22 (Social Services Consultant) has not been at the facility. V21 stated that R47 is allowed to go in and out of the building as he pleases. V21 stated that V2 (Director of Nursing) found beer cans and beer bottles behind R47's bed and pills in his drawer. V21 stated R47 has been drinking alcohol and not taking his meds. V21 stated that R47 had to be taken out of the facility 10/19/20 in restraints because he was intoxicated. V21 stated the administrator allows R47 to leave the facility and R47 became combative when the nurse on duty wouldn't allow him to leave the building on pass during a time when the administrator was not in the facility. 10/21/20 12:37 PM V3 (Minimum Data Set Coordinator) stated there is currently no social service worker for the facility. 10/21/20 12:46 PM V22 (Social Services Consultant) stated he serves as a social services consultant for the facility and provides guidance to the facilities social worker on social service duties. V22 stated he had been working with V23 (Social Services Worker) and had last been in the facility in September. V22 stated he does not provide social service consultation services at the facility monthly but does so once a quarter or as needed. V22 stated he was not aware V23 was no longer working in the facility and if there was a change in social services he would expect to be notified. V22 stated he would serve as the facility's social service worker if it was requested but he was not asked to provide those services. 10/21/20 01:24 PM, V1 (Administrator) stated that the facility currently uses a social services consultant. V1 stated he had to fire V23 (Social Services Worker) in September because she wouldn't follow instructions. V1 stated V22 (Social Services Consultant) comes in once a week and has remote access to perform duties. V1 stated that V22 is providing social services for the facility and a new social worker was just hired yesterday and will start on Monday. V1 stated V22 just does his own thing regarding providing social services. V1 could not clarify what social services V22 provides and stated V22 documents social service activities in the resident's medical records. V1 stated he could not afford to keep V22 on the payroll which is why he was hiring a social worker for the facility. V1 was asked to provide a list of residents seen by V22 but did not provide one during the survey. 10/21/20 03:00 PM V3 (Minimum Data Set Coordinator) stated on 10/05/20 when R47 returned from being out on pass she noticed R47 was singing and had blood tinged eyes and suspected he may be under the influence of a substance. V3 stated she asked R47 if he was ok then reported his condition to V1 (Administrator) and V2 (Director of Nursing). 10/21/20 03:15 PM - 4:30 PM V2 (Director of Nursing) stated that the facility does not track outside pass privileges because residents are not allowed out on pass due to COVID. V2 stated that R47 was allowed to go out on pass with V1 (Administrator) permission. V2 stated that R47 had been found with full and empty containers of alcohol in his room. Observed 2 full cans, multiple empty cans, and one empty bottle of alcohol that V2 stated was confiscated from R47's room on 10/19/20. V2 stated that when R47 was suspected of being under the influence of a substance on 10/05/20 a urine sample had been taken from R47 by V4 (Registered Nurse) to be tested for substances but the sample went missing. V2 stated no other urine sample was taken from R47 and he was never tested for substance use that day. V2 stated she reported this to V24 (Physician) and V24 was upset that R47 was allowed out on pass. V2 stated that R47 receives an antipsychotic medication. V2 stated that R47 was again allowed to leave the facility on a pass 10/08/20 with V1's (Administrator) permission but V1 had instructed staff not to document this information. V2 stated that V25 (Licensed Practical Nurse) was upset when she became aware that R47 was allowed to go out on pass 10/08/20 unsupervised stating R47 could have been hurt and this was during her shift. V2 stated that R47 hasn't had any visitors so he must have brought the alcohol in. V2 stated an investigation was not conducted to determine how R47 brought in the alcohol because the incident happened during the start of the annual survey. V2 stated V1 has had V16 (Activities Aid) escort R47 to the store and he may have accessed the alcohol while out of the facility but otherwise is not sure how R47 may have accessed the alcohol. V2 stated if a formal investigation was conducted she would have asked R47 how he accessed the alcohol. V2 stated V1 attempted to have a CNA (Certified Nursing Assistant) act as the social worker and questioned V1 on how a CNA is qualified to provide social services. 10/22/20 01:20 PM R47 stated he was very unhappy with the care and services at the facility and wished to discharge but there has not been a social worker to assist him with his discharge goal of transitioning to his own apartment. R47 stated he had not seen V23 (Social Worker) since August and had not received social services such as discharge planning, counseling, or [MEDICAL CONDITION] therapy. R47 stated he needs these services. 10/22/20 01:55 PM V1 (Administrator) stated V16 (Activities Aid) took R47 out of the facility last week to pay his phone bill and one other time. V1 stated that when staff escort residents out of the facility they sign them in and out on the log at receptionist desk and should also be document the activity in the resident's medical records. V1 stated a formal investigation on how R47 accessed alcohol was not conducted because he was not aware that R47 had alcohol in his possession. V1 stated he is not sure how R47 accessed alcohol and its possible staff may have provided him with it. V1 stated that he is not even sure if R47 ever drank the alcohol. V1 stated that V2 (Director of Nursing) had the alcohol that was allegedly confiscated from R47 in her possession. V1 stated that V2 did not inform him that on 10/19/20 R47 was found to be intoxicated and in possession of alcohol until 10/21/20 when V2 threw the alcohol contraband in his office. V1 stated he believed the alcohol belonged to V2 and she was likely consuming it and trying to sabotage V1 by alleging that R47 was found to be in possession of the alcohol and intoxicated. 10/22/20 03:13 PM R47 stated that because there was no social service worker to discuss his feelings and needs with, set up counseling or [MEDICAL CONDITION] therapy services for him, or assist him with discharging from the facility he became increasingly sad and depressed and began abusing alcohol to feel better. R47 stated he began sneaking in alcohol and drinking to feel better and cope with these issues. R47 stated he had been escorted by V16 (Activities Aid) in the community to pay his phone bill but had also been allowed to go out into the community without staff escorting him and visit his family. R47 stated that he and the other residents are not being monitored in the facility and therefore he was able to sneak out of the facility to get alcohol. R47 stated he never brought alcohol in the facility when he was out on pass but would drink it right outside of the facility when he did go out. R47 would not disclose how he got out of the facility but stated he was able to get out undetected. physician progress notes [REDACTED]. physician progress notes [REDACTED]. Nursing Progress Note dated 10/05/20 documents R47 was exhibiting behavior of and suspected of being under the influence of a substance; physician notified and order for drug screening was given and carried out. No documentation was found of drug screening results. physician progress notes [REDACTED]. Social Services Progress note dated 10/08/20 documents a quarterly care screening and interview was completed; R47 does not appear to be capable of unsupervised outside pass privileges at this time and does not appear capable of safely navigating in the community independently; R47 was invited to attend a care conference with his clinical team with social services to be present to address social services needs of resident. No documentation of a care conference or follow up from social services was found for R47. No other social service documentation was found for R47 after 08/11/20. Nursing Progress Note dated 10/19/20 documents R47 was observed to appear intoxicated, was found with alcohol in his room, was sent out to the hospital for evaluation and testing and returned from the hospital with a [DIAGNOSES REDACTED]. R47's current care plan documents he is at risk for alteration in Mood and Psychosocial well-being related to restrictions on visitations to the facility due to COVID-19 with interventions including Observe for changes in mood and/or psychosocial changes such as increased confusion, changes in sleep patterns, changes in behavior, nervousness, weight loss, crying episodes, etc.; Consult with MD if any changes in mood and/or psychosocial status is observed. Provide 1:1 socialization/activities and/or bedside socialization/activities as needed. R47's current care plan documents R47 has a diagnosis & history of severe mental illness including major [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident's problems & symptoms are manifested by at times poor contact with reality, hearing voices that are not present communicating with them, and depression with interventions including discuss the benefits of group or individual psychotherapy w/ the attending physician or psychiatrist. R47's care plan does not include [MEDICAL CONDITION] counseling or related social services. A social services and contraband policy was requested from V1 (Administrator) 10/22/20 and was not provided.

Based on observations, interview and record review, the facility failed to provide documentation to support the use of the anti-psychotic medications in dementia residents, failed to have documentation on targeted behaviors being treated and failed to provide documentation of non-pharmacological interventions prior and during the use of the anti-psychotic medications for 3 (R1, R2 and R3) of 3 residents reviewed for anti-psychotic medication in the sample of 3 residents. This failures have resulted in R2 exhibiting Tardive Dyskinesia (side affects) symptoms and R3 exhibiting excessive sleepiness. The findings include: On 3/8/18 between 9:45 AM to 10:45 AM accompanied by V3 (Director of Nursing), tour of the main nursing unit was conducted. R3 was sound asleep in the bed. V3 stated that R3 has dementia and is a fall risk. V3 stated that R3 has an (anti-slipping pad) in wheelchair along with a chair alarm. In the main dining room, R1 and R2, were participating (mostly observing) in an activity. V3 stated that R1 and R2 are both fall risks with dementia diagnoses. On 3/8/18 at 11:30 AM in the Main Dining Room, R1 is seated at the same table as R3. R2 is seated at another table. R3 was sound asleep in wheelchair at the dining room table. R3 did not touch his food. R3 stated not to be hungry when he was aroused by staff to eat something. R1 and R2 are both slow eaters but consumed a fair portion of their meals. At 12:05 PM, R3 was taken from the main dining room to the resident lounge where he continues to be lethargic and sleepy. On 3/13/18 at 10:20 AM, both R1 and R2 are in the main dining room for an activity. R2 is noticed to make an uncontrolled rabbit-like mouth movement. R1 is very quiet and calm and moves very little. At 4:10 PM, R1 was in bed and eyes closed but easily aroused by opening her eyes. R2 is a [AGE] year old, non-ambulating female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 is cognitively impaired with a BIMS of 4 and requires extensive assistance with transfers, dressing, hygiene and bathing. R2 is also incontinent of bowel and bladder. R2's (MONTH) (YEAR) P.O.S. and (MONTH) (YEAR) through (MONTH) (YEAR) M.A.R. document Nuedextra 20/10 mg daily for PBA. The Nuedextra was started 10/31/17 and discontinued on 12/6/17. On 12/7/17 the Nuedextra 20/10 mg is increased to twice a day. [MEDICATION NAME] ([MEDICAL CONDITION] medication) 0.25 mg is started 3/16/17 for [MEDICAL CONDITION]. V5's 1/29/18 psychiatric progress note documents that Nuedextra was increased to twice a day due to R2 saying disrespectful things and that the [MEDICATION NAME] will be kept since R2 exhibits mild Tardive Dyskinesia (T.D.) and no clear Extrapyramidal Symptoms. Per the V5's (psychiatrist) progress notes 4/24/17 documents R2 not taking the Nuedextra but restarting it on 12/6/17 progress note. There is no supporting documentation that R2 was experiencing PDA symptoms prior to initiation, during the discontinuation phase and the resuming of the Nuedextra medication. On 3/14/18 at 9:23 AM, V5 stated that he understood that R2 was seeing and hearing things that are not there and would be loud and say inappropriate things. V5 added that the criteria for PBA has widen to include people saying inappropriate things. V5 stated that he could discontinue the [MEDICATION NAME] because it is just a low dose. V5 stated that R2 does exhibit rabbit-like movement of her mouth which may be TD. On 3/15/18 at 9:17 AM, V6 (C.N.A.) stated that R2 does not exhibit any behaviors. At 9:19 AM, V7 (Licensed Practical Nurse/L.P.N.) stated she has been employed one month and she has not seen R2 exhibit any behaviors. At 9:22 AM, V8 (L.P.N.) stated she has been employed since (MONTH) (YEAR) and has seen R2 exhibit forgetfulness and is hard of hearing and will yell out to go to the bathroom but once she is attended to she is okay. At 9:25 AM, V9 (C.N.A.) who has worked in the facility for 4 years, stated she has witnessed R2 saying she needs to use the bathroom. There is no documentation to support R2 having any [MEDICAL CONDITION] nor is there any documentation on the targeted behavior being addressed nor any documentation of non-pharmacological interventions prior to and during the use of the [MEDICATION NAME] and Nuedextra medications. No staff member voiced any [MEDICAL CONDITION] for R2. On 3/14/18 at 9:41 AM and 11:48 AM, R3 was sound asleep on his bed. At 9:50 AM, V4 (R3's assigned certified nurse aide) stated that R3 ate very little for breakfast this morning and was very sleepy so he was laid down. V4 (C.N.A) stated she has been employed in the facility for one month and during this time, R3 has been very lethargic, hard to motivate, doesn't want to eat and at times hard to wake up. At 12:45 PM, in front of the nurses' station, R3 was alert, calm and pleasant. On 3/15/18 at 9:25 AM in the resident lounge, R3 was in wheelchair with head down but easily aroused. V9 (C.N.A.) stated that R3 does not have any harmful behaviors except that R3 wants to stand up from wheelchair. R3 is a [AGE] year old male who has recently started needing a wheel-chair for mobility. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 has a brief interview mental score (BIMS) of 8 which indicates cognitive impairment, has no behaviors that interfere with care, requires extensive assist of 2 staff members for ambulation and transfers, and extensive assistance with bathing and hygiene and is incontinent of bowel and bladder per the MDS. R3's (MONTH) (YEAR) physician order [REDACTED].S.) and the (MONTH) (YEAR) through (MONTH) (YEAR) medication administration records (MAR) documents that R3 has been receiving 0.5 milligrams (mg) of [MEDICATION NAME] (pyschotropic medication) daily since 1/21/2017. The [MEDICATION NAME] is being used for [MEDICAL CONDITION], single episode per the MARs and POS. R3 is also receiving [MEDICATION NAME] ([MEDICAL CONDITION] medication) 20 mg for the depression since 10/23/15. On 3/13/18 at 1:30 PM, V3 stated that the behavioral documentation and non-pharmacological interventions would be in the nurses' notes and care plan. There was nothing documented except that R3 has no behaviors. R3's clinical record lacked documentation of any non-pharmacological interventions. R3's [MEDICAL CONDITION] could not be explained when asked nor was there documentation to support the diagnoses. R3's care plan documents the [MEDICAL CONDITION] medication is used to manage and alleviate aggression and agitation. The interventions are to document behavioral symptoms and offer diversional activities. No documentation provided that the interventions were implemented. On 3/14/18 at V5 (psychiatrist) stated that he has known R3 for the last 7 years and when he first met R3, V5 stated R3 would say he just wants to die. V5 stated that R3 suffered from severe depression which why R3 is on [MEDICATION NAME] and that staff would tell him that R3 would make inappropriate comments as to why R3 is on [MEDICATION NAME]. V5 stated that he would re-assess the [MEDICATION NAME] and see if it can be discontinued. There is no documentation on the targeted behavior being addressed nor any documentation of non-pharmacological interventions prior to and during the use of the [MEDICATION NAME]. The [MEDICATION NAME] was never increased and has remained at the same dose since 10/23/15. R1 is a [AGE] year old, non-ambulatory female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 requires extensive assistance with activities of daily living except eating which requires set up only. R1 is cognitively impaired with a BIMS of 5. R1's (MONTH) (YEAR) P.O.S. and (MONTH) (YEAR) through (MONTH) (YEAR) M.A.R. document R1 receiving 200 mg of [MEDICATION NAME] (pyschotropic medication) at bedtime until 11/21/17 when it was decreased to 100 mg of [MEDICATION NAME] at bedtime. The documented [DIAGNOSES REDACTED]. R1 was started on 50 mg of [MEDICATION NAME] with little benefit. The little benefit is not explained or documented in the psychiatric note. There were no other documented entries of any targeted behavior warranting the use of the [MEDICATION NAME]. The documented [DIAGNOSES REDACTED]. On 3/13/18 at 2:05 PM, V5 (psychiatrist) stated that R1 did not have dementia when he first started treating her. V5 stated that R1 was started on the [MEDICATION NAME] due to psychotic issues. V5 stated that per nursing staff he was told that R1 was talking in her sleep and disturbing her roommates, possible auditory hallucinations. V5 stated that different staff members would tell him different things. V5 stated that he R1 use to have a lot of [MEDICAL CONDITION] but could not elaborate on the [MEDICAL CONDITION]. V5 states he usually comes in at 7 AM to do his assessments and usually talks to the night shift. When V5 was asked about the non-pharmacological interventions, V5 stated he would not know. On 3/13/18 at 2:15 PM, V3 stated that R1 has not been exhibiting any behaviors since she started her employment in (MONTH) (YEAR). V3 added that she wants to get all her dementia residents off the anti-psychotics medications. On 3/14/18 at 9:23 AM, V5 came in person to evaluate the residents and stated that R1 was having sleep issues about a year ago and if it is only sleep issues, the [MEDICATION NAME] would not be good choice. On 3/15/18 at 9:17 AM, V6 (C.N.A.) stated that R1 does exhibit talking out loud to self but does not voice any harm to self or others. At 9:19 AM, V7 (Licensed Practical Nurse/L.P.N.) stated she has been employed one month and she has seen R1 express verbal aggression which is difficult to re-direct but that R1 never voices any harmful verbiage. At 9:22 AM, V8 (L.P.N.) stated she has been employed since (MONTH) (YEAR) and has seen R1 exhibit verbal aggression but nothing harmful. At 9:25 AM, V9 (C.N.A.) who has worked in the facility for 4 years, stated she has not witnessed any behaviors from R1. R1's care plan for the [MEDICAL CONDITION] document it is used for behavior management. The intervention is to monitor and record targeted behavior symptoms. There is no documentation on the targeted behavior being addressed nor any documentation of non-pharmacological interventions prior to and during the use of the [MEDICATION NAME]. No staff member voiced any [MEDICAL CONDITION] for R1. The manufacturer's guidelines for [MEDICATION NAME] document that it is not recommended for residents with dementia related [MEDICAL CONDITION]. The facility's policy labeled [MEDICAL CONDITION] Drugs Usage documents when clinically appropriate, the facility staff will initiate non-medication approaches to assist in the treatment or alteration of the resident's behavior as behavioral redirection and environmental alterations. Each resident receiving any anti-psychotic medication for dementia will be observed for episodes of the behavioral symptoms being treated and/or manifestation of the disorder thought process, adverse reactions and side effects and the appropriateness of drug selection and dosage. Dementia with associated psychotic and/or agitated behaviors will be documented quantitatively and objectively to assist in assessing whether the behavior symptoms are transitory or permanent or not easily altered, relating the behavior symptoms to other events in resident's life, ruling out environmental symptoms and medical causes such as, fever, dehydration or infections. Anti-psychotics are not to be used if one or more of the following are the only indications, such as, [MEDICAL CONDITION], unsociability, uncooperativeness and agitated behaviors which do not present a danger to resident or others.

Based on record review and interview the facility failed to identify risk factors and provide interventions for one high risk for fall resident (R1) of three residents reviewed for falls in a sample of 4 residents. This failure has resulted in R1 sustaining a cut over the left eyebrow requiring 8 sutures. Findings Included: Medical record documented R1 was [AGE] years old admitted to facility on 5/10/2013 with [DIAGNOSES REDACTED]. Minimum Data Set for R1 dated 3/12/2017 scored 2 out of 15 for the Brief Interview for Mental Status(BIMS). According to MDS, R1 was ambulatory with supervision and needed supervision from staff with cueing and oversight for transfer. MDS of R1, Section G0300 A, B,C, D and E on balance during transitions and walking documented,Not steady, but able to stabilize without staff. Fall risk assessment for R1 dated 3/12/2017 checked off as not being high risk for falls. Fall assessment for R1 dated 5/12/2017 noted she was High risk for falls. Care plan for R1 noted problem of behavior as being compulsive and was high risk for falls related to unaware of safety needs initiated on 11/11/2013 and revised on 5/4/2017. Interventions included, to anticipate and meet residents' needs. There was no intervention which addressed compulsiveness of R1 and the way facility will anticipate and meet her safety needs. Final report of R1's incident sent to Illinois Department of Public Health (IDPH) from facility and written by Physician noted, Resident's fall is due to resident poor safety awareness and medical condition. Resident's gait is unsteady due to her Scoliosis. Resident was rushing in the activity at the time and due to her impulsiveness stood up and walked rushing, lost balance and fell . Facility's incident report for R1 dated 5/2/2017 documented a witnessed fall by R1 who got up from chair as she left activities, walked fast and fell . She sustained a cut over left eyebrow which was sutured with 8 sutures from the community hospital according to records. On 6/1/2017 at 11:00AM, E3 (Activity Aide) said she was the activity aide on 5/2/2017 when R1 fell , however, she did not see R1 and did not have R1 in her activity program that day. She said at that time R1 always walked fast in the hallway and sometimes she leaned on one side. She said every staff knew about R1's posture and her fast pace when she walked. On 5/30/2017 at 2:10PM, E6 (Certified Nursing Assistant, CNA) said R1 always walked fast and always leaned to one side. She said whenever R1 gets up from a sitting position, she was always in a hurry. E6 said she was afraid for R1 even before she fell and all the staff was aware of R1's posture when walking. On 5/31/2017 at 1:45PM, Z2 (family member of other resident) said about one month ago he saw R1 leaned to one side and walked so fast in the hallway that he was surprised she did not have a fall prior to 5/2/2017. He said he was afraid for her safety and notified management of what he observed. Facility has a surveillance camera and on 5/30/2017 at 12:30PM, E2 said the camera stopped working two days ago. E2 said there was no policy for Incidents and Accidents and the abuse policy incorporated accidents and incidents. She said she did not have a written care plan policy. On 5/30/2017, care plan added one intervention of chair and bed alarms for R1. Surveyor unable to contact Physician. However, on 5/3/3027 at 10:21AM, physician wrote, Was rushing and unsteady and not able to keep balance as Scoliosis is throwing off balance also. Facility fall policy dated 5/2012 noted, The root cause of the fall will be identified and new appropriate interventions will be implemented. The fall policy also noted, Every fall incident will be reviewed by the fall IDT (interdisciplinary team) committee to determine whether fall interventions are appropriate.

Based on observation, interview and record review, the facility failed to revise care plans, update fall assessments and follow policy for monitoring residents after falls, for residents with multiple falls. This was for 2 of 4 residents (R6, R7) reviewed for falls in a sample of 8. These failures resulted in R6 sustaining bilateral rib fractures and R7 sustaining a laceration requiring sutures as a result of falls. Findings include: 1.) R6's Fall Risk assessment dated [DATE] indicated R6 was at risk for falls. According to Nurses Notes dated 6/7/12 to 9/10/12, R6 has a fall history as follows: 6/7/12 at 7:00AM - R6 found face down in his room attempting to go to the bathroom. Laceration to right eyebrow. 6/9/12 - R6 fell in his room. 6/26/12 at 2:10AM - R6 found face down in his room attempting to go to the bathroom. 6/30/12 at 7:00AM - R6 found on floor in his room. 7/28/12 at 2:00AM - R6 found on floor in his room. Laceration to right elbow. 8/13/12 at 3:30AM - R6 found on floor in his room attempting to go to the bathroom. R6 complained of pain in ribs and legs. 9/10/12 at 6:30AM - R6 found on the floor in his room. Laceration to left eyebrow. R6's Nurse's Note dated 9/10/12 documents that he was sent out to the hospital after his fall. R6 was admitted to the hospital with [REDACTED]. R6's Physician order [REDACTED]. On 10/18/12 at 3:40PM, E7-Licensed Practical Nurse (LPN) stated, "(R6) was sent to the hospital after the fall and readmitted to us on 9/19/12 with the [DIAGNOSES REDACTED]. On 10/18/12 at 10:55AM, E7-LPN was asked, "What is done when a resident falls?" E7 stated, in part, that if a resident hits their head or if it is unknown then neuro checks are started and post fall assessments for 72 hours. E7 also stated that fall risk assessment and interventions on care plans are updated. On 11/1/12 at 11:25AM, E2-Director of Nursing (DON) stated, " Neuro checks are performed for 72 hours after the fall if the resident is suspected to hit head." An undated facility document with the heading "All Incidents" directs nursing staff of steps to be taken following every incident. Step 5 indicates "Fall risk care plan...The intervention that was put in place must be written on the careplan with date." Step 7 "Document! For 72 hours. Suspicion of head bumping object must do neuro checks." The facility Occurrence Report dated 9/10/12 related to R6's 9/10/12 fall indicates in section marked Personal Alarm, that no alarm is to be used. A section marked Care Plan intervention added or modified related to occurrence is marked "Yes" but the area to "specify" is left blank with no new interventions listed. R6's plan of care related to falls is dated 5/9/12 with review date of 8/9/12. There are multiple interventions, to include a bed alarm, with no dates documented alongside the interventions to indicate when interventions were put in place and that the care plan was updated with each fall. According to the Nurses Notes, all of R6's falls were unwitnessed. It could not be ruled out if R6 hit his head. On 3 occasions, R6 did hit his head. There were no documented neurological checks noted after the falls. R6's Fall Risk Assessment was inaccurately updated. On 9/19/12 it is documented that R6 had 1-2 falls in the past 3 months. R6 had 7 falls between 6/7/12 to 9/10/12. On 10/18/12 at 10:00AM, 12:45PM and 2:15PM and on 11/1/12 at 9:30AM, 12:30PM and 2:55PM, R6 was observed in bed without a bed alarm in place. R6's Care Plan dated 8/9/12 indicates that he should have a bed alarm in place. 2.) R7's Nurses Notes indicate that she was admitted to the facility on [DATE]. The Nurses Notes document that she is alert and oriented to person, place and sometimes time. R7 has slurred speech but able to communicate her needs. R7 has a history of right Subdural Hematoma and has right sided weakness. R7's fall history per Nurse's notes is as follows: 8/29/12 at 11:00PM - R7 was found on floor in her room laying on right side. 8/31/12 at 8:00AM - R7 was found on floor in her room laying on right side. 9/6/12 at 11:00AM - R7 was found on floor in her room sitting upright. 9/9/12 at 12:55PM - R7 was found in the prone position on floor in her room. Laceration to right eyelid. Sent to hospital. R7's Nurses Notes dated 9/9/12 indicate that she was sent to the hospital after the fall. According to R7's Nurses Notes dated 9/9/12, R7 returned to the facility at 8:00PM with 3 sutures on the right eyelid as a result of the fall incident. 9/17/12 at 5:00PM - R7 was found on the floor in her room. According to R7's Nurse's Notes, all of R7's falls were unwitnessed. There were no documented neurological checks noted after the falls. According to the facility's final summary for R7's 9/9/12 fall the facility will "reassess the resident's risk factors for falls and modify the care plan." R7's current Care Plan dated 8/30/12 contains multiple interventions but does not indicate when interventions were put in place or revised. There are no dates documented alongside the interventions. R7's Fall Assessment is dated 8/29/12 and has not been updated. The facility failed to accurately code R7 for falls on the Minimum Data Set (MDS) Assessment. According to R7's Minimum Data Set ((MDS) dated [DATE], R7 is coded for zero falls since admission. R7 had 5 falls from 8/29/12 to 9/17/12. On 11/1/12 at 12:15PM, R7 was observed sitting in a wheelchair in the hallway. There was no chair alarm affixed to her. According to R7's current Care Plan, R7 should have a chair alarm in place.

Based on record review and staff and other interviews, the facility failed to: 1) provide timely follow-up of a physician order [REDACTED].[REDACTED]'s surgical site; 4) provide timely nursing follow-up/MD notification when post-op resident (R2) developed temperature and drainage from surgical site 5) address resident's non-compliance issues. These failures resulted in a delay in recognizing that R2's surgical site had become infected, which resulted in the need for his surgical prosthesis to be removed and a 6 week course of IV antibiotics. Findings include: Review of R2's medical record reflects that R2 is a [AGE] year-old admitted to the facility on [DATE] status [REDACTED]. Additional [DIAGNOSES REDACTED]. He had been non-ambulatory for approximately 3 years. R2's admission MDS (minimum data set) scores R2 a '1' for cognition, indicating modified independence. The MDS indicates he requires some level of assistance with all ADLs. Upon admission, along with medication and dietary orders, R2's POS (physician order [REDACTED]. R2 was admitted on [DATE]. Review of R2's medical record contained no notes by E3 (wound nurse) until 9/21/10, 22 days after R2's admission, and the day R2 was sent to an appointment and then directly to the hospital for an infection and hardware removal. During telephone interview with E3 on 10/25/10, E3 stated that she was the facility wound nurse, and that she was currently coming to the facility on ce a week. Along with other duties, she assesses any new residents with any type of wound, does wound measurements, checks treatment orders/books as well as performing treatments when in the building. E3 stated that the admitting nurse is to do an initial assessment of the wound and obtain treatment orders. When she is not at the facility, staff nurses perform treatments/wound care. E3 stated that she only saw R2 one time, on 9/21/10. She recalled getting a phone call about R2 on the day before she was to come to the facility, on 9/20/10. She was told there was a male resident to see who had a wound that had not been treated. She saw R2 the next day, and at that time, noted his wound with a large amount of drainage which had soaked through his pants. The dressing that was in place was damp, and was dated 9/19/10. She did wound measurements, and during palpation, stated she could feel something protruding in the knee, but not protruding through the skin. R2 had an orthopedic appointment scheduled for that day, which she recommended he keep. E3 denied being notified of R2 at the time of his admission or the order for her to see R2. She also stated that she had reviewed the chart, and noted there were no treatment orders. E3 stated that if she had been notified, she would have either called the physician herself to obtain treatment orders, or made sure staff did so. According to E3, even if there were no specific treatment orders, nursing should be assessing the surgical incision site and be documenting circulation, pedal pulses, color/warmth, drainage, etc, as part of their routine care of a post-op surgical patient Nursing notes reviewed for R2 reflect no dcoumented notification of E3 until 9/20/10, which reads as follows: "CNA reported bandage soiled on left leg-bandage dated 9/19 was removed, site was cleaned and dried, and new dressing applied and dated-supervisor & Tx nurse to be made aware..." Review of E3's nursing note is dated 9/21/10 confirms that she did wound measurements and documented the following: "6.0 x 2.0 wound with 80% slough and 20% granulation with large amount serosanguinous drainage". Review of staff statement of E7 (CNA)written 9/22 reads, in part, "...while giving care I noticed that the left leg brace was off and couldn't be found. The week starting from 9/12 to 9/18, I assisted ...in giving care to R2 and I noticed the left knee was leaking. The brace still hadn't been found". During telephone interview with E7, she stated that she cared for R2 several times. Per E7, although he seemed upset, he never refused any care that she tried to provide. She stated she was not aware that his knee immobilizer was to be on at all times, and that she only saw him wearing his immobilizer once. She never saw him take it off. Sometimes when she entered the room, she would see it on the bedside table. Review of R2's nursing notes does not reflect any notes indicating that R2 refused to wear his knee immobilizer, that his knee immobilizer was in place or not in place, or that R2 had been seeing removing his knee immobilizer. Nursing notes do not address the status of the immobilizer at all. Review of R2's clinical record reflects no consistent monitoring and documentation of assessment of R2's surgical site. R2 was admitted post-op on 8/30. There is no description of his wound in nursing notes on admission, or in any nursing note until 9/21/10, when E3 documented a physical assessment of his wound/incision on the day he was transferred out of the facility. There is no wound assessment on 9/14/10, despite documentation of a fever. On 9/20/10, although it is documented that R2's bandage was soiled, again, there is no physical assesssment documented of the incision.site. During telephone interview with Z1, Z1 stated that he did not give specific wound care orders when R2 was admitted to the facility, but he expected his leg/incision to be kept clean and dry. Z1 also stated that he expected that R2's surgical site would be assessed at least daily, and that assessment would be documented, with physician notification of any unusual findings, such as swelling, increased pain, temperature, redness, drainage, etc. He did not think that R2 was admitted with a dressing in place, as his suture line had been glued. R2 was not septic upon admission to the facility, per Z1. According to Z1, this monitoring would fall under general nursing care of a post-op patient and would not require specific physician orders. According to Z1, he stated that he felt R2's infection had been there for "some time", and he felt it should have ben caught sooner. Z1 stated that the fact that his wound became infected resulted in the need for the hardware removal and a protracted course of IV antibiotics. While someone can get an infection even under the best circumstances, according to Z1, this infection should have been caught sooner, and consistent monitoring and appropriate, timely physician notification of changes in status would have allowed for that. The facility presented a "Weekly Wound Report" for R2, but the first documentation on that report was 9/21/10, authored by E3. The facility also presented 2 "CNA Skin Attention Forms" for R2, dated 9/9/10 and 9/13/10. The form indicates these are to be completed weekly, during the resident's bath. The form dated 9/9/10 indicates R2 accepted skin care and mouth care, but refused hair and nail care. There is also a hand written note indicating R2 used foul language and refused shaving. This form also contains some notes dated 9/22/10, after R2's discharge, and on a diagram, notes "old wounds" and an area of ster-strips. The form dated 9/13/10 reflects R2 accepted skin care and mouth care, but refused hair and nail care. It indicates "bed bath". On a diagram, it appears to indicate areas of change on the right upper outer thigh area, and in the center of the buttocks. The nurse is to follow up on any area indicated by the CNA, and this form was signed by E6. There is no corresponding note indicating assessment or follow-up of these areas anywhere in the record. This form does not address R2's surgical site. Review of R2's nursing notes reflect that on 9/14/10, R2's temp was documented as 100.8. Staff documented that R2 refused medication for the fever. There is no documentation/evidence of any nursing assessment of R2's incision site at that time, nor is there documentation/evidence of any physician being notified of R2's elevated temperature, even though R2 was a post- operative patient. On 11/10/10, a telephone interview was conducted with Z1, R2's orthopedic surgeon, who stated that he would expect that a phyhician would be notified if R2 had a temperature, and that a wound/incision assessment would be done and documented daily and as indicated as part of routine nursing process. During telephone interview with E7 on 11/5/10, E7 stated that earlier in his stay when she cared for R2, she did not see any drainage from his wound. However, later in his stay, several days before he left the facility, she did see drainage, and told the nurse (Z4-former employee). Review of nursing notes reflects no documentation regarding wound drainage until 9/20/10, one day before R2's discharge. During telephone interview with Z2 (physical therapist) on 10/25/10, Z2 stated that she told Z4 several times that she felt there was something wrong with R2, because he was flushed and seemed warm to touch. She could not recall the exact date of her conversation with Z4. She recalled talking to Z4 because R2 seemed flushed, and she requested that Z4 take R2's temp and other vital signs, and Z4 agreed. She did not witness Z4 do this and is not sure if it was done or not. She also recalls a second conversation she had with Z4 regarding R2, which took place several days after the first conversation, in which she informed Z4 that R2 was still flushed and that he appeared to have foul-smelling drainage from his wound. She is unsure what Z4 did regarding this information. Review of staff statement verified by E8 (HR) and written by Z6 (former DON) reflects that E5 and E9 (CNAs) noted pus-like discharge running from under his knee brace around 9/14/10 or 9/15/10 during a bed bath, and advised E6 (LPN). In that statement, E5 reported seeing several green-colored spots on R2's leg. The statement indicates that E6 cleaned and bandaged his leg. There are no nursing notes until 9/20/10 regarding leg drainage. During interview with E6 conducted on 10/25/10, E6 initially stated that no one had reported any concerns regarding R2 to her, and that she never saw him without his knee immobilizer on. She also stated that she never assessed his surgical site because that would have been done on the evening shift. She recalled he had some non-compliance issues with getting washed up, and she recalled him being on bedrest. Later in the interview, E6 recalled seeing his knee incision once, during change of shift, because of a late bed bath. She recalled a CNA calling her to the room to see R2's knee, and recalls that it was warm to touch and red. She believes she had the evening nurse accompany her to R2's room but does not recall who. She does not believe she documented her observations on R2. She thought there was "some kind of infection going on". She cannot recall the date of that observation. She believes she asked the evening nurse to call the phyhsician. After reviewing all of her nursing notes documented in R2's clinical record, she agrees she documented no actual assessment of the status of R2's leg in any of her notes, including whether or not there was any swelling, his ability to move his toes, circulation checks, observations, etc. During interview with the E2 (Acting DON/VP Operations) on 10/25/10, E2 indicated that staff had been disciplined and also terminated as a result of issues identified with R2's care. Review of disciplinary action form for Z4 confirms this. Per E2, Z4 no longer is employed at the facility. On 11/9, during a daily status interview conducted via telephon, E2 stated she wanted to present additional information for review. This information was reviewed, some of which had previously been presented. There was no information presented on 11/9/10 which reflected any additional documentation of monitoring or assessment of R2's surgical site, or that showed any action by the facility regarding the sttus of R2's wound until 9/21/10. During interview with E2 both on-site on 10/25/10 and via telephone on 11/9/10, E2 stated that there were non-compliance issues with R2. There are varying reports of the level of R2's non-compliance. R2's admission nursing assessment indicates R2 is "alert and cooperative". During interview with E7, E7 stated that although R2 seemed upset all the time, he never refused any care she tried to give him, but did state that you had to approach him calmly and slowly. Nursing notes on 9/9/10 reflect refusal of meds and bed bath, although staff were able to convince him to accept the bath. Nursing notes reflect that on 9/15/10, R2 refused to get out of bed to be weighed. E3 documented that R2 was resistive to her seeing him, but she was able to convince him to let her assess his wound. R2's MDS indicated R2 was resistive to care. Review of entire clinical record for R2 reflects no evidence of any care conference held with resident and/or family to address issues of non-compliance, nor any notes indicating the facility was attempting to transfer R2 to another facility who would be able to better meet his needs, due to his compliance issues. R2's care plan addressed behavioral issues, with the approaches of conveying acceptance during periods of inappropriate behavior, and encouraging diversioal activitis. On 9/9/10, his care plan was updated to include a goal of having R2 be cooperative with hygiene/care needs; the approach was, when feasible, assign a male CNA and reassess resident's cooperation with care.