Every finding on record at Citadel Care Center-Kankakee

Based on observation, interview, and record review, the facility failed to remove expired food items, reseal opened food items, and maintain temperature of freezer to keep foods solid. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 88 residents. On [DATE] at 11:33 AM, V12 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On [DATE] starting at 11:04 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and the following was found: Dry Storage: 1. ,d+[DATE] quart cartons of cultured reduced fat buttermilk dated best if used by [DATE]. Expired. 2. 1 quart of French vanilla coffee creamer dated best by [DATE]. Expired. 3. 8 ounce container of sour cream best by [DATE]. Expired. Reach in freezer in dry storage room: 4. An opened, not sealed traditional pie crust that is broken with some freezer burn. Reach in freezer in kitchen: 5. Opened, unsealed bag of beef franks in cardboard box that are soft, not frozen solid. V12 said the staff was just cleaning the freezer so the temperature might have dropped. V12 then checked the temperature of the beef franks and they were 27.2 degrees Fahrenheit. On [DATE] at 1:01 PM, V12 (Dietary Manager) said expired foods should be removed from storage immediately on the expiration date so the expired food is not served to the residents with the potential to make them sick. V12 said all opened food items should be resealed before frozen to prevent freezer burn and maintain the quality of the food. V12 said the freezer should be maintained at 0 degrees Fahrenheit or below and food items should be frozen solid to maintain food quality and prevent food from being thawed and refrozen multiple times. The facility's policy titled, Refrigerated Food last revised 2017 states, Refrigerated Potentially Hazardous Foods (PHF) or Time/Temperature Controlled (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by . The facility's policy titled, Storage of Frozen Foods last revised 2017 states, Policy: Frozen foods are maintained at a temperature level that keeps frozen foods solid. Procedure: . If taken out of the original container, food is tightly wrapped .Frozen food that is not solidly frozen is evaluated for the possibility of being discarded .Opened products that have not been properly sealed and dated are discarded .

Based on interview and record review, the facility failed to maintain a QAA (Quality Assessment and Assurance) committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist. This has a potential to affect all the residents in the facility. The findings include: On 11/21/24 at 09:23 AM, V1 (Administrator) said the Medical Director has not been to any QAA meetings in over a year. A review of all the facility's QAA attendance sheets for the last year, January - March 2024, April - June 2024, & July - September 2024 showed that the facility's Medical Director had not signed the attendance sheets. A review of the facility's 11/19/24 - 11/22/24 Long-Term Care Facility Application for Medicare and Medicaid showed a census of 88 residents.

Based on observation, interview, and record review the facility failed to treat all residents with respect and dignity. This applies to 1 resident (R47) reviewed for dignity in a sample of 25. The findings include: On 11/19/24 at 12:34 PM, R47 was observed in the hallway with yogurt spilled down the front of her sweatshirt and dripping down her face. V15 (Housekeeper) and V16 (LPN/Licensed Practical Nurse) walked past R47 and V15 said to R47, Oh my gosh look at your face! V16 (LPN) then whispered something to V15 (Housekeeper) and V15 said, What did I say wrong? People don't wipe it! R47 continued to walk down the hall and turned the corner and V15 and V16 walked down the hall in the opposite direction and did not stop to help clean up R47. On 11/21/24 at 1:08 PM, V2 (DON/Director of Nursing) said since R47 was up and walking around in the hallway, the staff should make sure she looks presentable. V2 said it is a dignity issue that R47 was not assisted and cleaned up when she was seen by staff with yogurt on her face and clothing. V2 said she didn't know why V15 would have made a loud comment in the hallway like that towards R47 and not asked the staff to assist with her hygiene instead. V2 said R47 does not talk a lot and really only says when she is ready to go smoke or ready for a beer. R47's MDS (Minimum Data Set) dated 10/4/24 shows she is moderately cognitively impaired, she has fluctuant inattention, disorganized thinking, and level of consciousness, and she requires substantial assistance with bathing. R47's Care Plan last reviewed 3/29/24 states she is at risk for ADL (Activity of Daily Living) self-care performance deficit related to Huntington's disease. The facility's policy titled, Quality of Life- Dignity last reviewed February 2020 states, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times .3. Some examples of ways which respect for choices and values are exercised include: a. Personal grooming .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents .12. Staff are expected to treat cognitively impaired residents with dignity and sensitivity .

Based on interview and record review, the facility failed to provide the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) Form CMS-1005 in writing to all residents who were discharged from Medicare Part A services with benefit days remaining. This applies to 3 residents (R47, R242, R91) reviewed for Advanced Beneficiary Notice and financial liability in a sample of 25. The findings include: V11 (BOM/Business Office Manager) filled out SNF Beneficiary Protection Notification Review Form CMS- 20052 for R47 and documented Medicare Part A skilled services start date was 8/16/24 and last covered day of Part A service was 10/4/24. V11 documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. V11 wrote the SNFABN was not provided to the resident/beneficiary because the NOMNC was issued. V11 filled out the SNF Beneficiary Protection Notification Review Form-20052 for R242 and documented Medicare Part A skilled services start date was 2/24/24 and last covered day of Part A service was 5/10/24. V11 documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. V11 wrote the SNFABN was not provided to the resident/beneficiary because the NOMNC was issued. V11 filled out the SNF Beneficiary Protection Notification Review Form-20052 for R91 and documented Medicare Part A skilled services start date was 8/16/24 and last covered day of Part A service was 11/11/24. V11 documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. V11 wrote the SNFABN was not provided to the resident/beneficiary because the NOMNC was issued. On 11/21/24 at 10:26 AM, V11 (BOM/Business Office Manager) said if a resident receives a NOMNC (Notice of Medicare Non Coverage), she does not give them a SNFABN because that was how she was trained. On 11/21/24 at 11:10 AM after reading the facility's policy on ABN, V11 said she should have done ABNs, but she did not. On 11/21/24 at 12:40 PM, V1 (Administrator) said she read the facility's policy on NOMNC and SNFABN and the SNFABNs should have been completed for R47, R242, and R91 but they were not. V1 said V11 (BOM) said she had never completed a SNFABN. The facility's policy titled, Notices of Non-coverage and Advanced Beneficiary Notices revised October 2024 states, The facility is committed to upholding resident rights and this includes following the guidelines set forth by regulations regarding notices of non-coverage. We want all of our residents and families to be aware of the rights they have under Medicare as well as properly notifying them of what expenses may incur when switching payment sources .SNFABN .The facility will issue the SNFABN prior to Medicare A services ending to inform them that there will potentially be a cost incurred to the resident as a result of the Med A coverage ending. Typically, the facility will make every effort to issue this notice at the same time as the NOMNC .SNFABN- End of covered Stay .If a resident is currently covered under Medicare and coverage is ending and the resident will remain in the SNF, the SNFABN must be provided to the resident notifying them that someone else will need to pay for the SNF stay after Medicare ends. This could be private, Medicaid, or other insurance. This would be in addition to the NOMNC you already provided. The SNFABN does not need to be given if the reason for ending Medicare is due to exhausting their 100 days .

Based on interview and record review, the facility failed to provide a resident and/or their family/POA (POA/Power of Attorney) in writing for the reason of transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 3 of 3 residents (R48, R64, and R78) reviewed for discharge in a sample of 25. The findings include: 1. On [DATE] at 1:38 PM, V1 (Administrator) stated we haven't been giving the residents or their representatives written documentation as for the reason the residents are sent out to the hospital. We call the family when they are transferred. I did not know we had to give the written documentation. The ombudsman should be notified of all discharges, transfers, and hospital admissions. We hadn't notified the ombudsman in the past. R48's Face Sheet showed R48 was admitted to the facility on [DATE]. R48 had multiple diagnoses which included Alzheimer's, asthma, convulsions, syncope and collapse, major depressive disorder, and schizophrenia. R48's Progress Notes showed the following: On [DATE] At 1500 resident was sitting in the dining room with the activities. Quiet with eyes closed but breathing. At 1533 CNA's (CNA/Certified Nursing Assistant) observed that resident was not breathing. They did not see her chest rise or fall and brought her to the nurse's station. Upon assessing no heartbeat heard and no breathing. Resident was placed on the floor and CPR (CPR/Cardiopulmonary Resuscitation) compressions started immediately. CODE blue called. At 1535 pulse and breathing returned. AED (AED/Automated External Defibrillator) pads applied; oxygen applied. 911 called, no shock was advised from AED. 1537 No shock advised from AED. 1537 IV (IV/Intravenous) started to left antecubital. Vitals ,d+[DATE] blood sugar 129. 1539 No shock advised from AED, breathing. 1540 911 arrived. 1544 911 transported resident to (Hospital) ER. 1546 Family notified and MD (MD/Medical Doctor) notified. Report called to (Hospital). Report given to (Nurse). [DATE] 2020 PM Resident is being admitted for observation. DX (DX/Diagnoses): altered mental status, hypothermia, and UTI (UTI/Urinary Tract Infection). R48 returned to the facility on [DATE]. On [DATE] 3:09 PM Resident was sent to ER (ER/emergency room ) per nurse practitioner this afternoon due to altered mental status and hypotension. Attempted to call son and sister with no success. Messages left. Spoke with third contact and informed her of send out. [DATE] 11:16 PM resident admitted to 3W, will be seen by neurology tomorrow. On [DATE] at 2:42 PM resident arrived at 1:23 PM via ambulance. Resident is sleepy at this time. Lungs clear, bowel sounds in all 4 quads. Bruise from IV on r arm. No documentation of written notice for reason of transfer or discharge to the hospital given to the resident or POA. No notice sent to the Ombudsman for transfer or discharge to hospital. Facility unable to provide written documentation for either hospital admission. 41384 2. On [DATE] at 12:55 PM, R64 and V4 (R64's Brother) denied that the facility provided written documentation of R64's hospital transfer. R64's [DATE] progress note showed that she was transferred to the hospital on [DATE]. R64's electronic health record did not show any documentation that a written notice was given to R64, her representative, or the Ombudsman about her hospital transfer. 3. On [DATE] at 11:16 AM, R78 said that he was sent to the hospital and the facility did not notify him in writing of the transfer. R78's [DATE] progress note showed that he was transferred to the hospital on [DATE]. R78's electronic health record did not show any documentation that a written notice was given to R78, a representative, or the Ombudsman about the hospital transfer. On [DATE] at 02:47 PM, V1 (Administrator) said the facility has not been giving written notification for the reason of transfer/discharge to the hospital to the residents, the resident's representative and a copy of the notice to the Ombudsman because the facility did not know they were supposed to do it.

Based on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R48, R64, and R78) reviewed for discharge in a sample of 25. The findings include: 1. On [DATE] at 1:38 PM, V1 (Administrator) Residents or the resident's representatives should have a bed policy given to them when they go out to the hospital. R48's Face Sheet showed R48 was admitted to the facility on [DATE]. R48 had multiple diagnoses which included Alzheimer's, asthma, convulsions, syncope and collapse, major depressive disorder, and schizophrenia. R48's Progress Notes showed the following: On [DATE] At 1500 resident was sitting in the dining room with the activities. Quiet with eyes closed but breathing. At 1533 CNA's (CNA/Certified Nursing Assistant) observed that resident was not breathing. They did not see her chest rise or fall and brought her to the nurse's station. Upon assessing no heartbeat heard and no breathing. Resident was placed on the floor and CPR (CPR/Cardiopulmonary Resuscitation) compressions started immediately. CODE blue called. At 1535 pulse and breathing returned. AED (AED/Automated External Defibrillator) pads applied; oxygen applied. 911 called, no shock was advised from AED. 1537 No shock advised from AED. 1537 IV (IV/Intravenous) started to left antecubital. Vitals ,d+[DATE] blood sugar 129. 1539 No shock advised from AED, breathing. 1540 911 arrived. 1544 911 transported resident to (Hospital) ER. 1546 Family notified and MD (MD/Medical Doctor) notified. Report called to (Hospital). Report given to (Nurse). [DATE] 2020 PM Resident is being admitted for observation. DX (DX/Diagnoses): altered mental status, hypothermia, and UTI (UTI/Urinary Tract Infection). R48 returned to the facility on [DATE]. On [DATE] 3:09 PM Resident was sent to ER (ER/emergency room ) per nurse practitioner this afternoon due to altered mental status and hypotension. Attempted to call son and sister with no success. Messages left. Spoke with third contact and informed her of send out. [DATE] 11:16 PM resident admitted to 3W, will be seen by neurology tomorrow. On [DATE] at 2:42 PM resident arrived at 1:23 PM via ambulance. Resident is sleepy at this time. Lungs clear, bowel sounds in all 4 quads. Bruise from IV on r arm. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 41384 2. On [DATE] at 12:55 PM, R64 and V4 (R64's Brother) were asked if the facility notified them of the facility's bed hold policy before being transferred to the hospital and they denied ever receiving the information. R64's [DATE] progress note showed that she was transferred to the hospital on [DATE]. R64's electronic health record did not show any documentation that the facility provided R64 or V4 with the facility's Bed Hold policy when R64 was sent to the hospital. 3. On [DATE] at 11:16 AM, R78 denied being notified by the facility of their Bed-Hold policy. R78's [DATE] progress note showed that he was transferred to the hospital on [DATE]. R78's electronic health record did not show any documentation that the facility provided R78 with the facility's Bed Hold policy when he was sent to the hospital. On [DATE] at 2:47 PM, V1 (Administrator) said that the facility is supposed to provide the residents and their representatives with the facility's Bed-Hold policy when they are transferred to the hospital. The facility's Bed-Hold and Returns policy ([DATE]) showed that prior to transfers and therapeutic leaves, residents and resident representatives will be informed in writing of bed-hold and return policy.

Based on observation, interview, and record review the facility failed to provide personal hygiene for 3 residents (R29, R86, & R64) who are dependent on ADL care (Activities of Daily Living) in a sample of 25. Findings include: 1. On 11/19/24 at 12:25 PM, R29 was observed with her nails long, jagged and with brown substance under the nails and her hair was oily. V5 (R29's niece) was present at that time and said that the staff needs to cut and clean her nails. R29's EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted to the facility on [DATE]. Her 10/18/24 MDS (Minimum Data Set) showed that cognitive skills for daily decision making are severely impaired, and she has long and short term memory problems. Her 10/10/24 MDS section GG showed that she is dependent on staff for personal hygiene. 2. On 11/19/24 at 12:41 PM, R64 was with V4 (R64's Brother) and her hair was observed oily, and she had an excessive amount of hair on her chin and upper lip. The hair was about 1 to 1 1/2 inches long. R64 said that it bothers her and that it makes her feel bad and then she began crying. V4 said that it has been over a month since the staff has shaved his sister. R64's EHR showed that she is a [AGE] year old female admitted to the facility on [DATE]. R64's 11/14/24 care plan showed that she has an ADL self-care performance deficit related to Parkinson's with interventions including needing assistance with bathing and showering, & nail hygiene. R64's 8/23/24 MDS section C showed that her cognition is moderately impaired, and she needs substantial/maximal assistance with personal hygiene. 3. On 11/19/24 at 10:42 AM, R86 was observed with a brown substance under his nails. R86 said that he provides his own nail care when the staff gives him the necessary supplies. R86's EHR showed that he is a [AGE] year old male admitted to the facility on [DATE]. R86's MDS section C showed that his cognition is moderately impaired, and section GG showed that he needs partial/moderate assistance with personal hygiene. R86's 9/12/24 care plan showed that R86 has an ADL self-care performance deficit related to decrease in grooming skills with interventions including staff assistance required for personal hygiene and oral care setup. On 11/21/24 at 10:11 AM, V1 (Administrator) said that her expectations are that staff provide nail care, remove residents' facial hair, and wash residents' hair for the resident's dignity. The facility's Activities of Daily Living (ADLs), Supporting policy (Revised date March 2018) showed that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). The policy also showed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure anti-contracture devices were applied to resident as ordered. This applies to 1 of 2 residents (R16) reviewed for anti-contracture devices in a sample of 25. The findings include: On 11/19/24 at 11:51 AM, R16 was observed in the dining room, sitting in her high back wheelchair participating in activities with other residents. R16 's right hand was in fist form laying on her abdomen. When asked if R16 wears an anti-contracture device, R16 smiled, did not respond. On 11/20/24 at 11:07 AM, R16 was observed in the dining room, siting in high back wheelchair, right hand still in fist form, no splint. Review of R16's Electronic Medical Record shows that R16 has the following diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness and muscle wasting and atrophy. R16's Minimum Data Set (MDS) of 10/3/24 shows that R16's cognition is severely impaired. R16's Physician order shows to have right hand palm protector, to wear at all times and take off for care. On 11/20/24 at 2:02 PM, V14 (Restorative Nurse Manager) provided list of residents that use anti-contracture devices; R16 was on the list. V14 said that R16 uses a right-hand palm protector because her right hand is contracted after she had a stroke. V14 said the palm protector is applied during the day and taken off at night. V14 said that R16 is compliant with wearing the palm protector. At 2:06 PM, V14 and surveyor observed R16 in dining room, R16's right hand still in fist form, R16 did not have right hand palm protector. At 2:07 PM, V14 found R16's palm protector in her bedroom dresser. The facility's Assistive Devices and Equipment policy (revised July 2017) states that devices and equipment that assist with resident mobility, safety and independence are provided for residents.

Based on observation, interview, and record review, the facility failed to properly position indwelling catheter drainage bag during wound care dressing change. This applies of 1 of 2 residents (R22) reviewed for indwelling catheter in a sample of 25. The findings include: On 11/20/24 at 9:58 AM, V9 (Wound Care Nurse Manager) and V10 (Memory Care Coordinator) provided wound care treatment to R22. At 10:09 AM, V9 unhooked R22's catheter drainage bag from the right side of the bed and placed the bag on R22's bed, while V10 turned R22 to her left side so that V9 could access R22's sacral wound. V9 completed R22's sacral wound dressing change, left the drainage bag on the bed. After the dressing change, V9 and V10 repositioned R22 in bed, and R22's catheter bag was under R22's leg. At 10:25 AM, V9 and V10 left R22's room, the catheter bag was still on the bed. At 11:00 AM, R22's catheter bag was still on the bed under R22's leg. Review of R22's Electronic Medical Record shows that R22 has the following diagnoses of osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region stage 4, and neuromuscular dysfunction of bladder. R22's Minimum Data Set (MDS) of 10/14/24 shows that R22's cognition is severely impaired. R22's has a physician order for indwelling catheter. R22's care plan (initiated 10/9/24) shows that R22 has indwelling catheter due to sacral wound and neurogenic muscular dysfunction, with intervention to position catheter bag and tubing below the level of the bladder. On 11/20/24 at 11:15 AM, V2 (Director of Nursing/DON) was informed of the catheter bag. V2 saw R22's catheter drainage bag on the bed. V2 said it should not be on the bed, it should be below the resident's bladder so the urine can flow properly and to prevent backflow of urine. The facility's Catheter Care, Urinary policy (revised July 2020) states that the urinary catheter drainage bag must be held or positioned lower than bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review the facility failed to notify the POA (POA/Power of Attorney) of changes in condition. This applies to 1 of 3 residents (R1) reviewed for policy and procedures. The findings include: On 01/30/24 at 1:53 PM, V4 (CNA/Certified Nursing Assistant) said she takes care of R1 all the time. V4 said she was taking care of R1 on 01/11/24 during the 6:30 AM-2:30 PM shift when she saw bulging to R1's right hip. V4 said she did not see any bruising on 01/11/24. V4 said she first saw the bruising a few days later after seeing the hip bulging. V4 said the bulging of the right hip had never looked that big before. V4 said she asked R1 if she was in pain and R1 said no. V4 said she told the nurse, V5 (LPN/Licensed Practical Nurse). V4 said V5 came in the shower room and assessed R1. V4 said she assumed V5 told the family about the bulging right hip. V4 said when I see bruising or anything abnormal, I report it to the nurse, the supervisor, and the abuse coordinator. On 01/30/24 at 2:07 PM, V5 (Licensed Practical Nurse) said she was called to the shower room on 01/11/24 by V4 (CNA) taking care of R1. V5 said V4 reported a bulging spot on R1's back of right hip. V5 said she never saw any bruising. V5 said the spot was not new, but it appeared to be a little more swollen than normal. V5 said she assessed the area and R1 was not in any pain or distress. V5 said at the end of her shift, she endorsed the incident in report about the bulging. V5 said she did not document that she notified R1's POA (POA/Power of Attorney) of the bulging spot. V5 said she started the incident report but did not complete it. V5 said she was not aware that she did not complete the incident report or the documentation. V5 said she did not notify the POA of the bulging spot. V5 said the normal processes when there is an accident or injury is to do the incident report, notify the doctor and the family. V5 said when incidents occur, the facility normally documents for 72 hours after the incident is found. V5 said she does not know if any documentation was done after 01/11/24 because she was not on that unit during the time it would have been documented. On 01/20/24 at 1:25 PM, V3 (Licensed Practical Nurse) said on 01/12/24 she was told in report from another nurse that R1 had a bruise to her right hip. V3 said the nurse told her that R1 might have hit her right hip on the edge of the bed or the bedside table. V3 said when she assessed R1 there were no changes in the size or color of the bruise. V3 said R1 told her she was not in pain. V3 said she never notified anyone that R1 had a bruise. V3 said she called R1's daughter (POA) on 01/15/24 or 01/16/24 to give her the results of the x-ray. V3 said she told R1's daughter there was no fracture or dislocation to the right hip. V3 said she told the daughter R1 had arthritis in the right hip and the bruise probably came from R1 bumping her hip on something. V3 said the normal process for finding a bruise is to do a risk management. It is like an incident report. We notify the family and the doctor of what we find. We report all bruises to the department managers. On 01/30/24 at 3:57 PM, V1 (Administrator) said on Saturday 01/20/24 the nurse on the floor called and said R1's daughter (POA) was in the facility, and she was upset stating R1's leg was deformed, and she had bruising to her leg. V1 said R1 bumped her hip on 01/11/24 and there is no documentation in the chart to support that. V1 said there was no documentation to support that the POA was notified of the incident. V1 said the normal process when injuries/accidents occur is to assess the resident, figure out what happened, do the incident report, notify the doctor and the family, and document everything in the progress notes. V1 said if the doctor is not notified of an injury or accident the patient could not get the proper assessment and care. V1 said if the family is not notified, they will not have the information about the injury or care that is being provided. V1 said the policy for changes in condition is to notify the physician and family immediately. On 01/30/24 at 9:20 AM, R1 was in her room walking around with a steady gait. R1 did not use any assistive devices for ambulation. R1 was alert and oriented x 1. V3 (Licensed Practical Nurse) assisted with the assessment of R1's right hip and leg. R1 had a protruding right hip bone and an old, dark black discoloration to the right hip area. R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses of syncope and collapse, diabetes, dementia, anxiety, adjustment disorder, glaucoma, hypertensive urgency, hyperglycemia, and contusion of right thigh. R1's MDS (MDS/Minimum Data Set) showed R1 had moderate cognitive impairment. R1's incident report dated 01/11/24 showed R1 bumped her right leg on an object in her room. The same report showed R1 had a knot on her right leg-upper thigh. R1's progress notes were reviewed from 01/10-01/24/24. There was no documentation on 01/11/24 the day of the incident that showed R1's POA was notified. There was no documentation until 01/20/24 regarding R1's right hip, leg, and thigh.

Based on observation, interview, and record review, the facility failed to assess and address pain before and during wound care to a resident. This failure has caused severe pain for one resident during dressing changes. This applies to 1 of 2 residents (R54) reviewed pain management in a sample of 31. The Findings include: R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/10/24 at 2:20 PM, observed V5 (Wound Care Nurse) and V7 (Certified Nursing Assistant - CNA/Memory Care Director) begin to provide wound care to R54's coccyx wound without assessing for pain. Observed V5 and V7 using the mattress linen to pull him up on the bed and R54 complaining of pain, saying, I have too much pain. In response to R54's pain, V5 said to R54, I know your nurse gave you pain medication. On 1/10/24 at 2:25 PM, V5 and V7 turned R54 to his right side to provide wound treatment to his coccyx wound. V5 sprayed wound cleanser on his unstageable wound (as per V5) and wiped it. R54 again complained of pain, saying, Ohh .too much pain, it's hurting. In response to R54's pain, V5 replied, I am not touching you now. On 1/10/24 at 2:35 PM, in response to the surveyor's inquiry, R54 stated, I have pain all over the place. It is 7 out of 10. I was given Norco, and it is not helping. On 1/10/24 at 2:35 PM, V5 stated, R54 was given pain medication, and that's why I didn't ask him for his pain level before starting. I am not sure I should have stopped treatment when he complained of pain. I have to look at the policy to see whether I should have stopped when R54 complained of pain during treatment. On 01/11/24 at 10:37 AM, R54 stated, Every day, I have pain when they do wound care. They give me one Norco pill, and that doesn't do anything. 01/11/24 10:45 AM, V2 (Director of Nursing / DON) stated, Our standard of practice is assessing residents for pain before wound care. The wound care nurse should have assessed the resident for pain before she started with wound care and should have stopped the wound treatment when the resident complained of pain during treatment. 01/11/24 10:15 AM V6 (Wound Care Nurse Practitioner) stated, Pain assessment is crucial before wound care, and the pain should be managed well. If pain is not managed well, it can cause the resident to deny treatment and care. The patient should have been assessed for pain. If the patient complains of pain during wound care, she should hold it and manage the pain to have a pleasant experience for the resident. The facility presented a wound care policy revised in the October 2010 document: 2. Review the resident's care plan to assess for any special needs (including pain as per Administrator) of the resident. A review of the Pain Assessment and Management Policy revised in March 2015) documented the steps in the procedure to recognize pain. 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain a. Verbal expressions such as groaning, crying, screaming. 4. Ask the resident if he/she is experiencing pain. Be aware .numbness or tingling.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 94 residents. On [DATE] at 11:26 AM, V3 (Director of Food and Nutrition Services) said there are no NPO (Nothing by Mouth) residents and all 94 residents eat from the facility kitchen. On [DATE] starting at 10:32 AM, the facility kitchen was toured in the presence of V3 and the following was found: Dry Storage: 1. Twelve 2 pound bags of sun dried raisins with expiration date [DATE]. 2. One 6 pound 9 ounce can of diced pears dated ,d+[DATE] with a large dent on rack of food to be served. V3 said the dented cans are supposed to be removed from circulation and not used because of the risk of botulism. 3. One 6 pound 9 ounce can of diced pears with no date. 4. Two 6 pound 9 ounce cans of diced peaches with no date. 5. Three 6 pound 9 ounce cans of fruit mix with no date. 6. Six 6 pound 9 ounce cans of mandarin oranges with no date. 7. Two 6 pound 8 ounce cans of apple sauce with no date. Meat Freezer: 8. 64 ounce bag of whole strawberries opened, not dated, and not sealed with freezer burn. V3 said freezer burn is a problems because it [NAME] the food and effects the taste. 9. Three 36 ounce cherry pies with no date. 10. 15 pound box of rib shaped pork patties, opened and not sealed with freezer burn. 11. Freezer floor dirty with approximately three 2 inch yellow colored puddles of unknown substance. V3 said that needed to be cleaned up. 12. 6 pound opened box of pork sausage patties, not sealed with freezer burn. Walk-in Freezer: 13. 3 inch yellowish brown puddle on right side wall by entrance. 14. Expired 12 ounce package of classic [NAME] with expiration date of [DATE] 15. 2 large boxes of pitas with delivery date of [DATE]. V3 said they were defrosted sometime last week, but she is not sure when. There is no defrost date on boxes. Milk Cooler: 16. 7 pitchers of drinks that are unlabeled and undated. On [DATE] at 10:20 AM, V3 said all foods need to be labeled and dated so staff know the expiration date and type of food item. V3 said if a resident is given expired food they can get sick. V3 said when a food item is defrosted, it needs to be labeled with a use by date to prevent expired food from being served. V3 said dented cans need to be taken out of circulation due to the risk of botulism and resident death. V3 said all cans need to be dated with received by date and stocked using the FIFO (First In First Out) method to make sure older products are used first. V3 said FIFO cannot be followed if the cans are not dated. V3 said all opened foods need to be sealed before restocking to keep critters or debris from contaminating the food. V3 said freezer burn effects the quality of the food and could cause spoilage. V3 said food storage areas should be clean and free from spills due to the risk of falls and/or cross contamination. The facility's policy titled, Storage of Dry Foods/Supplies developed ,d+[DATE] states, Policy: The facility will follow safe handling and storage of dry foods and supplies. Procedure: .The area should be clean, .dry and free from contaminants .Canned good will be removed from packaging, dated and stored using the First in, First out method. Opened products will be labeled and stored in tightly covered containers. Dented cans will be stored separately and marks for return or disposal . The facility's policy titled, Storage of Refrigerated/Frozen Items developed ,d+[DATE] states, Policy: The facility will follow safe handling and storage of refrigerated and frozen foods. Procedure: .Foods in the refrigerator will be covered, labeled and dated. Foods will be used by its use-by-date, frozen or discarded .

Based on observation, interview and record review the facility failed to provide personal care to dependent residents. This applies to 5 of 5 residents (R9, R14, R16, R32, and R54) reviewed for ADL's (ADL's/Activities of Daily Living) in the sample of 31. The findings include: 1. On 01/09/24 at 10:57 AM, R9 had stubble facial hair above the lip, under the chin, and both cheeks. R9 stated he wanted to be shaved. On 01/10/24 at 11:25 AM, R9 continued to have stubble facial hairs above the lip, under the chin, and both cheeks. R9 said he still wanted to be shaved. On 01/11/24 at 10:20 AM, R9 still had stubble facial hairs. R9's face sheet showed R9 had the following diagnoses chronic obstructive pulmonary disease, emphysema, insomnia, unsteadiness on feet, abnormalities of gait and mobility, malaise, dementia with anxiety, low back pain, right hip pain, major depressive disorder, hypertension, muscle wasting and atrophy, schizophrenia, and bradycardia. R9's MDS (MDS/Minimum Data Set) dated 10/18/23 showed R9's cognition was mildly impaired. The same MDS showed R9 required substantial/maximal assistance with personal hygiene. R9's ADL self-care performance deficit care plan stated Personal hygiene/oral care: I need assistance. I am on the restorative program. 2. On 01/09/24 at 11:03 AM, R16 had an accumulation of facial hair. R16 said he had not been shaved in a while. R16 said he would like to be shaved. R16's left hand fingernails were short with a dark colored substance underneath. On 01/10/24 at 11:30 AM, R16 continued to have an accumulation of facial hair. R16 said all I need is a haircut and a shave. R16 said he informed the staff he wanted to be shaved. On 01/11/24 at 12:22 PM, R16 continued to have facial hair. R16's face sheet showed R16 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, weakness, malaise, muscle wasting and atrophy, difficulty in walking, lack of coordination, alcoholic hepatitis without ascites, cholelithiasis without obstruction, hyperlipidemia, schizophrenia, and hypertension. R16's MDS dated [DATE] showed R16's cognition was moderately impaired. The same MDS showed R16 required substantial/maximal assistance with personal hygiene. 3. On 01/09/24 at 11:24 AM, R32 had an accumulation of facial hair. R32 said it's been a while since I last had a shave. R32 said he would like to be shaved. On 01/11/24 at 09:40 AM, R32 continued to have facial hair. R32's face sheet showed R32 was admitted to the facility with diagnoses of diabetes mellitus, left knee contracture, right hip pain, dysphagia, weakness, right and left knee pain, personal history of transient ischemic attack and cerebral infarction, insomnia, major depressive disorder, hyperlipidemia, seizures, paraplegia, hypertension, neuromuscular dysfunction of bladder, and metabolic encephalopathy. R32's MDS dated [DATE] showed R32 was cognitively intact. The same MDS showed R32 was dependent upon staff for all ADL's (ADL's/Activities of Daily Living). R32's ADL self-care performance deficit care plan intervention showed, Personal Hygiene: I need limited-extensive assistance by 1-2 staff with personal hygiene and oral care. On 01/11/24 at 11:40 AM, V2 said nail care and shaving is done as needed and on shower days. V2 said it is expected that nail care is done with showers. V2 said dirty fingernails is a dignity issues and an infection control issue. On 01/11/24 at 12:18 PM, V10 (CNA/Certified Nursing Assistant) said shaving and nail care is done after showers or as needed. V10 said residents are showered two times per week. V10 said residents should not have dirt under their fingernails or long facial hair. V10 said it is the responsibility of the CNA's to clean the resident's nails and shave them. The facility's Care of Fingernails/Toenails policy revised 02/2018 stated The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. The same policy's general guideline stated 1. Nail care includes cleaning and trimming. The facility's Shaving the Resident policy revised 02/2018 stated The purpose of this procedure is to promote cleanliness and to provide skin care. The facility's Activities of Daily Living (ADL's) policy revised 03/2018 stated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). The same policy stated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 34410 4. R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R54 is dependent on toilet hygiene. On 1/9/24 at 12:15 PM, R54 was in his bed, and V8 (Nurse) turned R54 to his right side per the surveyor's request. R54 was observed with a soaked incontinent brief with urine leaked onto the linen and mattress. Also, a piece of stool was observed between his inner buttocks. On 1/9/24 at 12:15 PM, R54 stated that the facility hadn't changed him yet. On 1/9/24 at 12:17 PM, V8 stated, The Certified Nursing Assistants are supposed to provide incontinent care. I will call the CNA to change him. Record review on R54's incontinent care plan document: Clean peri-area with each incontinent episode. On 1/9/24 at 1:48 PM, V2 (Director of Nursing / DON) stated that incontinent care should be provided to residents every two hours and as needed. The facility provided incontinent care policy revised 10/03 document: 5. Residents will be checked every two hours and prn (as needed) to provide care/incontinent care. 41384 5.On 01/09/24 at 10:43 AM, R14 was observed in her bed with her nails long, jagged, and with brown substances under the nails. R14 said she would like for her nails to be cleaned. On 01/11/24 at 12:29 PM, V1 (Administrator/RN) said that there was no reason why R14's nail hygiene was not done. V1 looked on her computer at R14's EHR (Electronic Health Record) to see if she had refused care and said there was no documentation showing any refusal. V1 then said R14's nails should be cut and cleaned to avoid injury or infections. R14's EHR showed that she is a [AGE] year old female admitted to the facility on [DATE]. R14's 10/18/23 MDS (Minimum Data Set) Section GG showed that she is dependent for personal hygiene. The facility's Fingernails/Toenails, Care of policy (February 2018) showed that proper nail care can aid in the prevention of skin problems around the nail bed, and staff should trim and smooth nails to prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to follow its isolation guidelines by cohorting isolation and non-isolation residents in the same room. The facility also failed to follow its standard precaution policy by not changing gloves and performing hand hygiene during incontinence care and when leaving an isolation room. This applies to 5 of 5 residents (R18, R41, R54, R145, and R344) reviewed for infection control in a sample of 31. The Findings include: 1. R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. 2. R145 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 01/09/24 at 11:37 AM, V5 (Wound Care Nurse) stated, R54 has Methicillin-resistant Staphylococcus Aureus (MRSA) infection with his right stump. R145 is not in isolation. We are combining those residents because R54's stump wound is covered with a dressing and is contained. On 1/9/24 at 11:45 AM, contact isolation signage was observed at the room door shared by R54 and R145. R54's right stump was observed with an old dressing coming off with drainage on the dressing. Upon notification, V4 (Certified Nursing Assistant) reapplied the old dressing and stated that she would notify the wound care nurse. The facility presented Isolation - Categories of Transmission Based Precaution document: Contact Precaution: The individual on contact precaution will be placed in a private room if possible. If a private room is unavailable, the infection preventionist will assess various risks associated with other resident placement options. During an infection control interview on 1/10/23 at 11:10 AM, V9 (Infection Preventionist) stated, We can combine isolation residents with non-isolation residents as long as the source of infection is contained. R54's source of infection with the right stump should have a dressing intact to contain the infected wound to minimize the risk of MRSA infection to his roommate (R145). 48526 3. On 01/10/2024 at 09:20 AM V10 (CNA/Certified Nursing Assistant) was observed coming out of R344's room with gloves on. V10 was observed in the hallway wearing the gloves. V10 did not perform hand hygiene. The facility had a sign posted on the wall next to R344's room. The sign stated R344 was on contact isolation. R344 had an isolation bin next to the room. V8 (Registered Nurse) stated R344 was on contact isolation for C-Diff (Clostridium Difficile). R344's face sheet showed R344 was admitted to the facility on [DATE] with the following diagnoses local infection of the skin and subcutaneous tissue, severe protein calorie malnutrition, enterocolitis due to clostridium difficile, anemia, and anal fistula. On 01/11/24 at 11:40 AM V2, DON (Director of Nursing) said gloves should not be worn in the hallways. V2 said when staff come out of isolation rooms, gloves should be removed. Staff members must wash their hands with soap and water after taking care of residents with C-Diff. On 01/11/24 at 12:18 PM, V10 said gloves should not be worn in the hallway when coming out of residents' rooms. V10 said I can transfer an infection if I don't remove my gloves when coming out of resident's rooms. On 01/11/24 at 12:31 PM, V9 (Infection Control Preventionist) said no one should come out of an isolation room with gloves on. The gloves should come off and the hands are washed with soap and water before exiting a room. It is cross contamination for a staff member to leave out of a room with gloves on. At no times should staff wear gloves in the hallway. The facility's Standard Precaution policy revised 10/2018 stated Gloves: gloves are removed promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. The Contact Precautions sign the facility utilizes next to isolation rooms stated to discard gloves before room exit. 41384 4. R41 is a [AGE] year old female that was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder and an Indwelling catheter. On 01/09/24 at 10:49 AM, V11 CNA (Certified Nurse's Assistant) was providing incontinence care for R41. V11 put on gloves and opened R41's brief, wiped R41's perineal area with a washcloth, wiping areas twice before folding the washcloth. V11 went to R41's rectal area and did not wash or clean the washcloth before going to the new area. V11 was observed wiping the area three times before folding the washcloth and wiping again. After V11 completed incontinence care, V11 did not remove her gloves and clean her hands, she continued with attaching the clean brief, adjusting the resident, and adjusting the sheets and blankets with the same dirty gloved hands. V11, then with same dirty gloved hands, remove the soil brief and put it on the back of the toilet in the resident's bathroom, then she removed her dirty gloves, did not clean her hands, and then gave R41 her remote control. V11 then put gloves on her uncleaned hands, picked up the soil brief, put it in a plastic bag, carried it through the hallway to the soiled utility room, removed her gloves, did not clean her hands, and opened the door to the soiled utility room and went inside. On 01/09/24 at 12:54 PM, V11 (CNA) said she should have only wiped once and then folded the towel, and she should have gotten a new towel before going to a different area. V11 said she should have removed her gloves and cleaned her hands when going from a dirty area before going to a clean area. On 01/10/24 at 11:41 AM, V12 (Nurse) was examining R41's urinary catheter and brief, checking to see if R41's catheter was leaking. V12 put on gloves, opened R41's brief, touched R41's perineal area and catheter tubing, closed R41's brief, pulled up the sheets, adjusted the bed with the bed control, adjusted the catheter bag, adjusted the resident in the bed, and then removed the dirty mattress pad with her gloved hands. V12 never removed her gloves and cleaned her hands after going from a dirty area before going to a clean area. V11 then removed her gloves did not clean her hands, put on new gloves and again adjusted the catheter bag. On 01/10/24 at 11:52 AM, V12 (Nurse) said she should have cleaned her hands before going to a clean area to prevent infections and cross contamination. On 01/11/24 at 12:24 PM, V1, Administrator said that the staff should have cleaned their hands when going from a dirty area to a clean area for infection control. V1 said staff should have only wiped one time then folded the towel, she said the staff should have cleaned the towel or got a new towel when she went to the new area, the front to back, one and done, for infection control. The facility's Catheter Care Urinary policy (September 2012) showed staff are to maintain clean techniques when handling or manipulation of the catheter, tubing, or drainage bag. The facility's Handwashing/Hand Hygiene policy (August 2015) showed that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the hand washing hand hygiene procedures to prevent the spread of infections. The use of alcohol based hand rub or alternatively soap and water for the following situations: before and after direct contact with residents, before and after handling an invasive device (e. g. urinary catheters), before moving from a contaminated body site to a clean body site during resident care, after contact with residents' intact skin, and after contact with blood or bodily fluids. The facility's Perineal Care policy (February 2018) showed the purpose of this procedure is to provide cleanliness and comfort to the resident to prevent infections and skin irritations. The procedures in the policy show the staff are to wash the perineal area first then rinse washcloth apply soap or skin cleanser and wash the rectal area next. 46003 5. On 01/09/24 at 11:41 AM, R18 was assisted with toileting by V13 C.N.A. (Certified Nursing Assistant). V13 pulled gloves from her pocket to put on, then applied a transfer belt to R18. V13 assisted R18 to stand at her bathroom handrail. V13 removed R18's soiled disposable undergarment and assisted her to sit on the toilet. V13 touched R18's right shoulder with her soiled gloves while speaking with R18. V13 C.N.A then assisted R18 to stand at the handrail using the transfer belt. V13 wiped R18's genitals and buttocks with a washcloth and placed it on the bathroom sink. V13 then pat R18 dry with a dry washcloth and placed it on the sink. V13 then applied a clean disposable undergarment and pulled R18's pants up with the same soiled gloves. R18 informed V13 her pants had urine on them. V13 pulled the pants with urine down. V13 assisted R18 to sit in the wheelchair using the transfer belt. V13 removed R18's shoes and pants with urine. V13 maneuvered R18's wheelchair out of the bathroom doorway with her soiled gloves. V13 went to R18's drawer opened and closed it. V13 opened R18's closet door and pulled out a pair of leopard print pants with the same soiled gloves. V13 then maneuvered R18's wheelchair back into the bathroom. V13 C.N.A. put R18's clean pants on up to her knees and shoes back on. Using the transfer belt, V13 assisted R18 to stand at the handrail and pull her pants up. V13 assisted R18 to sit back in her wheelchair and removed the transfer belt with the same soiled gloves. V13 then opened the bedroom door, maneuvered R18 to the door. V13 then removed her soiled gloves and tossed them in the trash bin next to the door and exited the room without doing hand hygiene. On 01/09/24 at 11:55 AM, V13 stated she didn't do hand hygiene or change her gloves because she forgot her box of gloves and does not use the glove supplied in resident rooms.

Based on observation, interview, and record review, the facility failed to provide dignity to 3 residents (R64) who was not properly clothed while in dining room, (R15) who's catheter bag was not covered, and in view of others, and (R16) who's shoes were not properly maintained and safe to wear in a sample of 31. Findings include: 1. On 01/09/24 at 12:27 PM, R64 was observed in the dining room with a hospital gown on. The gown was open in the back, and the gown was continuously falling in front. R64 kept having to pull up the gown while she tried to eat. R64 said that the staff had not changed her clothes for the day. On 1/9/24 at 12:27 PM, V7 (Memory Care Director/Certified Nurse's Assistant) said that R64 should not be in the dining room in a hospital gown, she should be fully dressed in day clothes. On 01/11/24 at 12:45 PM, V1 (Administrator/RN) said R64 should have been dressed in weather appropriate clothes that covered her, and that she wanted to wear. V1 said that R65 was not dressed appropriately because R64 was exposed and not provided with privacy. V1 said that the facility's policy is for staff to encourage and assist residents to dress in their own clothes rather than hospital gowns. R64's (Electronic Health Record) showed that R64 is a [AGE] year old female admitted to the facility on [DATE]. R64's 10/19/23 care plan showed that she is cognitively impaired due to a diagnosis of dementia and needs assistance with personal care. R64's 10/23/23 MDS (Minimum Data Set) Section C show that she is moderately impaired, and section GG showed that R64 needs substantial/maximal assistance for upper body dressing and is dependent for lower body dressing & putting on and taking off footwear. 2. On 01/09/24 at 10:37 AM, R15 was observed in his bed and his catheter bag was hanging from his bed and his door was open. There was no cover on the bag, and you could see his bag from the hallway. On 01/11/24 at 12:20 PM V1 (Administrator/RN) said that the catheter bag should have been covered for the resident's dignity. R15's EHR (Electronic Health Record) showed that he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including obstructive/reflux uropathy and his physician's order dated 10/23/23 for a Foley catheter (indwelling) for obstructive/reflux uropathy. The facility's Quality of Life policy dated August 2009 showed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Residents shall be groomed as they wish to be groomed, and residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. 48526 3. On 01/09/24 at 11:03 AM, R16 was sitting in a wheelchair in his room. R16 was able to propel himself in the wheelchair. R16 had on a black pair of shoes. The shoes did not have any shoelaces and the tongues were hanging out, touching the floor. R16 said my shoes are very old, and I want new shoes. On 01/10/24 at 11:30 AM, R16 continued to wear the black shoes. The black shoes still did not have any shoelaces, and the tongues were hanging out touching the floor. R16 said I need a new pair of shoes. R16 said he had spoken with the facility staff about needing a new pair of shoes. R16 said the staff told him they could not get him a new pair of shoes. R16 does not remember which staff member he spoke with about getting new shoes. On 01/11/24 at 12:22 PM, R16 continued to be in his room sitting in a wheelchair. V2 (Director of Nursing) was in the room. R16 stated my shoes are too little, and I want another pair. The shoes continued to be without shoelaces, and the tongue of the left shoe was touching the floor. On 01/11/24 at 11:40 AM, V2 said she did not know R16's shoes were in the condition they are in. V2 said R16 needed a new pair of shoes after observing the condition the shoes were in. V2 said the staff were unsure of what happened to R16's shoelaces. V2 said if the staff notices residents' clothes and shoes are torn and not appropriate, they can get items from a donated box. R16's face sheet showed R16 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, weakness, malaise, muscle wasting and atrophy, difficulty in walking, lack of coordination, alcoholic hepatitis without ascites, cholelithiasis without obstruction, hyperlipidemia, schizophrenia, and hypertension. R16's MDS dated [DATE] showed R16 required substantial/maximal assistance with putting on and taking off socks and shoes that is appropriate for safe mobility. R16's risk for falls care plan, not dated, stated ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair as an intervention.

Based on observation, interview, and record review, the facility failed to have an adaptive call light accessible for one resident and adaptive eating utensils for a dependent resident. This applies to 2 of 2 residents (R32 and R66) reviewed for accommodation of needs in a sample of 31. The findings include: 1. On 01/09/24 at 11:24 AM, R32 was sitting in a motorized wheelchair. R32's left arm was contracted to his chest. R32 was able to move his right arm. R32's thumb and fifth finger on his right hand was contracted in the downward position. R32's index, middle and ring fingers were in a straight position, and not able to move or flex. R32's left leg was contracted. R32 stated he needed to be repositioned. R32 attempted to press the call button in his room. R32 was unable to press the button due to the limited range of motion in both hands. The call light was pressed for R32 by the surveyor. On 01/10/24 at 12:10 PM, R32 still did not have the appropriate call light for him to use. R32 said he informed the staff of the need for another call light when he moved to the current room. On 01/11/24 at 09:40 AM R32 continued to have the call light he was not able to use in his room. R32 said he told the staff again he needed the touchpad call light from my old room. R32's face sheet showed R32 was admitted to the facility with diagnoses of diabetes mellitus, left knee contracture, right hip pain, dysphagia, weakness, right and left knee pain, personal history of transient ischemic attack and cerebral infarction, insomnia, major depressive disorder, hyperlipidemia, seizures, paraplegia, hypertension, neuromuscular dysfunction of bladder, and metabolic encephalopathy. R32's MDS dated [DATE] showed R32 was cognitively intact. The same MDS showed R32 was dependent upon staff for all ADL's (ADL's/Activities of Daily Living). R32's risk for falls care plan intervention stated, be sure my call light is within reach and encourage the resident to use it for assistance as needed. The same care plan showed another intervention to remind me to call for assistance needed. On 01/11/24 at 11:40 AM, V2 (DON/Director of Nursing) said all call lights should always be within reach and clipped to the bed. V2 said call lights should never be hanging and not within reach. V2 said residents who cannot push the call light should have a flat pad call light. V2 said if residents are not able to notify staff of needing assistance, there could be a delay in treatment or meeting their needs. All residents should have call lights that are accessible to them. The facility's Routine Resident Checks and Call Light Response policy revised 07/2013 stated 1. To ensure the safety and well-being for our residents, nursing staff shall make a routine resident check on each unit and to ensure the call-light is working and within easy reach. 46003 2. R66 has diagnoses that includes Type 2 Diabetes, Parkinson's Disease, and Autistic Disorder. R66's Minimum Data Set, dated dated dated [DATE] shows severe cognitive impairment. R66 requires staff supervision or touching assistance with eating while using suitable utensils to bring food to the mouth and swallow. R66's Care plan dated 12/01/2023 states R66 has a nutritional problem or potential nutritional problem. Therapy provided a special silverware sponge grip that will allow silverware to be held better. On 01/09/24 at 12:12 PM, R66 was served two egg salad sandwiches, diced beats served on a regular flat plate, a banana, and a pink drink. Resident attempted to scoop the beats up with a regular spoon and dropped them on her lap. R66 then ate the beats from her lap. R66's meal tray ticket listed a General Regular diet, double portions, and adaptive equipment starred and in bold font. The meal ticket did not list what adaptive equipment R66 was to have on her tray. 01/09/24 at 12:27 PM, V7 (Certified Nursing Assistant / Memory Care Coordinator) stated special adaptive equipment comes from the kitchen and if it is not on the tray staff should call the kitchen to get it. If a resident required special adaptive equipment, it would be listed on their meal ticket. V7 stated there were no residents in the dining room that required special adaptive equipment. On 01/10/24 at 12:58 PM, R66 was observed eating lunch. R66 was eating from a scoop plate. R66's utensils were a regular fork and regular spoon. On 01/11/24 at 12:12 PM, V3 (Director of Food and Nutrition Services) stated therapy services inform them what assistive meal devices residents require and dietary services add it to the meal ticket. V3 stated the only adaptive equipment being used by residents in the facility are scoop plates. On 01/11/24 at 12:37 PM, V15 (Physical Therapy Assistant / Director of Rehab Services) stated R66 was seen by the Occupational Therapist on 1/8/2024 for a post fall assessment. R66 was not assessed for eating devices at that time. If R66 assistive eating devices were to be changed she would need to be reassessed. V15 did not see any documentation of reassessment of assistive eating devices. On 01/09/24 at 12:56 PM, V2 DON (Director of Nursing) stated the assistive devices a resident requires should be listed on their meal ticket. If the device was not sent on the tray, staff should contact the kitchen to obtain it. The Restorative Nurse or Therapy Services determine what assistive devices residents require. A physicians order is not required. The assistive device a resident requires should be listed on their meal ticket and in their care plan. R66's care plan says she should have a sponge on her utensils. She will get a scoop plate or a flat plate depending on what she wants. The facility policy Assistance with Meals dated July 2017 states residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Adaptive devices will be provided for residents who need or request them. These may include devices such as silverware with enlarged / padded handles, plate guards and or specialized cups.

Based on observations, interviews and record reviews, the facility failed to provide non slip footwear to residents at high risk for falls. This applies to 2 of 2 residents (R50 and R75) reviewed for falls in a sample of 31. Findings include: 1. On 01/09/24 at 11:20 AM, R50 was observed in the dining room and hallway with no shoes or non-slip socks on. V14 CNA (Certified Nurse's Assistant) said she was R50's CNA for the day and she did not pay attention to her socks that she was wearing on this day. V14 said that they were the socks that R50 went to bed in the night before. On 01/09/24 at 11:23 AM, V7 (Memory Care Coordinator/CNA) said she had put R50's shoes under the storage unit in the dining room because R50 had taken them off. She said that around 10:45 am, she attempted to put R50's shoes back on her but R50 took them back off. V7 said she could have put on non-slip socks on R50, but she didn't do it because she knew R50 was going to get a shower that day. V7 said that she should have put on non-slip socks on R50 because she could have got up and fell . On 01/11/24 at 12:38 PM, V1 (Administrator) said staff should have replaced R50's shoes or put non-slip socks on her because R50 is a fall risk, and it would prevent her from slipping and falling. R50 EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including high risk for falls, history of right knee pain, schizophrenia, and psychoactive drug use. R50's 11/22/23 care plan showed that she has had falls on 2/15, 2/25, 3/15, 3/27, 5/15, 6/8, 6/15, 7/7, 8/1, 8/20, 10/31, and 11/6. R50's interventions included non-skid socks, and staff to assist with resident getting up, dressing and ADLS (activities of daily living) before breakfast. 2. On 01/09/24 at 11:30 AM, R75 was observed in the dining room with no shoes on and non-slip socks not on properly. The non-slip sides were on the sides of her feet, not on the sole of her feet. At 11:32 AM, V13 (CNA) was showed R75's non-slip socks and V13 said that the non-slip socks should be on the sole of the foot, so the resident doesn't fall. V13 said that the way R75 was wearing the non-slip socks could cause her to fall. On 01/11/24 at 12:35 PM, V1 (Administrator) said that R75's sock should have been applied properly even if she dressed herself. V1 said staff should have ensured they were on properly to prevent R75 from slipping and falling. R75's 6/18 care plan showed high risk for falls related to diagnoses of Huntington's disease. R75's care plan showed R75 had falls on 5/14, 5/27, 5/31, 6/18, 6/28, 7/6, 7/25, 8/6, 8/21, and 11/14. The care plan showed interventions including put nonskid socks on resident daily. The facility's Falls Guideline (7/16) showed that the facility will identify and evaluate those residents at risk for falls and facilitate as safe an environment as possible, and staff will ensure interventions are implemented to prevent resident falls.

Based on observation, interview, and record review, the facility failed to provide humidification with oxygen therapy. This applies to 2 of 3 residents (R39 and R87) reviewed for oxygen therapy in a sample of 31. The findings include: 1. R39 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. Record review on R39's Physician Order Sheet (POS) for 01/2024 documented oxygen therapy with nasal cannula at 2-3 liters per minute (L/M) and to change oxygen tubing and water bottle every week and as needed. On 1/9/23 at 11:04 AM, R39 was on his bed with a Nasal Cannula with no water in the humidifier bottle. R39 stated, My nose is dry, and it's better to have some water with a humidifier. 2. R87 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 1/9/23 at 10:42 AM, R87 was in his wheelchair with a Nasal Cannula with no water in the humidifier bottle. On 01/09/24 at 11:32 AM, V8 (Nurse) stated, The nurses are allowed to fill in water with a humidifier. I will take care of those empty humidified bottles. A review of the facility provided Oxygen Administration Policy revised in October 2010 document: Equipment and Supplies: The following equipment and supplies will be necessary for this procedure. 1. Humidifier bottle Steps in the Procedures: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 14. Periodically recheck the water level in a humidifying jar.

Based on observation, interview, and record review the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 4 residents (R27, R41, R47, R74) reviewed for ADL (activities of daily living) in the sample of 20. The findings include: 1. R41 has multiple diagnoses which includes cerebral infarction, type 2 diabetes mellitus, generalized muscle weakness, and muscle wasting and atrophy, based on the face sheet. R41's quarterly MDS (minimum data set) dated January 4, 2023 shows that the resident is moderately impaired with cognition and required extensive assistance from the staff with most of his ADLs including personal hygiene. On April 3, 2023 at 11:48 AM, R41 was in bed, alert and verbally responsive. R41's blanket that was covering the resident had a big brown stain. R41 stated that he spilled something from breakfast and wants to have his blanket changed. R41's fingernails were short but with accumulation of black substances underneath. R41 stated that he wants the staff to clean his fingernails. V15 (CNA/Certified Nursing Assistant) was made aware about the condition of R41's fingernails and the request for his fingernails to be cleaned. R41's active care plan last revised on March 31, 2023 shows that the resident is at risk for ADL self-care performance deficit related to muscle weakness and CVA (cerebrovascular accident). 2. R74 has multiple diagnoses which includes altered mental status and generalized muscle weakness, based on the face sheet. R74's quarterly MDS dated [DATE] shows that the resident is cognitively intact and required extensive assistance from the staff with most of her ADLs including personal hygiene. On March 3, 2023 at 1:22 PM, R74 was in bed, alert, oriented and verbally responsive. R74's fingernails were long and with accumulation of black substances underneath. R74 stated that she wanted the staff to trim and clean her fingernails. V15 (CNA) was present during the observation. R74's active care plan initiated on February 17, 2023 shows that the resident has ADL self-care performance deficit. On April 5, 2023 at 1:03 PM, V2 (Director of Nursing) stated that it is part of the nursing care, and it is expected that the nursing staff will provide trimming and cleaning of residents fingernails to assist especially those residents requiring assistance to maintain hygiene and cleanliness. V2 also stated that when a resident's blanket needs changing the staff should change it to ensure resident's cleanliness. 29562 3. The electronic medical record (EMR) shows that R27 is [AGE] years-old who has multiple medical diagnoses which include right sided weakness related to CVA (Cerebrovascular Accident) and has muscle weakness. On 4/04/23 at 10:57 AM, R27 was resting in bed. She was alert and oriented and was able to verbalize needs during the interview. R27 displayed long dirty fingernails (with black/brown substances underneath the resident's nails). R27 stated that she wanted someone to provide nail care for her. R27's Minimum Data Sheet (MDS) dated [DATE] shows that she is alert and oriented and requires extensive assistance for grooming and hygiene. 4. The electronic medical record (EMR) shows that R47 is [AGE] years-old who has multiple medical diagnoses which include paraplegia and muscle wasting and atrophy to multiple sites. MDS dated [DATE] shows that R47 is alert and oriented and requires extensive assistance with hygiene and grooming. On 4/03/23 at 12:30 PM, R47 was in the dining room, sitting in his wheelchair. R47 displayed long dirty fingernails (black/brown substances underneath nails and brownish discoloration in the nail beds). On 4/04/23 at 11:05 AM, R47 was sitting in his wheelchair in his bedroom, alert and oriented. R47 still displayed thick curly facial hair and long dirty fingernails. R47 stated that he wanted nail care. The staff does not have to clip his nails, but he wanted his nails to be cleaned.

Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI) and failed to provide and maintain indwelling urinary catheter care. This applies to 4 of 4 residents (R11, R12, R55, R79) reviewed for incontinence and catheter care in the sample of 20. The findings include: 1. On 4/05/23 at 11:11 AM, V15 and V17 (Both Certified Nursing Assistants/CNA) entered R11's bedroom to render incontinence care. V15 and V17 donned PPE (personal protective equipment) such as gown and gloves. V15 stated that R11 is on contact isolation for ESBL (Extended-spectrum Beta-lactamases) in the urine. On 4/05/23 at 11:15 AM, V15 and V17 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R11 who was wet with urine. V15 wiped R11's outer labia with wet washcloth, however he did not separate the labia to clean the inner folds. V15 and V17 assisted to position R11 on her left side then V15 proceeded to clean buttocks but he did not clean the rectal area and inner buttocks. 2. On 4/05/23 at 11:31 AM, V15 rendered incontinence care to R79 who was wet with urine. R79 also had a stain of fecal matter in the disposable brief. V15 wiped her buttocks, but did not clean the rectal area, applied new brief, then repositioned R79 and proceeded to clean her frontal peri-area while wearing same gloves. V15 wiped R79's outer labia with wet washcloth, however he did not separate the labia to clean the inner folds. On 4/05/23 at 4:05 PM, V2 (Director of Nursing/DON) stated that when staff provide incontinence care, the staff must clean from front to back and must include all the frontal and back peri-area to prevent infection. 16746 3. R12 is a female resident. R12 has multiple diagnoses which includes dementia without behavioral disturbance, neuromuscular dysfunction of bladder and history of UTI (urinary tract infection), based on the face sheet. R12's quarterly MDS (minimum data set) dated January 12, 2023 shows that the resident is severely impaired with cognition and required extensive assistance from the staff with most of her ADLs (activities of daily living) including toilet use and personal hygiene. The same MDS shows that R12 is incontinent of bowel and uses an indwelling urinary catheter. On April 5, 2023 at 12:37 PM, after gathering her needed supplies, V14 (CNA/Certified Nursing Assistance) with the assistance of V4 (Treatment Nurse) provided bowel incontinence care to R12. V14 and V4 positioned R12 on her right side. V4 unfastened R12's disposable brief. R12 had a moderate amount of wet stool. V14 used wash cloth wet with soap and water and cleaned R12's buttocks and anal area. After cleaning R12's back area, while the resident was still on her right side, V14 placed the disposable brief under the resident. Then, V14 and V4 turned and repositioned R12 on her back and fastened the disposable brief without cleaning the resident's front perineal area. R12 had an indwelling urinary catheter in place and catheter care was also not provided. When V14 and V4 were asked why R12's front perineal area was not cleaned and catheter care was not provided since the resident had bowel incontinence. V4 did not respond, while V14 stated that she normally just clean R12's buttocks and anal area after every bowel incontinence and she does not provide any front perineal care and catheter care. R12's active care plan showed that the resident is at risk for incontinence related to neuromuscular dysfunction of bladder. The same care plan showed multiple interventions which includes, Clean peri-area with each incontinence episode. On March 5, 2023 at 12:57 PM, V2 (Director of Nursing) stated that all residents who had bowel incontinence should be cleaned, on the back area for both buttocks and anal area, and including the front perineal area, especially for resident's with indwelling urinary catheter. V2 added that for female resident's the labial fold should be separated and thoroughly cleaned, including the groin and thigh areas to prevent potential infection of the urinary tract and to maintain hygiene. The facility's perineal care policy and procedure dated February 2018 showed, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The same policy and procedure showed in-part that for a female resident, a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. The facility's urinary catheter care policy and procedure revised in September 2014 showed, The purpose of this procedure is to prevent catheter-associated urinary infections. The policy and procedure showed that for a female resident, Use a washcloth with warm water and soap and cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. 4. R55 has multiple diagnoses which includes acute pyelonephritis, type 2 diabetes mellitus and sepsis (unspecified organism), based on the face sheet. R55's admission MDS dated [DATE] shows that the resident is cognitively intact and required limited to extensive assistance from the staff with ADLs. The same MDS shows that the resident is using an indwelling urinary catheter. R55's active order summary report showed an order dated March 20, 2023 for indwelling urinary catheter. On April 3, 2023 at 11:31 AM, R55 was in bed, alert and verbally responsive. R55's urinary drainage bag was hooked on the bedframe of the bed by the foot board area, however the said bag was resting directly on the floor. On April 4, 2023 at 3:12 PM, R55 was in bed, alert and verbally responsive. R55's urinary drainage bag was hooked on the bedframe of the bed by the foot board area, however the said bag was resting directly on the floor. This observation was pointed to V2 (Director of Nursing). V2 stated that the urinary catheter drainage bag should not be touching the floor to prevent urinary infection and to maintain infection control. The facility's urinary catheter care policy and procedure revised in September 2014 showed, The purpose of this procedure is to prevent catheter-associated urinary infections. The same policy and procedure showed under infection control, 2. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review the facility failed to ensure residents were provided adequate supervision during a community outing. The facility also failed to ensure the staff are knowledgeable about residents at risk for elopement and their individualized supervision needs and complete resident risk assessments and re-assessments timely. This failure resulted in Immediate Jeopardy when R1 and R2 eloped from a community outing without being witnessed by facility staff and were found by motorist on a busy highway impeding traffic. This applies to 3 of 7 residents (R1, R2, R3) reviewed for safety and supervision in the sample of 29. The Immediate Jeopardy began on May 19, 2022, at approximately 2:45 PM, when R1, R2 and R3 were left unsupervised to shop on a community outing. R1 and R2 eloped from an outing without being witnessed by facility staff. The Immediate Jeopardy was identified on 5/25/2022 at 1:04 PM. V1 (Administrator), V2 (Director of Nursing) and V19 (Vice President of Operations) were notified of the Immediate Jeopardy on 5/26/2022 at 4:00 PM but non-compliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training of staff on elopement training, activity outings and exit seeking behaviors. Findings include: A computerized web mapping platform documents the distance between the retail store and the farm retail store documents the walking distance as 0.9 miles. 5/26/2022 at 12:11 PM Illinois Route 50 between the retail store and farm retail store did not have a shoulder, sidewalk or crosswalks to safely walk between the stores. On 5/23/2022 at 11:05 AM V9 (Police Officer) stated on 5/19/2022 R1 and R2 were walking on Illinois Route 50 towards farm retail store in [NAME], Illinois; R1 was pushing R2 in a wheelchair after leaving a retail store in [NAME]. V10 (Community Bystander) was driving on Route 50 and saw R1 and R2 walking on the road and stopped to assist them. V9 stated they told V10 they lived in a nursing home and R1 asked V10 to take them to her home providing the address of her previous home. V10 instead dropped both R1 and R2 off at the closest nursing facility who contacted the police where V9 responded. V9 stated the facility was unaware R1 and R2 were missing and had not contacted the police. The [NAME] Police Incident Report dated 5/19/2022 documents the first police department contact was at 4:33 PM. This report documents V10 picked R1 and R2 up walking on Route 50 impeding traffic by the farm retail store. After placing R1 and R2 in her personal car, V10 then dropped R1 and R2 off at the nearest nursing facility which they did not reside at. This report further documents V10 reporting to the dispatcher both R1 and R2 are confused, one had an obvious stroke and they were unsure which facility they resided at. At 5:08 PM facility staff at their nursing facility were en route to pick up R1 and R2. On 5/23/2022 12:50 PM V4 (Activity Director) stated this was the first community outing since Covid (March 2020). V4 stated she and 2 other Activity Aides (V5, V6) left at approximately 2:30-245 PM for a shopping trip to retail store with R1-R7. V4 stated once they arrived at the retail store V4 assisted R5 and R7, V6 assisted R4 and V5 assisted R6 with their shopping. V4 stated R4-R7 needed assistance with shopping due to their physical needs and/or inability to hold their shopping baskets. V4 stated R3 was independent in a scooter and did not need staff supervision or assistance while he shopped. V4 stated R1 was pushing R2 in her wheelchair and they went off to shop unsupervised. V4 stated she thought R1 was oriented, further stating, I guess not so much- not as much as I thought. V4 stated the Activity Department completes resident shopping trips as community outings. V4 stated she or the accompanying activity staff do not stay with all residents while shopping and her normal protocol is to make arrangements with residents who shop unsupervised once they arrive at the store to meet at the front at a designated time. V4 stated only the residents who cannot push themselves in wheelchairs or get their own stuff are supervised. V4 stated R1-R3 were instructed to meet in the front of the store in an hour which was approximately 3:45-4 PM. V4 stated everyone except R1 and R2 were at the front of the store at the designated time. V4 stated V5 and V6 did a sweep through the store and then alerted V1 (Administrator). V4 stated V4-V6 also had a retail store employee complete an overhead page, spoke with security, and alerted a manager. While all this was being completed, V1 notified V4 that R1 and R2 had been found. V4 arrived at the other nursing facility and picked up R1 and R2 and returned them to their correct facility. R1's Admission Record documents R1 admitted on [DATE] with diagnoses to include Alzheimer's Disease, [CONDITION(S)] wit Delusions and Dementia with Behaviors. R1's Petition for Appointment of Guardian of Person and Estate dated 3/5/2021 document R1 as under the guardianship of the Office of State Guardian. On 5/23/2022 at 12:10 PM R1 stated when asked about the trip to retail store on 5/19/2022, As far as I can tell the bus stopped and we went into retail store. I was with that lady, yes (R2). We bought what we wanted and went back to the bus. The bus was there and we got on. Went to, wait, a heavy set girl who was congenial. I was not in my best shape. Somehow we got to farm retail store on the bus and I got into a car. R1 then stated another resident in addition to R2 was with them. R1 provided a first name of an unidentified resident and continued stating the third unidentified resident sat in the front seat of the car. R1 stated, There were 3 of us in the car with the lady. That's what it seems like, but I may be wrong. I walked a little. I was with (R2) in the front seat of the car. I didn't pass anyone on the road that I recall. I was in the car with staff. I went to my house on (provided address of her old house). I was taken by whomever was driving the car. I have a friend a few doors down and she has my car. I don't like it (car) to be sitting outside when I am not home. I drove my car back to my house. I cannot put my finger on how I got here- it is vague. R1's Minimum Data Set, dated dated dated [DATE] documents R1 with moderate cognitive impairments. R1's Elopement Risk assessment dated [DATE], shows R1 was at risk for elopement. R1's elopement risk assessment score was 7.0. The elopement risk assessment tool shows a score greater than 5.0 means the resident is at risk for elopement. R1's Community Skills assessment dated [DATE] documents R1 as not capable of unsupervised pass privileges. R1's Follow-Up Question Report for Behavior Monitoring and Interventions from the EMR (Electronic Medical Record) 4/26-5/25/2022 documents R1 with 3 incidents of exit seeking and elopement behaviors. R1's Psychiatric Physician Note dated 1/26/2022 documents R1 as alert and oriented 2-3 with periods of confusion and this note documents R1 is noted to refuse care and wander halls. On 5/23/2022 at 11:50 AM V7 (Nurse) stated R1 is forgetful, has poor judgement and resides on the alarmed dementia unit. V7 stated R1 does not leave the dementia unit unsupervised. On 5/24/2022 at 10:15 AM V14 (Nursing Assistant) stated R1 wanders and will go to the door and try to leave. V14 stated R1 is a resident that can make you think she is more oriented than she is and that's where mistakes come in. R2's Admission Record documents R2 admitted to the facility on [DATE] with diagnoses to include repeated falls, Diabetes and [CONDITION(S)] and [CONDITION(S)] due to a Stroke. R2 declined all attempts to be interviewed on 5/23-24/2022. On 5/23/2022 at 11:50 AM V7 (Nurse) stated R2 can be quite withdrawn and has right [CONDITION(S)] but can propel herself in the building in her wheelchair. V7 stated R2 cannot transfer herself independently but can stand pivot to transfer with one staff. V7 stated R2 has judgement issues, gets confused and has had some recent hypoglycemic episodes (low blood sugar levels). V7 stated R2 requires staff supervision. R2's Minimum Data Set, dated dated dated [DATE] documents R2 with intact cognition and requiring extensive assist of one staff for transfers and ADL care. R2's Elopement Risk assessment dated [DATE] documents a score of 3/not at risk. R2's Community Skills assessment dated [DATE] documents R2 as not capable of unsupervised pass privileges. 5/25/2022 at 10:40 AM V13 (Social Services) stated assessments for elopement risk and community skills are done every year at minimum. V13 stated there were some problems with the computer program triggering some assessments as due and they were missed. R2's Psychiatric Physician Note dated 4/19/2022 documents R2 as irritable and requiring cueing, withdrawn and difficult to engage during this assessment. R2 is documented as alert and oriented to time and person but forgetful. R2's Care Plan dated 4/1/2022 documents R2 at risk for falls for reasons including right [CONDITION(S)], impulsiveness, impaired safety awareness, impaired balance, forgets limits, and refusing assistance when staff attempt to provide it. On 5/23/2022 at 1:30 PM R3 sat in wheelchair and was interviewable with word finding issues. R3 stated he was on the shopping trip and was allowed to shop by himself using the store scooter. R3 stated he met back at the front of the store but the 2 ladies did not come back and the staff had to go looking for them. R3's Minimum Data Set, dated dated dated [DATE] documents R3 with moderate cognitive impairments. R3's Elopement Risk assessment dated [DATE] documents a score of 2/not at risk. R3's Community Skills assessment dated [DATE] documents R3 as not capable of unsupervised pass privileges. 2. On 5/24/2022 12:00 PM V1 (Administrator) provided lists of residents residing in the facility identified as elopement risks and elopement risk with personal body alarms. V1 identified R9-R14 as at risk for elopement with a personal body alarm and R1 and R15-R28 identified as at risk for elopement requiring no body alarm. On 5/24/2022 at 12:00 PM V1 stated, this was R1's first outing since admission to the facility. V1 stated the process for all outings is all residents are to be supervised and with staff. V1 confirmed R1 is on the alarmed dementia unit because she needs supervision. V1 was unaware of R1 having recent documented exit seeking behaviors. V1 stated the facility process to assess for elopement and supervision needs is done through risk assessments and Interdisciplinary Team (IDT) discussions. V1 stated the facility use the elopement risk assessment to determine if they are at risk in combination with observed and reported behaviors. From there the IDT discusses each resident and individualizes their supervision needs and determines if a wander guard is warranted. V1 stated any resident exhibiting new exit seeking behavior is re-assessed. 5/25/2022 10:40 V13 (Social Services) stated staff communication for individual supervision needs and elopement risk is done through verbal communication and staff can also reference the computerized assessments. V13 also stated the nurses are aware of residents elopement risk and supervision needs. V13 stated she did not know R1 was documented as making attempts to exit seek and if she had been aware she would have re-assessed R1. 5/24/2022 at 3:08 PM V1 stated all staff are trained to supervise residents and should be aware of the residents elopement risk and supervision needs. V1 stated it is V4's responsibility to train her staff in the Activity Department on elopement and supervision policies. 5/25/2022 9:15 AM V4 stated she prepares the list of residents at the facility at risk for elopement and wearing a personal body alarm. V4 stated the nurses inform her of which residents wear a personal body alarm and she places them on the list. V4 stated she is unaware of any other residents at risk for elopement or the facility process to determine who is at risk. The following staff were not able to identify the facility process to assess elopement risk, supervision needs and were not able to identify specific residents who were assessed as an elopement risk (without personal body alarms) as determined by the IDT: 5/25/2022 8:35 AM V7 (Nurse), 8:40 AM V18 (Nursing Assistant), 8:45 AM V16 (Nursing Assistant), 8:50 AM V17 (Nurse), 8:55 AM V8 (Nurse), 9:00 AM V14 (Nursing Assistant) and on 5/24/2022 at 12:35 PM V15 (Nurse). On 5/25/2022 at 1:04 PM V12 (Medical Director) stated R1 and R2 have dementia and poor safety judgement. V12 confirmed R2's blood sugars have not been stable. V12 stated R1 and R2 could have gotten lost and were found walking on a busy road that they had to cross. V12 stated all the residents at the nursing home should be supervised on outings further stating, They were not safe on that road and something could have happened, thankfully nothing did. The facility policy Off-Premise Activities dated 5/2021 documents off-premise activities are monitored for safety. The facility policy Safety and Supervision of Residents dated 7/2017 documents resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety shows 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting process. Individualized, Resident-Centered Approach to Safety shows 2. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for those residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environments, including adequate supervision. 4. Implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff. System Approach to Safety shows 1. The facility-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual's resident's assessed needs and identified hazards in the environment. The immediate Jeopardy that began on began on May 19, 2022, at approximately 2:45 PM was removed on May 31, 2022 at 3:30 PM when the facility took the following actions to remove the immediacy: All facility staff members were educated on elopement and resident safety, activity outings, new exit seeking and high risk behaviors and supervision as of May 31, 2022. The facility completed an audit of all resident records to ensure all residents have an up-to-date elopement risk assessment and community survival assessment on 5/26/2022. Any outdated assessments which were identified outdated during the audit of 5/26/2022 were updated and completed on 5/26/2022.

Based on interview and record review the facility failed to notify the physician of a resident's significant change of condition. This failure resulted in a delay in obtaining hospital treatment, a delay in stabilizing the resident's abnormally high blood pressure and resulted in [MEDICAL CONDITION] and admission to the intensive care unit. This applies to 1 of 3 residents (R1) reviewed for change of condition in the sample of 8. Findings include: On December 8, 2016, at 11:15 AM and 2:05 PM, E3 (RN) stated she was caring for R1 on November 26, 2016 on the day shift. E3 stated that she was new to the facility and not really familiar with R1's baseline. E3 stated that she learned in report that R1, who has some periods of confusion, had become more confused the night prior and had been up all night. R1's physician had been called the prior evening and labs were ordered which had been drawn, and results were pending. That morning, R1 was more difficult to arouse, but she took her morning medication. Her blood pressure was very high; E3 stated she thought it was around 191/76. E3 stated she documented this on R1's [MEDICAL TREATMENT] communication sheet but neglected to document it in R1's record in the computer. According to E3, R1 was groggy, but she put it down to R1 being up all night. E3 stated she did recognize that R1's blood pressure was high, and she went and looked at R1's blood pressure history and noted an occasional high reading at other times. When the transportation ambulance arrived somewhere around 10:30 AM or so, R1 was even less responsive; she would open her eyes to her name being called, but she was not speaking. E3 stated she did not call E2 (DON, Director of Nursing) (it was a Saturday and E2 was not in the building), nor did she call R1's physician; she stated she knew R1 was being transported by ambulance and if anything happened, could be taken to the hospital. E3 had the ambulance crew take her to [MEDICAL TREATMENT]. Facility Weights and Vitals Summary Report for R1 from October 1, 2016 through November 8, 2016 reflects a range of blood pressure readings for R1. The lowest reading was 110/66. There were 3 abnormally high readings, one of 200/88 on October 20, 2016 and one of 198/84 and then 176/88, both on October 11, 2016. Most readings were in the normal range. Nursing note dated November 26, 2016 authored by E3 timed at 1:15 PM as a late entry reads, Resident confused with mild altered mental status. Vitals WNL (within normal limits). Labs ordered, awaiting results. Upon [MEDICAL TREATMENT] transport arrival, resident appearing to have increased altered mental status. A note timed at 12:15 PM documents that R1 was sent out for [MEDICAL TREATMENT] and [MEDICAL TREATMENT] sent R1 to the hospital, where R1 was admitted . At 1:30 PM on 12/8/16, Z3 (Patient Care Manager of [MEDICAL TREATMENT] Unit) stated that when R1 arrived at their [MEDICAL TREATMENT] unit on November 26, 2016 she was unresponsive. Their [MEDICAL TREATMENT] staff did not feel that R1 was stable enough for her treatment and felt that she required evaluation in the hospital. Since the ambulance transport team was only a basic ambulance service, they put R1 in a [MEDICAL TREATMENT] chair and the [MEDICAL TREATMENT] staff called 911. According to Z3, R1's blood pressure on the transfer communication form from the facility was documented as 191/82. Z3 did not know what happened to the [MEDICAL TREATMENT] communication form, but thinks it went to the hospital with R1. On December 8, 2016 at 2:55 PM, Z2 (Dispatch Manager for Ambulance Transport Company) stated she had spoken to her crew regarding the transfer of R1 to the [MEDICAL TREATMENT] center on November 26, 2016. The crew had concerns that the resident did not seem her usual self but the nurse had told them to take R1 to [MEDICAL TREATMENT]. Z2 stated that they provide basic transportation service, and the crew on November 26, 2016 consisted of an EMT (Emergency Medical Technician) and a medic. Non-emergency Transport Form from transport company dated November 26, 2016 documents the following for R1: crew dispatched for a [AGE] year-old female. Upon arrival patient not responding to us. Nurse states she had an [MEDICATION NAME]. We awoke her to have her fall back asleep. Told to bring her to [MEDICAL TREATMENT] anyway, so we monitored her en route. Turn care over to RNs. This form also shows R1's mental status to be no verbal response; R1 was noted to respond to pain. emergency room (ER) Physician Documentation for R1 dated November 26, 2016 documents that R1's Blood Pressure upon arrival was 182/104. ER record notes that R1 was sent for normal [MEDICAL TREATMENT] treatment and found to be unresponsive. Ambulance personnel advised ER staff that upon their arrival at the facility, R1 was unresponsive. R1 was not able to answer questions. She was also noted to be twitching. Upon re-evaluation, R1 was having jerking of her body intermittently and was not verbally responsive. Clinical Impression was Hypertensive [MEDICAL CONDITION] with [MEDICAL CONDITIONS] on [MEDICAL TREATMENT], [MEDICAL CONDITION] and Leukocytosis. R1 received intravenous (IV) [MEDICATION NAME] to control [MEDICAL CONDITION] as well as medication to lower her blood pressure. She was admitted to the intensive care unit. Consultation note of November 27, 2016 documents that R1's highest blood pressure reading thus far had been 242/121. On November 27, 2016, R1 was awake but not making eye contact nor speaking. The jerking movements were lessened, having responded to medication. The facility's Progress note of December 1, 2016 timed at 8:05 PM reflects R1 was readmitted to the facility. R1's Admission face sheet provides numerous diagnoses for R1 including [MEDICAL CONDITION], diabetes, hypertensive kidney disease, [MEDICAL CONDITIONS]; there is no [DIAGNOSES REDACTED]. On December 8, 2016 at 3:20 PM, Z1 (MD for R1) stated he was not contacted on November 26, 2016 regarding R1's elevated blood pressure. Z1 stated that he should have been contacted. Had he been contacted and told that R1 had such a high blood pressure and decreased responsiveness, he would not have sent her to [MEDICAL TREATMENT]. According to Z1, in that situation, he would err on the side of caution and have her evaluated in the hospital first. If the ER felt she was stable enough, she could go to [MEDICAL TREATMENT] later. Z1 stated that if she was alert enough to take oral medication, he may have ordered medication be given at the facility. On December 14, 2016 at 10:40 AM, E2 stated that when R1's blood pressure was very high on November 26, 2016 and she had decreased responsiveness, E3 should have contacted someone; she could have called me (E2), I am always available by phone, or she could have spoken to other staff more familiar with R1. E2 further stated E3 should have contacted R1's physician. Facility policy entitled Functional Impairment-Clinical Protocol was provided by E1 (Administrator) when asked for the facility policy on Change of Condition. This policy states that staff will monitor and discuss the resident's functional progress during therapy and in general; it does not address an acute change in a resident's condition, nor does it instruct nursing staff to notify the physician for a change in medical condition. It does not indicate what constitutes a change in condition. On December 15, 2016 at 12:05 PM, E1 stated that this was their only policy on change of condition and agreed that it did not direct staff to call the physician for a change in medical condition. R1's current MAR (Medication Administration Record) reflects that R1 is now on [MEDICATION NAME] 500 mg daily for [MEDICAL CONDITION]. Prior to this, R1's MAR indicated [REDACTED]. On December 15, 2016 at 12:00 Noon, E2 confirmed that R1 had not had [MEDICAL CONDITION] previously, and had returned from the hospital on [MEDICATION NAME].

Based on interview and record review the facility failed to properly assess and seek immediate emergent care for a resident (R1) experiencing a significant change of condition. This failure resulted in a delay in obtaining hospital treatment, a delay in stabilizing the resident's abnormally high blood pressure and resulted in [MEDICAL CONDITION] and admission to the intensive care unit. This applies to 1 of 3 residents (R1) reviewed for change of condition in the sample of 8. Findings include: On December 8, 2016, at 11:15 AM and 2:05 PM, E3 (RN) stated she was caring for R1 on November 26, 2016 on the day shift. E3 stated that she was new to the facility and not really familiar with R1's baseline. E3 stated that she learned in report that R1, who has some periods of confusion, had become more confused the night prior and had been up all night. R1's physician had been called the prior evening and labs were ordered which had been drawn, and results were pending. That morning, R1 was more difficult to arouse, but she took her morning medication. Her blood pressure was very high; E3 stated she thought it was around 191/76. E3 stated she documented this on R1's [MEDICAL TREATMENT] communication sheet but neglected to document it in R1's record in the computer. According to E3, R1 was groggy, but she put it down to R1 being up all night. E3 stated she did recognize that R1's blood pressure was high, and she went and looked at R1's blood pressure history and noted an occasional high reading at other times. When the transportation ambulance arrived somewhere around 10:30 AM or so, R1 was even less responsive; she would open her eyes to her name being called, but she was not speaking. E3 stated she did not call E2 (DON, Director of Nursing) (it was a Saturday and E2 was not in the building), nor did she call R1's physician; she stated she knew R1 was being transported by ambulance and if anything happened, could be taken to the hospital. E3 had the ambulance crew take her to [MEDICAL TREATMENT]. Facility Weights and Vitals Summary Report for R1 from October 1, 2016 through November 8, 2016 reflects a range of blood pressure readings for R1. The lowest reading was 110/66. There were 3 abnormally high readings, one of 200/88 on October 20, 2016 and one of 198/84 and then 176/88, both on October 11, 2016. Most readings were in the normal range. Nursing note dated November 26, 2016 authored by E3 timed at 1:15 PM as a late entry reads, Resident confused with mild altered mental status. Vitals WNL (within normal limits). Labs ordered, awaiting results. Upon [MEDICAL TREATMENT] transport arrival, resident appearing to have increased altered mental status. A note timed at 12:15 PM documents that R1 was sent out for [MEDICAL TREATMENT] and [MEDICAL TREATMENT] sent R1 to the hospital, where R1 was admitted . At 1:30 PM on 12/8/16, Z3 (Patient Care Manager of [MEDICAL TREATMENT] Unit) stated that when R1 arrived at their [MEDICAL TREATMENT] unit on November 26, 2016 she was unresponsive. Their [MEDICAL TREATMENT] staff did not feel that R1 was stable enough for her treatment and felt that she required evaluation in the hospital. Since the ambulance transport team was only a basic ambulance service, they put R1 in a [MEDICAL TREATMENT] chair and the [MEDICAL TREATMENT] staff called 911. According to Z3, R1's blood pressure on the transfer communication form from the facility was documented as 191/82. Z3 did not know what happened to the [MEDICAL TREATMENT] communication form, but thinks it went to the hospital with R1. On December 8, 2016 at 2:55 PM, Z2 (Dispatch Manager for Ambulance Transport Company) stated she had spoken to her crew regarding the transfer of R1 to the [MEDICAL TREATMENT] center on November 26, 2016. The crew had concerns that the resident did not seem her usual self but the nurse had told them to take R1 to [MEDICAL TREATMENT]. Z2 stated that they provide basic transportation service, and the crew on November 26, 2016 consisted of an EMT (Emergency Medical Technician) and a medic. Non-emergency Transport Form from transport company dated November 26, 2016 documents the following for R1: crew dispatched for a [AGE] year-old female. Upon arrival patient not responding to us. Nurse states she had an [MEDICATION NAME]. We awoke her to have her fall back asleep. Told to bring her to [MEDICAL TREATMENT] anyway, so we monitored her en route. Turn care over to RNs. This form also shows R1's mental status to be no verbal response; R1 was noted to respond to pain. emergency room (ER) Physician Documentation for R1 dated November 26, 2016 documents that R1's Blood Pressure upon arrival was 182/104. ER record notes that R1 was sent for normal [MEDICAL TREATMENT] treatment and found to be unresponsive. Ambulance personnel advised ER staff that upon their arrival at the facility, R1 was unresponsive. R1 was not able to answer questions. She was also noted to be twitching. Upon re-evaluation, R1 was having jerking of her body intermittently and was not verbally responsive. Clinical Impression was Hypertensive [MEDICAL CONDITION] with [MEDICAL CONDITIONS] on [MEDICAL TREATMENT], [MEDICAL CONDITION] and Leukocytosis. R1 received intravenous (IV) [MEDICATION NAME] to control [MEDICAL CONDITION] as well as medication to lower her blood pressure. She was admitted to the intensive care unit. Consultation note of November 27, 2016 documents that R1's highest blood pressure reading thus far had been 242/121. On November 27, 2016, R1 was awake but not making eye contact nor speaking. The jerking movements were lessened, having responded to medication. The facility's Progress note of December 1, 2016 timed at 8:05 PM reflects R1 was readmitted to the facility. R1's Admission face sheet provides numerous diagnoses for R1 including [MEDICAL CONDITION], diabetes, hypertensive kidney disease, [MEDICAL CONDITIONS]; there is no [DIAGNOSES REDACTED]. On December 8, 2016 at 3:20 PM, Z1 (MD for R1) stated he was not contacted on November 26, 2016 regarding R1's elevated blood pressure. Z1 stated that he should have been contacted. Had he been contacted and told that R1 had such a high blood pressure and decreased responsiveness, he would not have sent her to [MEDICAL TREATMENT]. According to Z1, in that situation, he would err on the side of caution and have her evaluated in the hospital first. If the ER felt she was stable enough, she could go to [MEDICAL TREATMENT] later. Z1 stated that if she was alert enough to take oral medication, he may have ordered medication be given at the facility. On December 14, 2016 at 10:40 AM, E2 stated that when R1's blood pressure was very high on November 26, 2016 and she had decreased responsiveness, E3 should have contacted someone; she could have called me (E2), I am always available by phone, or she could have spoken to other staff more familiar with R1. E2 further stated E3 should have contacted R1's physician. Facility policy entitled Functional Impairment-Clinical Protocol was provided by E1 (Administrator) when asked for the facility policy on Change of Condition. This policy states that staff will monitor and discuss the resident's functional progress during therapy and in general; it does not address an acute change in a resident's condition, nor does it instruct nursing staff to notify the physician for a change in medical condition. It does not indicate what constitutes a change in condition. On December 15, 2016 at 12:05 PM, E1 stated that this was their only policy on change of condition and agreed that it did not direct staff to call the physician for a change in medical condition. R1's current MAR (Medication Administration Record) reflects that R1 is now on [MEDICATION NAME] 500 mg daily for [MEDICAL CONDITION]. Prior to this, R1's MAR indicated [REDACTED]. On December 15, 2016 at 12:00 Noon, E2 confirmed that R1 had not had [MEDICAL CONDITION] previously, and had returned from the hospital on [MEDICATION NAME].

Based on observations, interview and record review the facility failed to notify the physician of uncontrolled pain, notify the medical director when the attending physician failed to respoind to pain issues and update and modify the treatment plan for pain. This failure resulted in R1 experiencing uncontrolled pain without interventions. This applies to one of eight residents, R1, reviewed for pain from the sample of 16. The findings include: R1 was admitted to the facility on [DATE] per the admission face sheet. The current physician order [REDACTED]. The clinical record show through nursing and nutritional notes, R1 has had significant weight loss, loss of appetite and increasing pain. The clinical notes showed R1 developed an unavoidable pressure ulcer per the current wound care Physician Z1. On 9/28/115 at 4:45pm R1 was in a low bed. R1 was moaning and turning head back and forth. E5 (Licensed Practical Nurse) was standing over R1 attempting to administer medication. E5 came to the doorway and told E8 (Licensed Practical Nurse) R1 was not taking the medication. E8 told E5, You have to come down to R1's level and use a soft voice. E5 continued to attempt to give the medication to R1. At 5:00pm E5, Licensed Practical Nurse, went into R1's room. E5 stated R1 was getting [MEDICATION NAME] for pain. R1 started moaning and shaking head back and forth. R1's lips were tightly closed. E5 continued to push the spoon through R1's closed lips several times. E5 then offered R1 fluid from a glass with a straw. R1 took only a few sips of the fluid. At 5:10pm E6 Registered Nurse (wound nurse) came in the room to perform wound care on R1. R1 moaned and screamed out loudly throughout positioning and cleansing of the wounds. R1 continued to moan and showed facial grimacing, muscle tension and thrashing of arms throughout the wound care to the three wounds. E6 said R1's physician was not wanting to change pain management orders for R1. E6 said that no other routes had been tried for medications. On 9/29/15 E2 Director of Nursing said that the staff was to call her or the Medical Director if a physician is not returning a call or giving a resident something they need. The current care plan for pain for R1 is not individualized or updated to their current needs. R1's care plan for pain showed an intervention initiated on 4/17/15 to notify the physician if the current [MEDICATION NAME] regime is not effective and if the resident has worsening pain. The clinical record for R1 showed nursing note dated February 19 2015 that R1 had pain for 5 days and R1 described the pain as severe. R1 reported that this pain limits activities and sleep. A note written on 2/24/15 showed that an appointment with the physician was cancelled as no staff was scheduled to go with R1 to the appointment. The nursing notes do not show the physician was notified. The physician order [REDACTED]. Multiple entries by nursing staff on 3/14/15, 3/17/15, 5/21/15, 7/17/15,8/2/15, 8/7/15, 8/8/15, 8/12/15, 8/14/15, 8/16/15, 8/17/158/20/15 and 8/23/15 showing R1 screaming, moaning and crying out in pain. Many of the entries do not show the physician was notified. Some of the notes showed R1's physician would only make a decision of changing pain medicine from [MEDICATION NAME] or [MEDICATION NAME] after seeing the resident in his office. The nursing note dated 8/24/15 showed R1 was evaluated and accepted for palliative care by a community hospice agency. The nursing notes throughout September show many episodes of R1 screaming out complaining of pain and moaning. On 9/14/15 the nursing note showed that an order for [REDACTED]. A clinical note dated 9/8/15 from Hospice Nurse Practitioner recommends the [MEDICATION NAME] should be discontinued due to uncontrolled pain and R1 should be getting [MEDICATION NAME] scheduled and as needed. The note showed R1's physician should be called and notified of these recommendations. There is no documentation in R1's clinical record to show the Physicians notification and or response to this information. The physician order [REDACTED]. The Controlled Substance record showed the medication was not given on a consistent basis compared to the nursing notes showing when R1 had pain. The record showed on 9/28/15 R1 received the medication at 2:30pm and then again at 5:00pm right before the dressing change. The wound care assessments for R1 do not show if R1 had pain before during or after the treatment or if R1 received medication for pain. The Medication Administration Record [REDACTED]. A pain evaluation dated 7/17/15 and 9/10/15 did not show the severity of R1's pain or the ineffectiveness of the current treatments in place for pain. The pain evaluation dated for 9/28/15 at 6:04pm showed it was determined R1's current medications were not effective and a call was made to Z1(Medical Director) for further instruction. On 9/30/15 Z1 came to see R1 and prescribed [MEDICATION NAME] 10 to 20 milligrams every three hours as needed for pain per the wound care progress note. The policy for pain dated 2011 shows the staff are to develop/revise initial or interdisciplinary care plans as applicable, to contact the physician for orders and residents are evaluated daily for evidence of pain, pain evaluation before and after as needed pain medications are given and are to be recorded in the Medication Administration Record.

Based on record reviews and interviews the facility failed to reassess and evaluate one resident in the sample for new pain after an incident. This failure resulted in R1 experiencing unrelieved pain for six hours during transfers after an incident. This applies to one resident (R1) out of a sample of three residents reviewed for incidents. The findings include: Most recent MDS (minimum data set) dated 3/27/14 shows R1 requires extensive, 2 person assist with bed mobility and transfers and extensive, 1 person assist with all other activities of daily living. R1 is non-ambulatory. The final incident report submitted to the department dated 6/24/14 documents that R1 was sent to the hospital emergency roiagnom on [DATE] at 5:00 pm with complaints of right knee and ankle pain and returned at 11:15pm with [DIAGNOSES REDACTED]. This report does not state that the original incident and complaints of pain began around 9:30am on 6/20/14 and the injury was not identified by the facility until over 6 hours later. In the interim, R1 was transferred back to bed and up again to the wheelchair, complaining of pain. The initial report submitted to IDPH on 6/20/14 states R1 complained of pain at an 8 out 10 scale. When asked how R1 sustained fracture to right tibia/fibula, E2, (director of nursing) stated on 6/21/14 at 12:45pm that yesterday, (6/20/14) around 9:30am, E3 (nurse ' s aide) placed R1 ' s right leg on the leg rest but R1 did not want her leg on the leg rest and pulled it off, banging her ankle onto the bar of the bedside table that was placed over her. E2 said both E3 and E4 (nurse) heard R1 say " ow, ow, you snapped my leg. " E2 said that Z1(spouse) came in at 4:00pm and brought R1 to the nursing station, stating that R1 was saying " they cracked my leg. " E3 stated via phone interview on 6/26/14 at 12:10pm that she was R1's nurse's aide the morning of 6/20/14. E3 said that she (E3) placed the gait belt around R1 (sitting on edge of bed) and pivoted R1 into the wheelchair. Once R1 was in the wheelchair, E3 picked up R1's leg to place it on the footrest and R1 yelled "ow, ow, you snapped my leg." E3 stated that R 1 did not want her leg on the foot rest and when she slid it off, the ankle smacked the bar of the over bed table. E3 said she notified E4 that R1 was having pain. E3 went on to add that she did not tell E4 what had happened with the transfer or that R1 ' s leg had hit the table. Facility interview dated 6/21/14, with E3 states that she heard R1 tell Z1 (R1 ' s spouse) over the phone at 10:30am "my leg hurts; it feels like it's snapped." E3 informed E4 that R1 was still complaining of pain at 11:30am. E3 said that she transferred R1 back to bed after lunch between 1:30pm and 2:00pm, still complaining of pain. E4 confirmed on 6/26/14 at 12:40pm that she heard R1 say "ow, ow, you snapped my leg" on 6/20/14 around 9:30am. E4 stated she went in and assessed R1's leg and administered R1 [MEDICATION NAME] 9 (pain medication) at 9:30am. The facility interview with E4 about the incident states E4 also acknowledged that E3 informed her (E4) at 10:30am that R1 was making accusations that E3 broke her (R1) leg. E4 did not document in the nursing notes until 4:32 pm, when the ambulance was on the way to take R1 to ER. In phone interview, E4 stated she had been very busy that day with another resident who was dying. E4 stated that she had assessed R1 around 2:30pm and did not see anything abnormal. According to the facility ' s investigation, E6 ( 3-11pm nurse) stated in the facility interview that on 6/20/14 at about 4:20pm, Z1 brought R1 to her (E6) saying that R1 is complaining of pain to her right leg. E6 ' s statement continues saying that as she started to lift the pant leg up to examine R1, R1 yelled. E6 went on to add that, "could see purple discoloration of the right and outer aspects of her leg below the knee and swelling. The leg alignment was abnormal below the knee. (R1) was not able to move her leg." E4 stated during phone interview on 6/26/14 that R1 ' s complaint of pain throughout the day on 6/20/14 to the right lower leg and knee area was new. E4 stated she had no idea how R1's right leg could have been injured to that extent within a 2 hour timeframe, from 2:30pm to 4:30pm when per E7's (nurse) assessed R1. The facility statement dated 6/20/14 documents that R1's "right leg was rotated and she had very large bruises up her right leg to her knee cap." Interview with Z2 (R1's physician) on 6/26/14 at 11:40am said he could not recall when the facility notified him about R1's complaints of pain. Z1 said that if a known and /or witnessed incident followed by new complaints of pain occurs, staff should assess the resident and watch her closely. Facility's pain policy and procedure states that "whenever possible the underlying cause of pain is identified and addressed through review of relevant medical history (R1 had known history of severe [MEDICAL CONDITION], spinal stenosis, bone/cartilage disorder, pathological fracture of vertebrae) and completion of comprehensive pain evaluation." Facility did not follow this protocol for R1's complaint of new pain on 6/20/14. E2 (Director of Nursing) confirmed on 6/25/14 at 1:40pm that the only documentation regarding this incident was the nurse's note dated 6/20/14 at 4:30pm, when R1 was being sent to ER. There was no evidence that R1 had been assessed after the incident and when the resident experienced new pain symptoms. E5 (R1's nurse's aide on 3-11 pm shift on 6/20/14) stated via phone interview on 6/26/14 at 10:35am that about 4:15pm she heard R1 yelling out from her bed that her leg was hurting. E5 entered R1 ' s room and observed that R1 ' s right leg was very red and swollen from the knee cap down. E5 went on to add that R1 was then transfered into the wheelchair and started to scream, "it hurts. " E5 wheeled R1 to the nurse's station and informed E6 (nurse) that this was a different pain reaction from R1, causing her to scream out in pain and be combative and that R1's leg needs to be assessed. Z1 (family member) stated via phone on 6/26/14 at 11:10am that R1 called and asked him to come to the facility. R1 stated to Z1 " they were transferring me from bed to wheelchair and cracked my leg. " Z1 stated that R1 ' s right leg does not bend and her left leg bends a little. Z1 said that he got to the facility about 4:10pm on 6/20/14 and found R1 sitting in the foyer. Z1 noticed right away that something was wrong with her right leg because it was flopped over. Z1 called the nurse to look at R1's leg and both saw that R1's leg was bruised, swollen and crooked. They told me a portable xray was on the way and I said I wanted her sent to the hospital now because whatever is wrong with her leg, they (facility) wouldn't be able to fix it. Then I was told I should have called the nurse when (R1) told me her leg was cracked when they got her up. They made me feel like it was my fault.

Based on record review and observation the facility failed to provide necessary care and services for: one resident (R16) in the sample of 20 who sustained injury from a fall and complained of severe pain with breathing. Findings include: Medical record review shows R16 was [AGE] years old and admitted to facility on 3/30/10 following a fall at home with resulting right femur fracture. Hospital consultation dated 7/6/10 states R16 "fell at nursing home on 7/1/10 while she was trying to get to the bathroom. She fell on the right side with multiple rib fractures. R16 has severe [MEDICAL CONDITION] with chronic [MEDICAL CONDITION]." Review of incident report and corresponding investigation shows on 7/1/10 at 10:45pm, R16 was found on the floor in her room "wedged between the radiator and chair." Nurses notes dated 7/1/10 at 10:45pm state R16 was found sitting on floor leaning against wall bent over side ways with head against heater. Right head abrasion...assisted to bed, reddened area to mid spine, now complains of pain to right rib area..." The next documented observation at 11:45pm (one hour later) states R16 "now complains of pain with breathing, neb (nebulizer) treatment given." There is no documentation indicating how R16 responded to the breathing treatments or response to care over the next eight hours. The next nursing entry at 8:00am. R16 complains of pain to the side at a 9. X-rays ordered to be done today. Pain medications were given again at this time and one hour later the pain remained at a nine. A breathing treatment was given again. This would constitute a significant change and the physician should have been notified at this point . VS 98.9, 24, 128/68, O2 96. The next nurses note is at 10:30am, 2 1/2 hours later. R16 "lethargic, had a difficult time remaining awake during conversation. complained of right side pain especially with deep breathing. Denies hitting head but on observation (R16) had large bump on left side of head above ear." It is unclear how R16 sustained this bump to the left side of the head as the initial note after the fall only identified the bump on the right side of the head. R16 was sent to the hospital on [DATE], 12 hours after she initially fell . The hospital consultation dated 7/3/10 states R16 has multiple rib fractures and that multiple intercostal blocks to T4-T5, T6-T7, T8-T9, T10-T11 and T12 was performed to assist with decreasing the pain as a result of the rib fractures. E2 (director of nurses) stated on 10/14/11 at 1:40pm she did not know why the nurse on duty did not perform a more comprehensive assessment of R16, considering there were continuous complaints about severe pain with breathing even after medication. E2 stated she (E2) was not employed by the facility at this time. Reviewing the medical record, E2 stated she could find no other evidence of R16 having complaints of severe pain with breathing prior to the fall and that this would have constituted a change in condition. E2 also said there should have been more nursing documentation stating how R16 responded to the breathing treatments and more frequent monitoring and documenting how R16 progressed during the night.

Based on observation, record review and interview the facility failed to: - develop and implement specific and individualized interventions to prevent falls for R4 and R17 who are identified at risk for falling. - ensure the staff had assistive devices including bed alarm and appropriate mattress for R4; and ensure R17's call light was functional and the mattress was appropriate. As a result: - R4 fell on [DATE], 4/30/11 and 5/5/11. On 5/8/11 the X-Ray results indicate she sustained fracture to her right femur. - R17 who was admitted to the facility on [DATE] with status [REDACTED]. This is for two of five residents in the sample of 20 residents (R4 and R17) who were identified to be at risk for falling. Findings include: 1. On 10/11/11 at 12:30 pm R4 was seated in her adult recliner. She was restless. There was no staff in attendance in the dining room. R4 was confused and disoriented, mumbled when asked questions. R4's Nurses Notes noted the following: - 3/24/11 4:30 am found resident on her knees at the side of bed. No scoop mattress on her bed. - 4/30/11 9:00 am resident sitting in adult recliner at table for breakfast, Certified Nurse Aide (CNA) reported R4 stood up and fell on to the bed then on to back and rolled over onto right side. - 5/5/11 8:20 pm R4 was found on floor at the foot of her bed lying on her left side ... she began moaning 'my head.' R4's bed alarm was not sounding. - 5/6/11 10:25 pm R4 complained of pain to right upper thigh, 'it hurts.' - 5/7/11 5:00 am R4 complained of pain to right hip area, has grimacing and stated 'it hurts.' -5/7/11 4:00 pm R4 complained of pain to right knee and right thigh, purplish bruising noted to right inner thigh. At 4:15 pm received order for X-Ray of right hip. - 5/8/11 1:40 pm X-Ray was done at the facility which showed right trochanteric fracture. At 7:15 pm R4 was admitted to the hospital with [REDACTED]. Review of R4's fall incident assessment conducted on the dates of her falling (3/25, 4/30, and 5/5/11) did not indicate why she is at risk for falling or why she is falling. R4 has a care plan developed on 5/25/07 revised on 5/12/11. This care plan has interventions to use scoop mattress, have bed alarm and chair alarm. These interventions were not implemented on 3/24/11 and 5/5/11. E2, the Director of Nurses on 10/13/11 at 11:15 am stated R4's scoop mattress was supposed to prevent R4 from rolling out of the bed, but the scoop mattress was replaced with low air loss mattress because of her risk for the development of pressure sores. The facility did not consider alternatives for scoop mattress. There was no explanation of why R4's bed alarm did not sound when she fell on [DATE]. R4's 5/5/11 incident care plan revision noted, putting resident too early to bed caused the incident and putting R4 to bed later is additional intervention. This intervention was not added to the care plan. 2. R17's closed records indicated he was admitted to the facility on [DATE] with status [REDACTED]. R17's Nurses Notes on 8/3/11 at 3:30 am R17 was sitting on floor in room, his back was leaning on wheel chair, he was next to bed with legs slightly bent. R17 stated he was trying to move from his bed to wheel chair to use the bath room. R17 who was alert and oriented, voiced pain in his right knee, shoulder. His right knee was swollen. R17 was sent to the hospital for evaluation and treatment. At the hospital it was found R17's right shoulder joint (Acromioclavicular Joint) was separated and re-injured (sprained), his replaced right knee. R17's 8/3/11 incident investigation noted R17 stated his mattress contributed to his fall. During the investigation of the incident per staff and resident interview R17's call light did not work and he was yelling for help. The investigation report also mentioned a new mattress was provided, call lights functioning was evaluated, but did not determine why the call light was not functioning. The investigation did not address if R17's chair was locked when he transferred him self from bed to wheel chair and the breaks were functioning properly. The facility had a care plan dated 7/15/11 for R17 at risk for falls due to use of psychotropic medications, status [REDACTED]. The interventions are generalized and none of the interventions addressed the use of proper mattress or use of call light. On 10/13/11 at 11:15 am E2 stated the care plan interventions should have been specific to his transfer functional ability. E2 could not explain why R17's call light was not functioning on 8/3/11 when staff and resident tried the call light.