Every finding on record at Dekalb County Rehab & Nursing

Based on interview and record review, the facility failed to have fall prevention interventions in place for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall and injury which required eight staples to the top of his head. The findings include:R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including dementia, malnutrition, repeated falls, need for assistance with personal care, cognitive communication deficit, unsteadiness on feet, weakness, low back pain, anxiety disorder, and unspecified visual disturbance.R1's Care Plan initiated on April 28, 2026, shows R1 has a VERY HIGH RISK for falls & has impaired safety related to his cognition secondary to Dementia w/ Anxiety, history of repeated falls & some w/ major injury, weakness, impulsiveness, vision/hearing problems & unsteadiness on feet. R1 has an extensive history of falls at home & a prior facility, including fall with a major injury where R1 sustained a broken nose & brain bleed. R1 continuously self-transfers despite education. R1 has bed and chair alarms in place for his safety. R1 has been observed to lean back when he is standing at the toilet to urinate but refuses to sit down or use a urinal. R1 is very impulsive and unsteady, requiring staff's supervision/assistance at all times while transferring or ambulating; please remember to utilize a gait belt for my safety. Use extensive 1 assist during transfers/toileting. Use extensive 1 assist during ambulation using a gait belt, 2 wheeled walker & w/c to follow.R1's Fall Risk assessment dated [DATE], shows R1 has a high risk for falling.The facility's State Report form dated June 1, 2026, shows R1 was assisted to a scale when he lost his balance and fell to his right side. Staff noted a hematoma on the right posterior aspect of R1's head and an abrasion to his left lower lip. R1 was sent out to the local emergency room where staples were placed to his head.The ambulance report dated June 1, 2026, shows, Secondary assessment noted a hematoma on back right side of head with laceration. Goose egg approximately 3 centimeters with bleeding controlled. Patient noted to have a laceration to lower left lip with swelling. No signs of infiltration, bleeding, or swelling noted.R1's local Hospital Records dated June 1, 2026, shows, Laceration to the posterior scalp. Five centimeters were anesthetized with 1% lidocaine with epi irrigated. Explored superficial but will require staples and staples were applied X 10 with good approximation tolerated well.On June 3, 2026, at 9:21 AM, V3 Memory Care Unit Manager said V4 (Certified Nursing Assistant/CNA) was taking R1 out of the unit to get his weight. V3 said another CNA came and got her and said that R1 had fallen. V3 said when she got to R1, he was lying on his right side, and both of his hands were behind his head holding it. V3 said R1 was saying, I'm ok, I'm ok. V3 said R1's left bottom lip was also swollen. V3 said there was a small amount of blood, but that the blood had stopped before the ambulance came. V3 said that R1 received staples to his head. V3 said that R1 is back to his baseline. V3 said prior to R1's fall, R1 was transferred with one staff assist, a wheeled walker, and a gait belt. V3 said that V4 did not have a gait belt on R1 but should have. V3 said V4 told her that she was getting R1 off the scale when someone called V4's name and V4 turned her head and that's when R1 fell.On June 3, 2026, at 9:50 AM, V4 CNA said R1 was holding onto the scale when she heard someone call her name and she turned to look at who it was. V4 said that R1's walker was on his left side. V4 said then R1 fell while he was reaching for his walker. V4 said R1 landed on his right side. V4 said there was a small amount of blood. V4 said that R1 was trying to get off of the scale when he fell. V4 said R1 did not have a gait belt on him. V4 said that she was not holding R1 when he fell.On June 3, 2026, at 10:05 am, R1 was laying in his bed on his right side. There were multiple staples to the backside of R1's left side of his head. There was a lemon sized purple area noted to the left side of his chin and lip.June 4, 2026, 11:04 AM V7 Nurse Practitioner said R1 had a fall and hit his head. V7 said she was already in the facility, so she went and assessed R1. R1 had a hematoma to the back of his right head with a small open area with a small amount of blood. V7 said the bleeding was controlled. V7 said R1 had a swollen lip. R1 was sent out due to R1 being on a blood thinner. V7 said the hematoma was about the size of a large marble, but she would not have anticipated R1 coming back to the facility with staples in his head. V7 said R1 received eight staples, not ten. V7 said sometimes hematomas will be to be cut out if they feel like the area need to be investigated or debrided.On June 3, 2026, at 10:13 AM, V5 Restorative CNA said gait belts should be on residents when they are transferring. V5 said all residents should have gait belts on unless they are transferred with a lift or are independent. V5 said gait belts are used so that staff have something to hold onto so staff is not holding onto the residents' limbs or clothing. Transfers are safer when gait belts are used, and it can help prevent a fall or lessen the impact when residents fall. V5 also said that staff should be always holding onto the residents when they are transferring so that if they do fall, the staff can catch them or lower them to the floor.The facility's Transfer/Gait Belts policy reviewed January 2024 shows, Gait belts/transfer belts are to be properly used in the transfer and ambulation of any resident needing assistance with these activities.

Based on observation, interview, and record review the facility failed to complete the cooling process for a turkey roast. This applies to all residents in the facility. The findings include: The Center for Medicare and Medicaid form 671 dated 4/1/25 shows there are 109 residents in the facility. On 4/1/2025 at 10:20 AM, V6 Dietary Manager said a turkey roast was being cooked today to serve tomorrow. V6 said a cooling log would be completed for this. When asked for a copy of the cooling log, V6 could not find the cooling binder in the kitchen and went into her office and returned with a copy of a blank cool down label sticker sheet. At 1:00PM on 4/1/25 the turkey roast was observed in the refrigerator covered with foil and dated 4/1/25. V6 pulled the roast from the refrigerator and checked its temperature and at 1:15 PM ( 2 1/2 hours after removed from the oven) the temperature was 100 degrees Fahrenheit (F). V6 was not sure what time the roast was placed in the refrigerator to cool and was not aware of who even cooked the roast. V6 had to go ask several staff members before she found out it was V8 [NAME] who had baked the roast. V6 said no cooling logs were started for the turkey roast. On 4/1/25 at 1:30 PM, V8 said she cooked the roast that morning and when the temperature reached 165 degrees F, she pulled it from the oven at 10:45 AM. V8 said she cut the roast up into several pieces, labeled it with the date and placed in the refrigerator. V8 said she did not know when she was to check the temperature again and where to document the time and temperature of the roast, she would have to ask her supervisor. On 4/1/25 at 1:35 PM, V7 Assistant Dietary Manager said, that is not our policy, a sticker should be put on the food being cooled when it is first stored in the refrigerator. The roast should have been at 70 degrees F by the 2-hour mark, I'll have to go get a new turkey roast now. On 4/2/25 at 9:30 AM V6 said she had to throw away the turkey roast cooked yesterday due to proper cooling not taking place. On 4/02/25 at 9:40 AM, V6 Dietary Manager and V7 said they have begun training the staff on cooling foods. A new binder has been made for the cooling logs. V6 said it's important to monitor the cooling of food to prevent food [NAME] illnesses. The undated policy for cool down/leftovers provided by the facility shows all cooked items that will be utilized for service at a later time must have a cool down label and be recorded in the cool down log in the cool down binder. Temperature logging must include the date the food was made, the food item, temperature at the time when out of the oven, temperature at 2 hours, and temperature at 4 hours. The total cool down process should take no longer that 6 hours. Stage one cool foods from 135 degrees F to 70 degrees F within 2 hours, stage 2 cool foods from 70 degrees F to 41 degrees F within 4 hours.

Based on observation, interview, and record review, the facility failed to perform hand hygiene during lunch service and failed to follow its hand hygiene policy and procedure. This deficiency affected all 37 residents reviewed for infection control currently residing in the memory care unit and has the potential to affect all 109 residents currently residing in the facility. Findings include: On 04/01/2025, upon entering the facility, surveyors were provided with a resident daily census dated 04/01/2025 that documented 37 residents in the CVS (country view square) memory care unit. Centers for Medicare and Medicaid Services form 671 dated 04/01/2025 documented 109 residents currently residing at the facility. On 04/01/2025 at 12:30 PM, during lunch service, V11 (Activities) was walking throughout the larger dining room/activity room on this unit, going table to table and removing dirty plates, cups, and silverware from resident dining tables. V11 also removed several soiled clothing protectors from the tables that she was holding close to her body and were touching her clothes. V11 (Activities) was observed interacting with residents in this unit's dining room and in the smaller dining room that is behind and to the left of this larger dining room. V11 was encouraging many residents to either eat more of their lunch or drink more fluids then moved the resident's dinnerware around with her hands then would place a different item within the resident's reach. V11 continued to remove dirty dishes and clothing protectors from table to table and was not observed performing hand hygiene at any time between tables. On 04/01/2025 at 12:37 PM, V11 (Activities) coughed into her closed hand in the larger unit dining room then proceeded to move from table to table, clearing plates or moving food items within resident's reach. At 12:46 PM,V11 (Activities) checked her hands and appeared to be looking for something on her hands then proceeded to wipe her hands on a used clothing protector. V11 then continued to remove dirty dishes and clothing protectors from table to table and encouraged several residents to continue eating by moving resident's dinnerware within their reach. V11 (Activities) was not observed performing hand hygiene at any time during this observation period. On 04/01/2025 at 1:07 PM, V11 (Activities) said this was her third day at facility and added that infection control policy and procedures were covered during her orientation training. V11 then said she should have performed hand hygiene after coughing into her hand and when clearing dirty dishes from table to table prior to handling any other resident's food of food or cup. On 04/01/2025 at 09:17 AM, V4 (Infection Preventionist) said staff should perform hand hygiene after touching their hair, face, etc., and especially after coughing into their hand or blowing their nose. V4 added that staff should perform hand hygiene between residents, and if using hand sanitizer, staff should wash their hands with soap and water after using sanitizer three times and/or if their hands are visibly soiled. Hand hygiene procedure for all staff reads in part: Purpose: to prevent the spread of disease organisms form one resident to another, and to safeguard the health of all employees. Gloves provide additional protection from microorganisms but do not eliminate the need for hand hygiene before and after the use of gloves. In the absence of a true emergency, personnel should always wash their hands or use alcohol-based hand sanitizer when coming on duty .before and after contact with a source that is likely to be contaminated with secretions/excretions from residents, such as procedures involving the mouth and face-oral care, feeding .before and after eating, after handling soiled [tissue], after going to the bathroom, after blowing or wiping one's nose .In addition to hand washing, alcohol-based hand sanitizer may be used to disinfect hands .Regular handwashing should still be utilized when hands are visibly soiled and after every 3 uses of hand sanitizer .when serving meals, hand sanitizer is to be used between each resident served.

Based on the interview and record review, the facility failed to ensure the Safety of a resident while pushing their wheelchair for one of 6 residents (R40) reviewed for Safety in the sample of 24. The findings include: R40's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include paroxysmal atrial fibrillation, lymphedema, bilateral primary osteoarthritis of bilateral knees, polyneuropathy, and age-related osteoporosis. R40's facility assessment dated [DATE] showed she has no cognitive impairment. On 4/02/25 at 9:18 AM, R40 said she was recuperating from a fall. R40 said, I was negligent in some ways, and so were they. The girl got fired because of it. We have a rule about footrests. If you don't have foot pedals on, they are not allowed to push you . I was coming back to my room after an activity, I was maneuvering myself. The activity gal said, 'Let me give you a push' . It was a rush, rush, rush because they had to punch out before 4:30, so they didn't have overtime. She started to push me, and she was going a little fast; I said, 'Whoa, whoa?' As we turned to come out of the dining room, I must have put my feet down. I felt like I was shot out of a cannon. I fell and fell on my knees first, then my hands went out. They all came running . R40's Health Status Note dated 3/18/25 showed, 4:05 PM, called to nursing station/north hallway and noted resident with hands and knees on the floor, wheelchair behind her. The incident was witnessed by staff. The resident was sitting in a wheelchair with her hands full of belongings and went forward. On 4/03/25 at 10:46 AM, V20 LPN (Licensed Practical Nurse) said she didn't witness the incident. I was coming out of a room with a resident when they called for help. All I saw was where she was when I came out of the room. I was told that she was being pushed in her wheelchair, and when she came around the corner, she came out of her chair. She had mentioned to the person pushing her that her chair was acting funny. There were no foot pedals on her wheelchair. I think it was just unfortunately that someone thought they were being nice to help her . she had no injuries . R40's care plan initiated on 10/21/21 showed, I am at risk for falls related to impaired mobility . Intervention 3/18/25: Staff education is needed to utilize leg rests at all times when transporting residents related to falls . On 4/03/25 at 10:53 AM, V17 (Restorative Nurse) said she did the fall investigations. V17 said, Safety was the determining factor to [R40's] fall. The employee who was assisting the resident went back to her room. Apparently, she had items in her arms, and she asked the activity aide to transport her. She didn't follow our policy and didn't put the foot pedals on the chair prior to assisting her. [R40] put her feet down and fell forward out of the chair. No injuries . On 4/03/25 at 11:34 AM, V2 DON (Director of Nursing) said the expectation is that if they are not able to propel themselves, we want foot pedals on the wheelchair vs. expecting them to hold their feet up. It is our expectation that they would have used the leg rests for Safety. The facility's Safety Policy, revised in March 2025, stated, [The facility] and its staff recognize the importance of ensuring each resident's Safety while they reside at the Nursing Home. The following identified various types of security measures the Nursing Home has to ensure this Safety: 13. Leg Rests: Encourage residents who are able to propel themselves to allow staff to place leg rests on wheelchairs for transportation/safety needs.

Based on observation, interview, and record review, the facility failed to ensure that an indwelling catheter tube remained off the floor for one of two residents (R18) reviewed for catheters in the sample of 24. The findings include: R18's face sheet printed on 4/3/25 showed diagnoses including but not limited to left-side hemiparesis following a stroke, below-the-knee amputation, peripheral vascular disease, aphasia (difficulty talking), and neuromuscular dysfunction of the bladder. R18's facility assessment dated [DATE] showed no cognitive impairment and the use of a urinary catheter. The same evaluation showed no behaviors. R18's April 2025 physician order report showed an order starting on 3/30/25 for 750 milligrams of Levofloxacin (an antibiotic) daily to treat pneumonia and a urinary tract infection for seven days. On 4/1/25 at 12:24 PM, R18 was in her wheelchair while seated at the lunch table in the group dining room. R18's catheter tubing was fully resting on the floor during the entire meal. The tablemate's milk cup was inadvertently knocked over and spilled onto the floor and the tubing during the meal. Staff cleaned up the milk spill while the tubing remained in place on the floor. On 4/3/25 at 10:34 AM, V3 (Assistant Director of Nurses) stated that catheter tubing needs to always stay off the floor. There is the potential for germs to cross contaminate the tubing and cause infections. Staff should be checking placement daily and frequently throughout the day. V3 said R18 has a behavior of pulling on the tubing by herself. However, it was noted that this behavior is not care planned and no interventions have been initiated, highlighting a significant gap in our care planning and execution. R18's care plan showed a focus area related to the use of the indwelling urinary catheter revision dated 4/3/25 (during the survey). Interventions included do not allow tubing or any part of the drainage system to touch the floor. This revision underscores the need for continuous improvement and vigilance in our care planning and execution. The same care plan showed a focus area related to the history of past urinary tract infections. The facility's undated Catheter Care policy states: Please remember that the bladder is ordinarily a sterile environment. Therefore, the introduction of any microorganisms will immediately start a chain of events resulting in a bladder infection.

Based on observations, interview, and record review, the facility failed to ensure accurate monthly weights were obtained for 1 of 3 residents (R51); and failed to document accurate meal intakes and/or offer alternative meal options for 1 (R83) reviewed for nutrition in the sample of 24. Findings include: 1. R51's face sheet indicated resident admitted to facility on 10/07/2022 and has a past medical history not limited to: dementia, cognitive communication deficit, dysphagia (oral phase), anxiety, and need for assistance with personal care. R51's minimum data set section K dated 01/01/2025 documented weight loss of more than 5% or more in the last month or loss of 10% or more in the last 6 months. R51's active orders as of 04/03/2025 showed the following: 120 cubic centimeters (cc) of [high calorie nutrition] two times a day for weight loss and monthly weight monitoring. R51's care plan last revised on 04/03/2025 documented: lives on CVS unit; have maintained my weight last 3 months, current weight is 116 pounds; on comfort care with no hospitalization s; nutritional problem or potential for nutritional problems related to poor intakes and resistance for assistance at times with meals/intakes. On 04/02/2025 at 03:32 PM, R51's weight summary that documented a weight of 127.5 lbs. (pounds) on 12/01/2024 at 09:39 AM with wheelchair; 111.0 lbs. on 01/01/2025 at 12:06 PM while sitting; 116.0 lbs. on 01/02/2025 at 13:13 (12:13 PM) with wheelchair; 128.0 lbs. on 02/02/2025 at 14:44 (02:44 PM) with mechanical lift; and 116.0 lbs. on 03/04/2025 at 15:04 (03:04 PM) with wheelchair. No April weight was documented at this time. On 04/02/2025 at 02:35 PM, V2 (Director of Nursing) said when there is a discrepancy with a resident's monthly weight, they are reweighed. V2 then said she needed to follow-up with V5 (Dementia Unit Coordinator) regarding the weight discrepancies for R51 because she monitors weights on that unit. On 04/03/2025 at 08:26 AM, review of R51's weight summary showed previous weight of 128.0 lbs. on 02/02/2025 was now struck out on 04/02/2025 at 4:31PM with a new weight of 118.0 lbs. documented on same date at 07:31. The Summary also documented a weight of 117.3 lbs. on 04/02/2025 at 08:25. On 04/03/2025 at 10:40 AM, V5 (Dementia Unit Coordinator) said R51's normal weight range is from 110 to 116 lbs. and her appetite is normally between 25-50% for most meals. V5 then said there was a weight discrepancy with R51's weight on 01/2025 with weight of 137.5 obtained. V5 added that after R51 was reweighed twice, and the last weight obtained was 128 lbs. V5 (Dementia Unit Coordinator) then said the weight of 128 lbs. obtained on 02/02/205 was likely an error because R51 had no signs of weight gain or edema, and her lungs were clear. V5 said she communicated these findings to R51's physician on 02/02/2025 with no new orders or concerns. V5 (Dementia Unit Coordinator) added that residents should be weighed with the same type as previous month, either wheelchair, standing, or with a mechanical lift and any residents with a discrepancy of 5 lbs., increase or decrease, should be reweighed. At 10:51 AM, V5 (Dementia Unit Coordinator) said after monthly weights are completed for the unit, she reviews the weights and if she finds any discrepancies, she requests a reweigh for that resident. V5 then said, we are getting 2 new scales. The facility Weight Protocol last revised 03/2021 documented it is the policy of the [NAME] County Rehab and Nursing Center to take and record the resident's weights at the following times: upon admission; monthly record on vital sign record; additional resident weights may be taken if resident's condition warrants; if unable to weight a resident per protocol, supportive documentation must be made in the resident's record; nutritional status including resident's weight is reviewed by Food Service Director. Upon admission, monthly, at resident's care plan session and more frequently if resident's weight status warrants; resident physician will be notified if resident has a 5% or greater weight gain or loss in a 30 day period, or 7.5% weight gain/loss during previous three months and 10% weight gain/loss during the previous six months. This notification will be recorded; upon admission, establish usual body weight from the social medical history form .If no information is available dietary will take the residents weight for the past year and average for the usual body weight; weekly weights for 1 month for any resident on food and fluid intake study. The facility Weight Change policy revised 03/2021 documented: nursing to weigh residents monthly; reports weights to dietary manager; weights will be entered into prime program; list of resident weights will be produced given to nursing management; weights will then be monitored by the RD, Dietary Manager, Nursing Management for any significant weight losses, gains, trends; RD and/or Dietary Manger will chart on resident's condition and make recommendations as deemed necessary. 41639 2) R83's electronic face sheet printed on 4/3/25 showed R83 has diagnoses including but not limited to displaced fracture of right femur, displaced fracture of right humerus, osteoporosis, and dementia with behaviors. R83's facility assessment dated [DATE] showed R83 has severe cognitive impairment. R83's most recent dietary assessment dated [DATE] showed Thin BMI(body mass index) = 17. Intakes fair to good at meals. Follow intakes and weights . On 4/1/25 at 12:18PM, R83 received her lunch tray. At 12:37PM, V11 (Activity aide) pushed R83's plate in front of her and stated, Here's your food you should eat. R83 stated she did not want the meal on her plate and V11 walked away. R83 was then given a health shake to drink and was not offered any additional meal options. R83 ate less than 25% of her lunch meal. R83's meal intake documentation dated 4/1/25 showed R83 consumed 51-75% of her lunch meal. On 4/2/25 at 8:51AM, R83 had a bowl of berries and hot cereal in front of her for her breakfast meal. R83 ate 2 bites of her oatmeal and none of her berries. R83 ate less than 25% of her breakfast meal. R83's meal tray was removed by dietary staff and no alternative meal options were offered. R83's meal intake documentation dated 4/2/25 showed R83 consumed 76-100% of her breakfast. On 4/2/25 at 12:06PM, R83's lunch tray was served and consisted of turkey, stuffing, green bean casserole, cranberries, and pumpkin pie. R83 fed herself bread, 4 bites of turkey, and the whipped cream off her pumpkin pie. At 1:02PM, V15 (Certified Nursing Assistant-CNA) removed R83's lunch tray and stated, I'm going to take your tray since you're not eating it. V15 did not offer R83 any alternative meal options. R83 ate less than 25% of her lunch meal. R83's meal intake documentation dated 4/2/25 showed R83 consumed 26-50% of her lunch meal. On 4/2/25 at 2:14PM, V14 (CNA) stated, On this unit we offer a shake, ice cream, or cottage cheese if a resident is not eating their meal. I think there are other things but I'm not sure what they are. I did not feed (R83) this morning so I'm not sure how much she ate. I did document that she ate 76-100% but I'm not sure who told me that's how much she ate. The dietary staff and activity staff help clear the trays so if they don't tell me how much someone eats, we just talk amongst ourselves while we are charting to figure out who ate what. I guess I shouldn't be documenting the intakes if I didn't personally observe the resident's tray. On 4/3/25 at 10:00AM, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated, Dietary & CNA's document the meal intakes. If the CNA is feeding the resident or has the direct observation of the intake, then they can document it. It is important to document the correct amount to get an accurate picture of their intakes. Alternatives that we offer are ice cream, cottage cheese, health shakes, or the alternative menu options. There are plenty of things we can get for them, but I don't know if (R83) would accept any of them. We should ask residents though if they aren't eating if they want something else. I don't know how important it is to document meal intakes, the weights are a better indicator of their nutritional status. The facility's policy titled, Documentation of Oral Intake dated 03/2021 showed, Purpose: To document oral intake of meals and supplements and to determine the adequacy of residents caloric and nutrient intake .3. The amount of food consumed for entire tray contents will be documented as: 25%=1/4 food taken 50%= 1/2 food taken 75%= 3/4 food taken 100%= all food taken .5. Intake record reviewed by registered dietician, dietary manager and/or nursing quarterly prior to care plan conference, and more frequently depending on resident's status .

Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R32) reviewed for oxygen in the sample of 24. The findings include: R32's face sheet printed on 4/3/25 showed diagnoses including but not limited to Parkinsonism, hypertension, dementia, and depression. R32's facility assessment dated [DATE] showed staff assistance needed for all ADLs (activities of daily living). R32's April 2025 physician order summary report showed an order start dated 3/22/24 for oxygen to be administered at 1 liter per minute via nasal cannula to maintain oxygen saturation levels at greater than 90%. The order stated PLEASE WEAN AS TOLERATED every shift for hypoxia. On 4/1/25 at 11:01 AM, R32 was in bed and asleep. R32 was wearing her oxygen and the meter showed it was being administered at a rate of 3 liters per minute. At 12:40 PM, R32 was in bed asleep and the oxygen was still running at a rate of 3 liters. On 4/2/25 at 9:51 AM, R32 was in bed and the oxygen was being administered at a rate of 2 liters per minute. At 12:40 PM, the oxygen was still running at a rate of 2 liters. V12 (Certified Nurse Aide) confirmed the rate as 2 liters. V12 said the nurses are responsible for checking the levels and ensuring it is running at the correct rate. On 4/3/25 at 9:00 AM, V13 (Registered Nurse) observed R32's oxygen setting and confirmed it was being administered at a rate of 2 liters per minute. V13 stated the order is for only one liter per minute. V13 said the rate should be set as ordered. If the setting is too high, it can cause carbon dioxide to build up. If the setting is too low, residents are not getting enough oxygen. V13 stated the setting should be checked at every medication pass and during resident care. On 4/3/25 at 9:39 AM, V2 (Director of Nurses) stated oxygen should be administered as ordered by the physician. Nurses should be checking the levels frequently throughout their shifts when rounding. Being given too high or even too low has the potential to cause health problems. Incorrect rates are going against doctor orders and that is wrong. Errors in the administration rate should be found and corrected right away. R32's care plan showed a focus area related to respiratory. Interventions included give oxygen via nasal cannula at 1-2 liters per minute continuously to maintain oxygen saturation levels greater than 92%. (Not the same as parameters as on order.) The facility's Administration of Oxygen policy revision dated 5/15 states under the procedure section: Obtain specific order for the number of liters.

Based on observation, interview, and record review the facility failed to ensure occupational services were provided for 1 of 1 resident (R39) reviewed for therapy services in the sample of 24. The findings include: R39's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, congestive heart failure, Chronic Obstructive Pulmonary Disease, chronic respiratory failure with hypoxia, emphysema, obstructive sleep apnea, hypertension, chronic kidney disease, hypothyroidism, hyperlipidemia, osteoarthritis left hand, and trigger finger. R39's facility assessment dated [DATE] showed she had moderate cognitive impairment and has upper extremity impairment in range of motion. R1's Progress Notes from her 3/12/25 Orthopaedic Surgery visit showed, . Referral to Specialty: Occupational Therapy . On 4/02/25 at 9:50 AM, R39 said, I'm supposed to start therapy for my hand. I had a lump that was removed and now for some reason these two fingers and my thumb feel like they are asleep. I don't know when I am going to start that, they haven't come to me about it yet. R39's 3/27/25 Care Conference Note showed, . follow-up with [physician] where she received cortisone injection to left thumb r/t pain, MRI on 3/3/25 of hand and second cortisone injection on 3/12/25 in addition to new orders for OT and to follow-up again in 6 weeks . R39's Care Plan initiated 6/19/23 and revised 3/9/25 showed, I I have arthritis of the left hand. I was admitted with a left-hand trigger thumb. I had surgical procedure performed on 3-8-24 per [physician] for Left Thumb Trigger Finger Release . Intervention: 3/12/25: OT referral, Follow Up with [physician] in 6 weeks, Received cortisone injection to thumb in office . On 4/3/25 at 10:00 AM, V18 (Therapy Area Manager) said R39 has not been seen by the therapy department since 5/31/24 and there have been no recent evaluations. V18 said the order for scar management would be so the scar tissue does not adhere and to get better range of motion. On 4/03/25 at 10:03 AM, V19 (Program Manager/Physical Therapy Assistant) said when an order is received for therapy services they are usually able to get the resident evaluated in 2-3 days depending on how long it takes to hear from insurance and authorize the therapy services. V19 said the therapy department did not receive the order dated 3/12/25 for therapy services for R39. V19 said he thinks the order he received for R39's therapy services was received Friday of last week (March 28). V19 said he finds out about new orders for therapy from V17 (Restorative Nurse) on a weekly basis. On 4/03/25 at 11:04 AM, V17 (Restorative Nurse) said R39 is not on any restorative programs such as range of motion, because she has refused programs in the past. V17 said she could not find documentation of R39's refusals for restorative programming. V17 said, . Our therapy company is informed of new orders as we get them. I would have to double check with them if they have done an evaluation yet or not. I'm not sure how he looks it up but usually he knows the orders before I put them out there for him. He would have been able to see them before 3/28/25. I type in a list for him for people to be reviewed or screened for therapy and [R39] was on the list. I update the list daily as I get the orders . I see the OT referral . I don't know how long it takes to get on therapy . The facility's undated policy and procedure showed, Physician Orders . If therapy (Physical Therapy, Occupational Therapy, Speech Therapy, Respiratory Therapy) ordered: Call Rehab nurse at [extension] leave a voicemail if after hours .

Based on observation, interview and record review the facility failed to ensure a resident (R2) was transferred safely and in a manner to prevent a resident fall. The facility failed to ensure care-planned, fall interventions were in place for a resident (R2) with a recent fall. The facility failed to ensure a resident (R3) was supervised while being toileted which contributed to a resident fall. These failures apply to 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 3. The findings include: 1. R2's Incident Note dated 12/25/24 showed, CNA (certified nursing assistant) notified me that resident had fallen while being transferred from wheelchair to sit stand (stand mechanical lift). CNA's said resident seem very nervous and anxious and would not stay still. When I arrived to resident room, I saw him on the floor on his side shaking and nervous . Resident is nonverbal so I couldn't ask if he was in pain . During assessment, I noticed resident has long red abrasion on the middle of his back . R2 remained in the facility post-fall and was monitored by facility staff. R2's care plan dated 10/22/24 showed R2 was severely cognitively impaired related to his diagnosis of Alzheimer's disease. The care plan showed R2 did not understand content of task and environment. I don't verbally respond. The plan showed R2 had a communication problem related to me not fully understanding contents of conversation. R2 was at high risk for falls due to his impaired cognition, poor safety awareness, and overestimating his physical abilities. The plan showed, I like to stand up from my wheelchair without staff assistance. R2's fall interventions included R2 was to have a bed or chair alarm in place at all times. R2 required a sit-to stand lift for all transfers. On 1/7/25 at 11:13 AM, R2 was seated in a wheelchair in his room with no staff present. R2 was observed repositioning his bottom forward in his wheelchair and attempted to stand but was unsuccessful. A chair/pad alarm was in place on the seat of R2's wheelchair, however the cord that connected the alarm box to R2's chair/pad was disconnected. The alarm box was turned off and not functioning. This surveyor attempted converse with R2 but got no verbal response from him. On 1/7/25 at 11:41 AM, R2 remained seated in a wheelchair in his room with no staff present. The alarm box remained disconnected from R2's chair/pad alarm. The alarm box was still turned off. On 1/7/25 at 11:17 AM, V4 Licensed Practical Nurse stated R2 used to try and get up on his own so he has bed and chair alarms in place as fall interventions. On 1/7/25 at 10:48 AM, V8 Certified Nursing Assistant (CNA) stated she and V9 CNA were present when R2 fell on [DATE]. V8 CNA stated, (R2) was in the hall, trying to take his clothes off so we wheeled him into his room to put him into bed. He was anxious. He is always confused. He can't follow directions. He is nonverbal. We positioned the sit-to-stand in front of (R2) while he was seated in the wheelchair. He held onto the stand and was rocking back and forth. He kept shaking the stand with his hands. We didn't even get him strapped into the stand when he pulled himself forward out of the wheelchair onto the floor . On 1/7/25 at 11:30 AM, V3 Assistant Director of Nursing (ADON) stated R2 had a history of scooting forward in his wheelchair. V3 stated, (R2) is hard to redirect due to his cognition. If (R2) was holding onto the stand (sit-to-stand) and sliding forward in his wheelchair, they (V8 and V9 CNA's) should have stopped the transfer. The facility's sit-to-stand lift operator's instruction manual dated 10/24/24 showed patients should be able to bear some weight, have upper body strength and be able to follow simple commands to safely be transferred via a sit-to-stand lift. The manual showed if a patient does not meet each of these three criteria, a total body lift (hoyer mechanical lift) must be used. 2. R3's Incident Note dated 12/9/24 showed R3 was transferred to the toilet by V10 CNA. While on the toilet, R3 asked V10 CNA to get her a tissue for her nose. V10 CNA left R3 alone on the toilet as she walked out of R3's bathroom to retrieve a tissue for R3. The note showed when V10 CNA walked back into R3's bathroom, R3 was lying on the bathroom floor as she had fallen forward off the toilet. R3 was sent to a local hospital for an evaluation on 12/9/24. R3 returned to the facility on [DATE] with no diagnosed injuries as a result of the fall. R3's care plan dated 9/19/24 showed R3 was at high risk of falls due to her impaired mobility related to her diagnosis of CVA (stroke). The plan showed, I have poor safety awareness and lack functional limitations/judgement. I overestimate my physical capabilities. I have a tendency to not utilize my call-light for assistance and attempt self-transfers. I am impulsive and impatient . I frequently refuse the gait belt during transfers and require education on safety . On 1/7/25, three attempts to contact V10 CNA via phone for an interview were unsuccessful. On 1/7/25 at 10:40 AM, V7 Registered Nurse (RN) stated she was the nurse assigned to R3 on 12/9/24. V7 stated, (V10 CNA) came and got me because (R3) had fallen off the toilet. I walked into the bathroom and found (R3) on the floor. (V10) stated she had left (R3) alone on the toilet to go get her a tissue for her nose. When (V10) came back, (R3) was on the floor. I don't know why she didn't just give (R3) toilet paper to blow her nose . V7 stated any resident that is high risk for falls should be supervised when toileted. On 1/7/25 at 11:23 AM, V11 RN stated any resident that is impulsive, has poor safety awareness and has a history of self-transferring should be supervised by staff when toileted.

Based on observation, interview, and record review, the facility failed to handle and store three bulk bin scoops in a sanitary manner. This has the potential to effect all residents in the facility. The findings include: The CMS 671, dated 3/3/24, shows there are 105 residents residing in the facility. On 3/3/24 at 09:13 AM, the bulk bin of white rice in the dry storage room had a scoop inside the bin, lying on top of the white rice. On 3/3/24 at 11:21 AM, a bulk container of brown sugar outside of the Oak dining room kitchenette had a purple handle ice cream scoop inside the container, lying on top of the brown sugar. On 3/4/24 at 10:17 AM, the bulk bin of flour underneath the food prep counter had a scoop in the bin, resting on top of the flour. On 3/4/24 at 10:30 AM, V12 (Food Service Director) said, They (the kitchen staff) know scoops should not be on top of food ingredients. This can increase the risk of cross contamination and bacterial growth.

Based on observation, interview, and record review, the facility failed to provide feeding assistance in a dignified manner for four of 21 residents (R42, R55, R58, R84) reviewed for dignity in the sample of 21. The findings include: On 3/4/24 at 11:56 AM, V4, V5, and V6, CNAs (Certified Nursing Assistants), were feeding R42, R55, R58, and R84 their lunch meals while standing up. There was an empty chair at R58 and R84's table, and an empty chair at R42 and R55's table. On 3/5/24 at 10:52 AM, V8, RN (Registered Nurse) said staff should sit and feed resident for dignity concerns. At 11:14 AM, V6, CNA, said staff should sit down to feed residents, because if staff stand up to feed residents, then it is a dignity issue. The facility's Resident Care Philosophy policy, reviewed March 2006, shows, A Philosophy of care is based upon a basic belief and respect for the dignity and worth of the individual. Each resident will be treated with compassion and will experience vitality to the extent individually possible.

Based on observation, interview, and record review, the facility failed to provide residents eating from the Oak and Birch dining rooms with the correct serving sizes for the parmesan herb potatoes, regular carrots, mechanical soft ham, pureed ham, au gratin potatoes, and mashed potatoes. This applies to 4 of 21 residents (R9, R32, R50, R75) reviewed for diets in the sample of 21. The findings include: Facility provided list of residents served from the Oak dining room kitchenette for lunch on 3/3/24 shows R32 was served. Facility provided list of residents served from the Birch dining room kitchenette for lunch on 3/3/24 shows R9, R75, and R50 were served. Facility Diet Spreadsheet, dated 10/17/23, shows the lunch meal for 3/3/24 consisted of baked glazed ham, parmesan herb potatoes, carrots, apple pie, and a dinner roll. On 3/3/24 at 11:40 AM, V12 (Food Service Director) and V13 (Assistant Dietary Manager) began to place serving utensils in the appropriate foods for the lunch service in the Oak dining room kitchenette. The parmesan herb potatoes had a #10 scoop, which provides 3 ounces (oz) of volume. The carrots had a 3 oz spoodle. The mechanical soft ham had a #20 scoop, which provides 1.625 oz of volume. The pureed ham had a #12 scoop, which provides 2.66 oz of volume. The au gratin potatoes had a #10 scoop, which provides 3 oz of volume. The mashed potatoes had a #12 scoop, which provides 2.66 oz of volume. On 3/3/24 from 11:55 AM until 12:15 PM, V14 (Cook) served each plate out of the Oak dining room with a single scoop of all foods. V14 then packed up the foods and transported them with the serving utensils to the Birch dining room kitchenette. On 3/3/24 from 12:35 PM until 1:15 PM, V14 served each plate out of the Birch dining room kitchenette with a single scoop of all foods. The parmesan herb potatoes had a #10 scoop, which provides 3 oz of volume. The carrots had a 3 oz spoodle. The mechanical soft ham had a #20 scoop, which provides 1.625 ounces of volume. The puree ham had a #12 scoop, which provides 2.66 oz of volume. The au gratin potatoes had a #10 scoop, which provides 3 oz of volume. The mashed potatoes had a #12 scoop, which provides 2.66 oz of volume. Facility Diet Spreadsheet, dated 10/17/23, shows the parmesan herb potatoes was supposed to be served using a 4 oz spoodle. The #10 scoop used provides 1 ounce less than the 4 oz spoodle. Facility Diet Spreadsheet, dated 10/17/23, shows the carrots were supposed to be served using a 4 oz spoodle. The 3 oz spoodle used provides 1 ounce less than the 4 oz spoodle. Facility Diet Spreadsheet, dated 10/17/23, shows the mechanical soft ham was supposed to be served using a #8 scoop, which provides 4 oz of volume. The #20 scoop used provides 2.375 ounces less than the #8 scoop. Facility Diet Spreadsheet, dated 10/17/23, shows the pureed ham was supposed to be served using a #10 scoop, which provides 3 oz of volume. The #12 scoop used provides 0.33 ounces less than the #10 scoop. Facility provided au gratin recipe, dated 3/22/23, shows the au gratin potatoes were supposed to be served using a #8 scoop, which provides 4 oz of volume. The #10 scoop used provides 1 ounce less than the #8 scoop. Facility provided mashed potato recipe, dated 3/22/23, shows the mashed potatoes were supposed to be served using a #8 scoop, which provides 4 oz of volume. The #12 scoop used provides 1.33 ounces less than the #8 scoop. On 3/3/24 at 12:37 PM, V14 said the carrots were supposed to be served using a 4 oz spoodle, but believes they are low on them, which is why a 3 oz spoodle was used instead. On 3/4/24 at 10:37 AM, V12 said, If cooks don't use the correct scoop sizes, residents are at risk of getting the incorrect amount of calories, protein, and total nutrients. This can lead to weight loss.

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary indwelling catheter bag was not touching the floor to prevent contamination for 1 of 4 residents (R86) reviewed for catheters in the sample of 21. The findings include: On 3/3/24 at 9:44 AM, R86 was sitting in her wheelchair in her room. R86's catheter bag was hanging from the underside of her wheelchair. R86's catheter bag was touching the floor. On 3/3/24 at 10:52 AM, R86 was propelling herself down the hallway. R86's catheter bag was dragging on the floor as she propelled herself down the hallway. R86 did not have a privacy bag on the catheter bag. On 3/4/24 at 2:31 PM, V2 (Director of Nursing) said urinary catheter bags should be kept off of the floor for infection control reasons. R86's Urinary Catheter Care Plan shows, Do not allow tubing or any part of the drainage system to touch the floor. The facility's Caring for Residents with Foley Catheter Drainage Setups Policy, revised 1/2024, shows, The catheter bag container is attached to the side of the bed frame. Do not allow the bag to touch floor. When resident is up in the w/c (wheelchair), place foley drainage bag in drainage pouch under w/c seat. Tubing should be threaded under seat, above cross bars. Be sure pouch is attached securely under w/c seat and is high enough off floor to not sag onto floor with weight of urine

Based on observation, interview, and record review, the facility failed to provide behavioral interventions for a resident with a diagnosis of dementia that was displaying behaviors for one of 15 residents (R62) reviewed for dementia care in the sample of 21. The findings include: R62's Admission Record, dated 3/4/24, shows R62 was admitted tot he facility on 2/26/19, with diagnoses including dementia, Alzheimer's, restlessness and agitation, generalized anxiety disorder, major depressive disorder, anxiety disorder, over active bladder, and need for assistance with personal care. R62's Care Plan, initiated 3/1/24, shows, I have a history of often ambulating up and down the halls and will become momentarily tearful, whimper, and cry out before continuing to ambulate against/down the hall. Care Plan initiated 11/16/23, shows, Walk with me to/from resident dining room for all meals or as often as I will tolerate. Encourage me to walk as much as I will tolerate and praise my efforts. On 3/3/24 at 9:30 AM, R62 was sitting in her wheelchair in the large dining room. V11, Activity Aide, was sitting in a chair next to R62. R62 made numerous attempts to stand up; V11 guided R62 to sit back down. At 9:47 AM, V10, CNA (Certified Nursing Assistant), said she is going to take R62 to the bathroom to see if that is why she keeps trying to stand up. V10 took R62 to the bathroom. R62 was placed back at the table with V11 after using the bathroom. At 10:10 AM, R62 was attempting to stand up and was trying to walk. V11 again guided R62 to sit down. R62 was crying out loud. R62's wheelchair was locked and in front of a table. R62 made numerous attempts to stand up until 11:08 AM. At 11:08 AM, V11 placed R62 in the small dining room in front of a table and locked her wheelchair. At 11:42 AM, V9, RN (Registered Nurse), was shaking a maraca in front of R62. Each time R62 attempted to stand up and move, R62 was guided to sit back down in her wheelchair. R62 attempted to stand up and move at 11:41 AM. V9 was holding onto R62's left arm and R62 yelled, Let me go! I want to move! V9 again guided R62 to sit down. V10, CNA, came over to R62 and switched spots with V9. V10 continued to shake the maraca in front of R62. R62 continued to make multiple attempts to stand up and move until lunch came at 12:00 PM. There were no attempts made by staff to ambulate R62 during the entire observation. On 3/4/24 at 11:41 AM, V8, RN, said R62 is able to walk with a gait belt and a walker with a wheelchair following her, depending on the day. V8 said when R62 is showing behaviors of restlessness or anxiety, then ambulation and toileting are the staffs' first go to. V8 also said snacks and drinks are also offered. V8 said R62 also likes to color. V8 said sometimes walking works and sometimes it does not, but walking is an intervention that staff use to help with restlessness. On 3/5/24 at 11:14 AM, V6, CNA, said R62 constantly tries to stand up. V6 said R62 screams and tries to walk unsafely. V6 said R62 can get frustrated at times when staff try to help her. V6 said if R62 is restless, then staff offer her snacks, take her to the bathroom, and offer her root beer because R62 really likes root beer. V6 said sometimes R62 can walk safely and sometimes she can't. V6 said walking R62 can be used to manage R62's behaviors. On 3/5/24 at 1:51 PM, V15 (R62's Daughter) said R62 was a pacer. V15 said when R62 lived at home, R62 would pace back and forth. V15 said R62 roamed the facility on her own, until it was not safe to do it on her own. The facility's Activity Schedule policy, undated, shows, Dementia residents are often unable to cope with set agendas due to their cognitive impairment. The purpose is to ensure we are providing an environment conducive to our residents needs. To maintain a resident at the highest functional level possible.

Based on observation, interview, and record review, the facility failed to provide two residents with a smooth consistency pureed pork chop that was free of chunks. This applies to 2 of 2 residents (R13, R55) reviewed for pureed diets in the sample of 21. The findings include: On 3/3/24 at 1:24 PM, the facility provided a test tray of pureed ham, pureed pork chop, and pureed carrots. The pureed pork chop was not smooth and contained chunks of pork chop that required chewing. On 3/3/24 at 1:34 PM, V12 (Food Service Director) said the pureed pork chop texture was not good because it had chunks. The ideal texture should be smooth, free of chunks, and similar to baby pudding or applesauce. R13's lunch meal ticket, dated 3/3/24, shows R13 received the pureed pork chop. R55's lunch meal ticket, dated 3/3/24, shows R55 received the pureed pork chop. Facility Puree Food Texture log, dated February 2024, states, . Food must be smooth, with no beads of meat or other food present.

Based on interview and record review, the facility failed to ambulate residents with the assistance of a gait belt to ensure residents were ambulated in a safe manner. This failure applies to 2 of 4 residents (R1, R2) in the sample of 4 reviewed for safety and supervision. This failure resulted in R1 falling while ambulating with staff, resulting in R1 fracturing her left femur (upper leg) and requiring hospitalization . The findings include: 1. The facility's Witnessed Fall incident report, dated 1/10/24, showed R1 was walking in her room, with the use of her walker and with V7, Certified Nursing Assistant (CNA), present, when R1's knees buckled and R1 fell to the floor. The report showed R1's left leg got caught under a bedside dresser during the fall. R1 complained of pain to her left leg. 911 was called. R1 was transferred to a local hospital via ambulance. R1's hospital records, dated 1/11/24-1/15/24, were reviewed. The records showed R1 was admitted to the hospital with a diagnosis of a displaced distal femoral fracture after sustaining a witnessed fall at the facility. R1 was discharged from the hospital on 1/15/24, when she returned to the facility. R1's Fall Scale assessments, dated 10/25/23 and 1/10/24, each showed R1 was at high risk for falls. R1's care plan, revised on 10/25/23, showed R1 was at risk for falls due to her history of previous falls, impaired cognition, weakness, and poor vision. The care plan showed, I have a history of bilateral knee buckling during ambulation . The care plan showed R1 required the extensive assistance of one staff, with the use of a gait belt, for all transfers and ambulation. R1 was cognitively impaired related to her diagnoses of dementia and Alzheimer's disease. On 1/24/24 at 8:30 AM, an attempt to interview R1 about her fall on 1/10/24 was unsuccessful, due to her impaired cognition. On 1/24/24 at 9:18 AM, V7, CNA, stated she was the only staff member with R1 when she fell on [DATE]. V7 CNA stated she did not have a gait belt on R1 when ambulating her on 1/10/24. V7, CNA, stated, I was walking with (R1). Her knees buckled and she went down. I think her left leg broke because it got stuck under the dresser. It happened so fast. I couldn't catch her. I should have been using a gait belt on her. She complained of pain to her leg right away. On 1/24/24 at 9:35 AM, V8, Nurse, stated she was called to R1's room, by V7, CNA, on 1/10/24. V8 stated, When I got to the room, (R1) was on the floor. She complained of pain to her leg. (V7) did not have a gait belt on (R1). On 1/24/24 at 11:11 AM, V4, Restorative Nurse, stated staff are to use a gait belt when transferring or ambulating any resident that requires any level of staff assistance to do so. V4 stated, The purpose of the gait belt is for staff to help lower a resident to the floor, if they start to fall, to prevent any injury . Prior to (R1's) fall on 1/10/24, she required the assistance of one staff. with use of gait belt, when walking. She has a history of previous falls and her knees buckling when she walks. On 1/24/24 at 11:01 AM, V5, Nurse Practitioner, stated, Staff should refer to a resident's care plan or get report on how to transfer a resident. All staff should be using a gait belt when transferring or walking a resident. That is pretty much the standard. 2. The facility's Witnessed Fall incident report, dated 12/21/23, showed R2 was walking in her room, with V6 CNA, when the resident lost balance and began to fall. R2 was assisted to the ground by V6 CNA. R2 received no injuries from the fall. The report showed, Resident lost her balance while ambulating with staff. Staff to use gait belt . R2's Fall Scale assessment, dated 12/19/23, showed R2 was at high risk for falls. R2's care plan, revised on 6/29/23, showed R2 was at risk for falls due to her history of repeated falls, impaired cognition related to her dementia diagnosis, obesity, and generalized weakness. The care plan showed, I need limited-extensive assistance from one staff member with one of their hands on my gait belt during ambulation. On 1/24/24 at 9:40 AM, V6, CNA, stated she was the only staff member with R2 when she fell on [DATE]. V6 CNA stated she did not have a gait belt on R2 when ambulating her on 12/21/23. V6, CNA, stated, We were walking back from the bathroom. She was using her walker. (R2) started to lose her balance and went down. I tried to catch her and guide her to the floor. I grabbed her arm and under her butt to lay her down on the floor. I was not using a gait belt. I should have been. On 1/24/24 at 11:11 AM, V4, Restorative Nurse, stated R2 required the use of a gait belt, one staff member, and a walker when ambulating due to her history of previous falls. The facility's Transfer/Gait Belt policy dated March 2015 showed, Gait belts/Transfer belts are to be properly used in the transfer and ambulation of any resident needing assistance with those activities.

Based on observation, interview, and record review facility, failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents exhibiting symptoms of COVID-19; failed to have a system in place to accurately track/trend resident and staff exposures to COVID-19 during a facility outbreak; failed to have an effective system in place to test staff and residents for COVID-19 during a facility outbreak; and failed to ensure COVID negative residents were not exposed to COVID positive residents. These failures resulted in a facility outbreak of COVID-19 which, as of 9/11/23, included twenty-eight positive residents and fourteen positive staff. Three of the twenty-eight residents were hospitalized for COVID. These failures have the potential to affect all 72 residents residing in the A Building of the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 8/25/23, when V13, Certified Nursing Assistant (CNA), provided cares to residents in the A Building, while exhibiting symptoms of COVID-19. V1 (Administrator) was notified of the Immediate Jeopardy on 9/12/23 at 2:31 PM. This surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 9/13/23, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: A facility roster, dated 9/11/23, showed a census of 72 residents in the A Building. A facility map, dated 9/11/23, showed the A Building was divided into 4 wings which included A-North, A-South, A-East, and A-West. A facility resident/staff COVID-19 report, printed 9/11/23, showed the COVID-19 outbreak started on 8/24/23, when a staff member tested positive. The report showed by 9/3/23, the COVID outbreak had spread to residents on the A-West, A-South, and A-North wings of the A Building. By 9/8/23, twenty-eight residents had tested positive for COVID. All twenty-eight residents resided in the A Building. Fourteen staff had tested positive. Of those fourteen staff members, thirteen of them worked in the A Building. As of 9/8/23, three residents (R13-R15) had been hospitalized due to COVID. 1. R7's Health Status Note, dated 9/4/23, showed R7 had tested positive for COVID-19. R7 was placed on droplet/contact isolation (transmission-based precautions) for ten days. On 9/11/23 at 10:41 AM, V3 Assistant Director of Nursing (ADON) exited R7's room, after providing cares to R7, without doffing her contaminated N95 mask or plastic face shield. V3 walked over to a PPE cart in the hallway, removed her face shield, and placed the contaminated face shield in the top drawer of the cart, on top of a box of gloves and N95 masks. At no time did R7 remove her contaminated N95 mask. R9's Physician Order, dated 9/3/23, showed R9 was placed on droplet/contact isolation, for ten days, after testing positive for COVID. On 9/11/23 at 10:48 AM, V4 and V5, CNA's (Certified Nursing Assistants), exited R9's room. V4, CNA, exited the room without removing her contaminated N95 mask. V5, CNA, exited the room without removing her contaminated N95 mask, or disinfecting the face shield she wore in R9's room. R10's Physician Order, dated 9/6/23, showed R10 was placed on droplet/contact isolation, for ten days, after testing positive for COVID. On 9/11/23 at 11:06 AM, V8, Registered Nurse, donned PPE and entered R10's to administer medications to R10. At 11:08 AM, V8 exited R10's room without doffing her contaminated N95 mask or disinfecting her face shield. V8 then pushed her medication cart down to the nurses station, while wearing the contaminated PPE. On 9/12/23 at 7:35 AM, V2, Director of Nursing (DON), stated, Staff must remove and discard their N95 masks, before exiting a COVID positive room. Staff must disinfect their face shields prior to exiting a COVID positive room to attempt to prevent the spread of COVID-19. The facility's Standard Precautions/Transmission-Based Precautions policy (undated) showed staff are to remove and discard all PPE (gloves, gown, mask, and eye protection) prior to exiting the room of a resident on any transmission-based precautions. 2. The facility's nursing schedule, dated 8/24/23, showed V13, CNA, worked from 11:00 PM on 8/24/23 until 7:00 AM on 8/25/23 on the A-South wing. V13, CNA's, urgent care discharge report, dated 8/26/23, showed V13 tested positive for COVID-19. On 9/12/23 at 10:51 AM, V13, CNA, stated she developed a sore throat while working the night shift on 8/24/23. V13 stated, I noticed my throat was sore towards the end of my shift. I was tired by didn't think much of it. I didn't report my symptoms to anyone. Later that day (on 8/25/23), I started to feel worse and had a fever. I went and got tested for COVID. I was positive. V13, CNA, stated on 8/24/23, she provided cares to residents on the A-South wing, which included incontinence care, toileting, and transferring residents out of bed. V13 stated she did not wear a mask while providing cares to residents during her shift. On 9/11/23 at 12:48 PM, V9, Infection Preventionist (IP)/RN, stated V13, CNA, failed to report to facility management, that she had developed a sore throat and fatigue towards the end of her shift on the morning of 8/25/23. V9 stated V13 finished her shift and left the facility without being tested for COVID, or reporting her symptoms. V9 stated she was notified of V13's positive COVID test on 8/26/23. V9 stated, If staff become sick at work, they should notify their supervisor immediately, get tested for COVID, and immediately be removed from resident care to avoid potentially exposing residents to COVID. When V9 was asked if she had tested the residents V13, CNA, had provided cares to on 8/24/23-8/25/23, V9 stated, I took the contact tracing approach. I didn't feel (V13, CNA) had really any close contact to any residents during her shift, so I didn't test anyone. The facility's COVID-19 Testing Plan and Strategy policy, dated 5/25/23, showed, Any resident or HCP (healthcare professional) who develops fever or symptoms consistent with COVID-19, regardless of vaccination status, should receive a COVID test as soon as possible. 3. R1's Health Status Note, dated 9/2/23, showed R1 had developed complaints of nausea and had one episode of vomiting. R1 was COVID tested , which showed a negative result. R1's Administrative Note, dated 9/3/23, showed R1 had developed generalized congestion. The note showed no documentation R1 was retested for COVID, or placed on isolation. R1's Health Status Note, dated 9/4/23, showed R1 tested positive for COVID, and was placed on isolation at that time. On 9/11/23 at 11:03 AM, V7, CNA, stated she felt facility administration didn't act quick enough to try to stop the COVID outbreak. V7 stated, I took care of (R1) on September 3rd and 4th (2023). I reported to her nurse, both days, that I didn't think (R1) felt well. (R1) was pale, not eating, and tired. She had a cough. I know they didn't test her on September 3rd. She also wasn't on isolation on September 3rd. On 9/12/23 at 8:26 AM, V15, RN, stated she cared for R1 on 9/3/23. V15 stated, (R1) had generalized congestion, which I medicated her for. I did not retest her for COVID or put her on isolation at that time. A physician order for R1, dated 9/4/23, showed R1 was not placed on droplet/contact isolation until two days after developing COVID symptoms. R2's Health Status Note, dated 8/30/23, showed R2 developed a new onset of fever. The note showed R2 tested negative for COVID. The note showed no documentation R2 was placed on isolation at that time. R2's Health Status Notes, dated 8/31/23, showed R2 continued to have a fever. The notes showed no documentation R2 was retested for COVID. R2's Health Status Note, dated 9/1/23, showed R2 appeared lethargic with continued fevers. R2 had developed a slight cough. R2 tested positive for COVID, and was placed on isolation at that time. A physician order for R2, dated 9/1/23, showed R2 was not placed on droplet/contact isolation until two days after developing COVID symptoms. R3's Plan of Care notes, dated 9/1/23, showed R3 had developed cold symptoms and fatigue. The notes showed R3 required supplemental oxygen to keep her oxygen level within normal limits. R3 was tested for COVID, which showed a negative result. The notes showed no documentation R3 was placed on isolation at that time. R3's Health Status Note, dated 9/3/23, showed R3 still required supplemental oxygen. The note showed R3 had been started on an antibiotic, for treatment of pneumonia. The note showed R3's daughter had taken R3 outside for a visit. R3's COVID test results and Health Status Notes, dated 9/4/23, showed R3 tested positive for COVID, and was placed on isolation at that time (three days after developing symptoms). On 9/12/23 at 11:20 AM, V17, Communicable Disease (CD) Coordinator for the local health department stated, Any resident that has been exposed to COVID and develops symptoms must be placed on droplet/contact isolation immediately, even if their initial COVID test is negative. They are to remain on isolation for 5 days. They can come off isolation if they no longer have symptoms and their day 1, day 3, and day 5 COVID tests are negative. The facility's Infection Control COVID-19 policy, dated 5/25/23, showed, Monitoring residents for fever or symptoms, such as shortness of breath, new or change in cough, and sore throat; and asking residents to report if they feel feverish and have symptoms of respiratory infection. If symptoms are identified, move to action steps to prevent the spread of respiratory germs within the campus to include restricting residents with fever or acute respiratory symptoms to their room . 4. V19's (Respiratory Therapist) Time Clock Report, dated 9/1/23, showed V19 worked 8:15 AM-4:30 PM in the A Building. The facility's COVID-19 tracking report, dated 9/1/23, showed V19 tested positive for COVID on the evening of 9/1/23 after he began feeling off. V18's (Dietary Aide) Time Care report, dated 8/30/23, showed V18 worked as a dietary aide in the A Building from 4:31 PM-7:40 PM. The facility's COVID-19 tracking report, dated 9/1/23, showed V18 tested positive for COVID on 8/31/23. The facility's nursing schedule, dated 8/31/23, showed V21, CNA, worked on the A-North wing from 6:00 AM-3:00 PM. V21's COVID test, dated 9/1/23, showed V21 tested positive for COVID. On 9/12/23 at 10:15 AM, V9, IP/RN, stated she did not complete any contact tracing to track/trace which residents or staff had potentially been exposed to COVID by V18, V19, or V21. V9 stated, When the COVID outbreak started, we only had one positive staff member, so I decided to take the contact tracing/testing approach to the outbreak. As the outbreak got worse, I continued to use the contact tracing method to track potential exposures caused by our positive residents, but I didn't track the potential exposures our positive staff may have caused. I didn't know contact tracing included tracking exposures created by our positive staff. When V9 was asked why she did not change to the broad-based tracing/testing approach when the facility's COVID outbreak had spread to three of the four wings in the A Building (by 9/3/23), V9 stated, I thought it was ok for me to continue with the contact tracing. It just spread so fast. It was chaos. V9 stated she did not begin broad-based COVID testing for residents, in the A Building, until 9/7/23. Broad-based testing for staff, in the A Building, was not started until 9/11/23. On 9/12/23 at 11:20 AM, V17, Communicable Disease (CD) Coordinator for the local health department, stated, Contract tracing/testing for COVID is only effective if facilities contract trace potential exposures caused by both, positive residents and positive staff. We had told (V9 IP/RN), multiple times, that she was to stop using the contact tracing approach for their outbreak, and start the broad-based approach. (V16, CD Staff) spoke with (V9) on 9/1/23 and told her to switch to broad-based testing. (V12, CD Staff) spoke with (V9) again on 9/5/23 and told her to start doing the broad-based testing immediately. We told (V9) the contact tracing approach is ok to use if the outbreak is contained to 1-2 residents on the same hallway or wing. If multiple residents start turning positive per day, or the outbreak spreads to other hallways/wings, they must change to the broad-based approach. The facility's COVID-19 Testing Plan and Strategy policy, dated 5/25/23, showed one confirmed COVID-19 case, resident or staff, triggered an outbreak investigation. The policy showed the facility should considered a broad-based approach to an outbreak if additional cases are identified from testing close contacts or higher-risk exposures, facilities should expand testing as determined by the distribution and number of cases throughout the facility and ability to identify close contacts . 5. On 9/11/23 at 11:03 AM, R4 was seated in a wheelchair, by the nurses station, on the unit of the COVID outbreak. R4 wore a surgical mask, down under her chin, with her mouth and nose exposed. On 9/11/23 at 11:44 AM, R5 was seated in a reclined wheelchair, in the hallway, outside of COVID positive rooms (rooms 270, 271). The doors to rooms [ROOM NUMBERS] were wide open. No mask was noted on R5. On 9/12/23 at 7:35 AM, V2, DON, stated, The doors to rooms of COVID positive residents should be closed, unless the residents are a fall risk. If a resident is COVID negative, the resident can come out of their room, but they must have a surgical mask on. On 9/12/23 at 9:03 AM, V14, Nurse Practitioner, for R1-R3 stated, The expectation is that the facility is following the IDPH (Illinois Department of Public Health) guidelines for COVID and is putting measures in place to stop the spread of COVID in the facility. The Immediate Jeopardy that began on 8/25/23 was removed on 9/13/23, when the facility took the following actions to remove the immediacy: 1. Broad-based COVID-19 testing of residents in the A Building was completed on 9/7/23, with no positive results. 2. The facility will ensure broad-based COVID testing will be completed for all residents in A Building two times each week until fourteen days have passed without a positive COVID test. 3. Broad-based COVID testing of employees in A Building was completed on 9/11/23, with no positive results. 4. The facility will ensure broad-based COVID testing will be completed for all employees in A Building two times each week until fourteen days have passed without a positive COVID test. 5. The Medical Director was updated regarding the COVID concerns on 9/12/23. 6. The facility will implement audits to ensure proper PPE use. This audit is to be completed by the Nursing House Supervisor or designee. Fifteen audits will be completed each week for two months. The DON or designee will report the results of the audits to the Quality Assurance committee. The QA committee will follow up as necessary. 7. The facility employee's health policies will be reviewed/revised to include immediate reporting of COVID symptoms and positive COVID test results. 8. The facility will ensure residents who are exposed to COVID and/or exhibiting COVID symptoms are immediately placed on isolation; implementing broad-based testing if more than one positive COVID case on a unit; all staff and residents on affected COVID units to wear masks while in hallways or common areas, during outbreak. 9. The facility will implement an audit tool to assess any current or new resident admissions for signs of symptoms of COVID to determine isolation needs. This audit is to be completed by a nurse. Daily audits will be completed each week for two months. The DON or designee will report the results of the audits to the QA committee. The QA committee will follow up as necessary. 10. The facility will review/revise the infection control policy to ensure that residents who are exposed to COVID and/or exhibiting COVID symptoms are immediately placed on isolation; implementing broad-based testing if more than one positive COVID case on a unit; all staff and residents on affected COVID units to wear masks while in hallways or common areas, during outbreak. 11. The facility will have a QA committee meeting, regarding COVID, on 9/15/23, to include the Medical Director and QA team. 12. The facility staff will be re-educated by the Education Nurse/Infection Preventionist regarding immediate reporting of COVID symptoms to management, donning/doffing PPE procedures, revised facility employee health policies, and the revised infection control policy.

Based on observation, interview, and record revie,w the facility failed to ensure meals were delivered to residents at an appetizing temperature for 1 of 3 residents (R6) reviewed for food temperatures in the sample of 15. The findings include: On 9/11/23 at 11:25 AM, R6 stated, The food here is awful. It's always served late and always cold. I eat in my room. I refuse to eat in the dining room. Come back when my lunch is served, so you can see how cold it is. On 9/11/23 at 11:47 AM, V9, Infection Preventionist/Registered Nurse, delivered R6's lunch tray to R6 in his room. R6 tasted the au gratin potatoes on his tray. R6 stated to V9, The food is cold. I not going to eat this. I don't want it. I used to work in food service. Go get a thermometer and check it yourself. At 11:48 AM, this surveyor and V9, checked the temperatures of the foods on R6's lunch tray using a thermometer provided by the facility. The thermometer showed R6's au gratin potatoes were 133.5 degrees Fahrenheit (F), and the creamed corn was 126.7 degrees (F). On 9/11/23 at 2:00 PM, V11, Dietary Manager, stated, Hot foods should not be served to residents if the food temperatures are less than 135 degrees (F). Food temperatures are checked after cooking. Food is then plated in the kitchen, covered with a lid, and placed on a baker's rack (an open, nonheated rack) to be delivered to residents that eat in their rooms. Once food trays are delivered to the floor, staff should be immediately delivering the trays to residents. The facility's Preparation of Foods policy (undated) showed it was the policy of the facility's dietary department to strive to serve foods in acceptable temperature ranges as required by the state rules and regulations .Hot foods received by residents should be at temperature of 135 degrees F or greater .

Based on interview and record review, the facility failed to reassess a resident for change of diet after losing dentures, and failed to supervise residents in the dining room at mealtime for 1 of 3 residents (R4) reviewed for choking. This failure resulted in R4 choking in the dining room on [DATE] and expiring at the hospital on [DATE]. The Immediate Jeopardy began on [DATE] when R4's lower dentures were noted to be missing. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:30 AM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R4's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease, Diabetes Type 2, Atherosclerotic Heart Disease, hypertension, muscle weakness, vascular dementia with behavioral disturbance, and personal history of peptic ulcer disease. R4's facility assessment dated [DATE] showed he had moderate cognitive impairment and required no help or staff oversight while eating. R4's most recent dietary assessment, completed by V10 (Registered Dietitian), was dated [DATE] (approximately 5 months from survey date), and the dentition section was not completed. R4's most recent Dietary Resident Interview, completed by V26 (Dietary Manager), was dated [DATE], and only addressed resident preferences for food. R4's [DATE] physician order sheet showed an order dated [DATE] for, General diet, regular texture, thin consistency. R4's Care Plan initiated on [DATE] showed, . I have dentures. I fail to take them often when performing oral care on myself, I have my upper denture. I have a history of throwing my bottom partial out in the garbage or leaving them in a napkin at my table when I eat meals . I am inquiring about receiving a new pair of dentures . Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted . Revision on [DATE] . I require mouth inspections every shift with cares. Report changes to the nurse . R4's Care Conference Note, dated [DATE] at 2:30 PM, showed, Care conference held this afternoon with resident in attendance and POA (Power of Attorney) (V28) in attendance via phone call in . POA expressed concerns with missing items that this writer is following up with management and nursing staff on items listed. POA requesting a sign be placed on table to remind resident if he has his dentures or not prior to leaving the dining room due to continued forgetfulness of dentures at mealtimes. Informed unit clerk to perform this request. POA states she contacted dentist . R4's Social Services Note entered by V27 (Registered Nurse/Restorative Nurse), dated [DATE], showed, Writer and SSD (Social Services Director) search resident's room looking for misplaced lower dentures, but were unsuccessful in finding them. Resident believes he wrapped them in paper towels. Education provided regarding placing dentures in denture container. Resident is eligible for new dentures in [DATE] . Resident and POA notified . R4's Health Status Note entered by V18, LPN (Licensed Practical Nurse), dated [DATE] at 2:10 PM, showed, Returned with P.N. (progress note) to return to the dentist next week for another fitting of his lower dentures. No date and time provided yet. R4's Health Status Note entered by V9 (Registered Nurse/House Supervisor), dated [DATE] at 11:36 AM, showed, Conducted phone conference with POA, (V28, R4's daughter) and (V29, R4's son) . Made aware of dental appointment for lower dentures for Monday ([DATE]) that (V29) will take patient to, written on Calendar for staff/talked about how to prevent patient from losing them again . The facility's [DATE] menu showed, Waffles and Fried Chicken with syrup . R4's [DATE] meal ticket from the dietary department showed R4 was served fried chicken and waffles. R4's [DATE] nursing progress note entered by V12, LPN, showed, 18:15 (6:15 PM) Resident in dining room eating dinner when his tablemate called out Nurse I think he is choking this writer was assisting another resident and turned and saw resident seated in chair, bending forward and holding on to the table. I moved in front of resident, his eyes were open, skin pink and he was unable to speak, I could hear some shallow inspiratory gurgles, at which time I explained to the resident I was going to perform back blows and the Heimlich maneuver. I did 5 back blows without success and kneeled behind resident and tried 5 abdominal thrusts without success. I checked resident's mouth and couldn't see any food, checked carotid pulse which I could feel and repeated this sequence without success. Resident was awake and small inspiratory breaths could be heard and carotid pulse could be felt. I had (V19, CNA- Certified Nursing Assistant) take over 5 abdominal thrusts while I called 911 at 18:18 (6:18 PM) and then house supervisor for assistance. Pulse checks, mouth checks and 5 back blows and abdominal thrusts were continued until (V17, House Supervisor) arrived at 18:20 (6:20 PM) which time he took over and EMS (Emergency Medical Services) had arrived at 18:25 (6:25 PM). EMS took resident out of the facility at 18:50 (6:50 PM) POA (Power of Attorney) #1 called at 18:51 (6:51 PM) and message left to call back. POA#2 was updated at 18:53 (6:53 PM). DON (Director of Nursing) and ADON (Assistant Director of Nursing) notified. Daughter POA #1 called back at 20:05 (8:05 PM) asking what had happened? All questions answered, stated she had to perform the Heimlich on her father when they went out to eat before and stated that the family hadn't gotten his bottom dentures back from the dentist yet . The facility's seating chart for R4's dining room provided by V2, DON (Director of Nursing), dated [DATE], showed R4 shared a dining table with R8, R9, and R10. R8's facility assessment assessment, dated [DATE], showed she has no cognitive impairment. R9's facility assessment, dated [DATE], showed she has no cognitive impairment. R10's facility assessment, dated [DATE], showed he has no cognitive impairment. On [DATE] at 8:48 AM, R8 said, (R4) sits to the left of me at the table. We were served waffles and chicken that night. He had been coughing quite a bit lately. He would cough and cough until he got past the spell. I'm a retired nurse so I've been watching him over the past weeks start coughing more and more while he was eating. He had just put a piece of chicken in his mouth and started coughing right away. I said '(R4) can you talk to me??' He shook his head 'no'. I use a walker, but I left it behind and hurried out to the nurse's station and went into that area. The nurse was walking into the little room behind the nurse's station and I said 'Come Come, (R4) is choking!' She put down what she was doing and she went into the dining room to talk to him; he couldn't talk. She got another nurse to come in and the two of them were doing the Heimlich. I think when he started coughing he inhaled deep and the chicken went further down. They got a male nurse and called the ambulance. Now there were 3 or 4 of them and they got (R4) onto the floor at that time. (R4) was already changed to an ashen color by then; it was too late for him. The paramedics got there with their equipment and we were ushered out of the dining room. He didn't have his bottom set of teeth. He put a piece of chicken in his mouth and just started gasping. It went so fast there was hardly any time to do anything properly. (R4's) coughing was getting worse as the weeks went on. I noticed he was having difficulty eating for at least the last ,d+[DATE] weeks because he kept coughing and having more difficulty with his food. He could always get it out before though, but this time was different. He had been missing his bottom teeth for at least a couple of weeks, but I can't say for sure how long. When this happened, he had his upper set of teeth in. There is only 1 table between our table and the exit. I didn't look to see if there were staff in the other part of the dining room before I went out to the nurse's station to get the nurse, but I know nobody else came to the table to help before I got back with the nurse. It was obvious he was having a lot of difficulty. If there was staff in there, I think they must have just thought he was having another coughing spell. He was in serious trouble this time. On [DATE] at 1:27 PM, R9 said, I was a table mate of (R4), but I had left the table before he actually choked and died . Everyone else was still at the table. (R4) was coughing a lot during meals and food would fall out of his mouth during meals. (R8) said nobody came over when he first started choking. On [DATE] at 1:30 PM, R10 said, I was in the dining room when (R4) choked. His hands were up by his throat and spit came out of his mouth. Two staff came and did the Heimlich but the food was too far down. He had been coughing more during meals. He didn't have bottom teeth. On [DATE] at 10:35 AM, R5 said, I eat in the dining room. They don't have as much staff as they should. They serve everyone and then they disappear. If we need something there isn't anyone to go get it. It's a major concern because you look around and they have all left. It concerns me because there should be at least one person there to help. I go to resident council meetings and its been brought up a couple times in there. The [DATE] nursing daily schedule and assignments showed V12, LPN (Licensed Practical Nurse), V13, CNA (Certified Nursing Assistant), and V16, CNA, were assigned to R4's hall, and V20, CNA, assigned as a dining room float. On [DATE] at 1:52 PM, V12, LPN, said, I was in the back of the dining room. I heard someone say 'Nurse I think he is choking'. It was (R8) that was speaking. (R8) was standing there with her walker. He was sitting and holding onto the table. I walked around to the front and he appeared in distress. His mouth was open and he was making gargling noises. I told him I was going to try to help. I did back blows and squatted behind him and did the Heimlich but it was not successful. I heard a little bit of breath sounds, but it was not getting better. The CNA secretary (V19) was nearby, so I asked her to take over so I could call 911 and get the supervisor who is bigger and stronger than I am to come and help. I was hoping they could do it better since my hands kept slipping. He stayed in the chair because I didn't want to lay him down with the thick sludgy liquid that was in his mouth. (V17, CNA Supervisor) took over the abdominal thrusts and I started moving people. The paramedics were here quickly. After a little bit I think EMS (Emergency Medical Services) had to start CPR (Cardiopulmonary Resuscitation). When I called the family to let them know what happened, I think it was the daughter that told me about the bottom dentures. I'm not sure how long he was without his bottom dentures . I remember seeing on the nursing clipboard that he did not have his bottom dentures. I don't know how long ago that was. We would definitely have a discussion on downgrading his diet, but it was my understanding that the family was working on getting him another set of dentures. On [DATE] at 2:59 PM, V13, CNA, said, It was dinner time. There were 2 of us and we only have 1 resident we need to feed. We also had a resident who was sick and stayed in their room. While my partner was in the dining room feeding the resident who needs assistance, I went into the room of the resident that was sick because I knew my partner was going to be in the dining room. I don't think V16, CNA, was in there when he started choking because I think it was literally the beginning of feeding. On [DATE] at 10:54 AM, V16, CNA, said, I had been taking residents back after the meal. I toileted a resident and then came back. (V12, LPN) was in the entryway to the dining room passing medications when I left to go to the resident's room. When I returned to the dining room (V12) told me what was going on and the paramedics were already here. When I came out of the room I saw paramedics working on (R4). I was trying to get everyone out of the dining room . He had a regular diet with regular liquids, no precautions. I did not know he didn't have bottom dentures. I feel they probably should have changed his diet if he didn't have any bottom teeth. I didn't notice him having trouble eating when I was in there. The nurse told me he didn't have bottom dentures after the incident. They took his top denture out when they were giving him the Heimlich. After that I went into his room to see if his bottom dentures were in there, they were not in his room and his denture cup was empty. On [DATE] at 11:30 AM, V20, CNA (assigned as dining room float), said, I was at work in the facility at the time of (R4's) incident but I was nowhere near where (R4) was. I was in a room at the end of another hallway with a resident who was actively passing. The dining room I was attending that day is also not the dining room where (R4) eats. On [DATE] at 10:44 AM, V19, CNA/Ward Secretary, said, I was finishing my day up and getting doctor envelopes ready for the next day when I heard someone yell 'help'. I don't know who said it, I just headed that way as soon as I heard it. I was reaching that table and I saw the nurse behind (R4's) wheelchair trying to do the Heimlich. I don't recall seeing other staff in there, but my focus was on the commotion. I took over the Heimlich maneuver because the nurses usually have phones. She was calling 911. While I was doing the Heimlich I could hear a wheezing sound which was why I kept doing the Heimlich. I checked his mouth and it was no chunks coming out of his mouth. I did maybe 20 thrusts and in between checking the mouth. By that time, (V17, House Supervisor) got there and he is a bigger man so he took over the doing the Heimlich. Emergency personnel arrived and took over; the emergency personnel transferred him to the floor. I oversee the people sitting out by the nursing station eating and answer call lights on one of the other halls. I had been down answering a call light and when I arrived back is when I heard someone yell for help. On [DATE] at 11:08 AM, V18, LPN, said, He was going out to appointments to get dentures repaired. He went out for a fitting and he wasn't happy with how they fit, so he was supposed to go back for another fitting. He had his upper denture, but I don't think he had a lower denture. Without dentures, we would make sure his food was cut up. I don't know if we would do a diet change, we would probably ask him if he had trouble chewing. He was alert and oriented with some confusion and forgetfulness. I would imagine we asked him if he was having trouble eating. Dietary aides are responsible for cutting up the resident's food, the CNAs are a backup. On [DATE] at 12:50 PM, V9, RN (Registered Nurse), said, I know he was supposed to go for an appointment coming up. At times he would forget to put in his upper dentures and we would remind him. I know I talked to the family, and they were taking him to the dentist appointments to get his lower dentures replaced. I'm not sure how long it had been since he had his lower dentures. We would usually do a speech evaluation and they would determine his needs. He did not have any choking incidents that I was aware of prior to this. On [DATE] at 1:15 PM, V11, RN, said, If we have a resident misplaced dentures, I would definitely have the diet changed for that day because it would be hard for them to macerate without teeth. I would fill out a missing item list, we would call the family and start getting the ball rolling on either getting the dentures replaced, or getting a diet change. On [DATE] at 12:21 PM, V7, RN, said, (R4) had an upcoming dentist appointment. V7 checked the calendar and found an appointment had been scheduled for R4 to go to the dentist to get his lower dentures on [DATE]. On [DATE] at 11:52 AM, V5 (Therapy Program Manager) said, (R4) has not been on therapy services for a long time. He has not been on speech therapy. It's been awhile. On [DATE] at 9:50 AM, V5 said, (R4) wasn't seen for speech therapy since 2016. We document a screening on every resident in the facility every 30 days. To do a screening, we speak with the resident and staff. We don't document anything other than a screening was done, unless we feel they need services. No staff told me he was missing his bottom dentures. It was a rumor he was taking his dentures out. It would only make a difference to me if he was having difficulty eating. Most of our residents have adapted to eating without their dentures. If it was bothering him or if staff would notice he was having difficulty, they would let the nurse know, and the nurse would get a referral for Speech Therapy to evaluate. Our screenings are not a hands-on thing, we only interview. On [DATE] at 1:23 PM, V10, Registered Dietitian, said, I receive a list from the kitchen when I come in. I document my visits in the dietary progress notes in the electronic record unless its an initial or an annual assessment which I put under the assessment section. I was not informed that (R4) had lost his dentures. If I had been told, I would have referred him to speech therapy and downgraded his diet to mechanical soft. If his whole bottom teeth are missing, he would be having a harder time chewing and moving food around. I would look at that as a safety issue with choking. (V26, Dietary Manager) is in a meeting every morning and puts the list together of residents for me to see. I'm available by phone at if they have something urgent they can call. On [DATE] at 11:34 AM, V21 (Speech Therapist Consultant) said she does not work at this facility usually, but does work for the same company that comes to his building. V21 said she was in the facility on Monday, [DATE], to do an in-service on swallowing, diets, dentures, when to get an evaluation, and sitting upright. On [DATE] at 1:50 PM, V26 (Dietary Manager) said, In the evening we have a night time cook and 4 aides. On the evening of (R4's) choking incident, there were no dietary staff present in the dining room because they had already finished up in (R4's) dining room, and had moved on the other dining room. I found out his dentures were missing back in either March or April during a care plan meeting. At that care plan meeting we talked about him taking his dentures out and wrapping them in a napkin and putting them in his pocket. The facility's [DATE] Resident Council Meeting Minutes showed, . A few residents expressed concern about the amount of staff in the dining rooms. The facility response directly under the concern showed, Care needs for each resident are evaluated and seating charts are adjusted as needed to ensure the proper level of care for each resident. Occasionally CNAs are pulled away to assist other residents that have care needs during meal times. The facility's [DATE] Resident Council Meeting Minutes showed, .One resident stated that on occasion they have a hard time finding someone to provide extra assistance in the dining rooms . The facility response directly under the concern showed, Dining room floats have been assigned to help residents that return to their rooms early. Staff are being re-educated to be sure that someone remains in the dining room to assist the remaining residents . The facility's policy reviewed [DATE] titled Resident's Meal Time showed, It is the policy of the Nursing Department of (the facility) that all unit staff nursing personnel shall be available to assist in the feeding of the resident during their meal times. Nursing staff are to schedule their breaks accordingly . The facility's policy with review date of [DATE] titled Resident's Meal Time that showed, It is the policy of the Nursing Department of (the facility) that all unit staff nursing personnel shall be available to assist in the feeding of the residents during their meal times. The facility's undated policy and procedure showed, Nutrition Policy . Comprehensive Assessment, Residents will be assessed for nutritional status and risk factors on admissions, annually, and as condition warrants .The assessment will be completed by the licensed dietitian in accordance with accepted clinical practice . The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy: 1. Nursing staff immediately performed the Heimlich maneuver on R4 after resident experienced choking episode. 911 was called, EMS arrived and began CPR on resident; resident was transferred to (Acute Care Hospital). The POA and physician were notified. Completed [DATE] 2. The facility reported this incident to the IDPH on [DATE] via fax, email, and phone call to IDPH at the [NAME] IDPH office. Completed [DATE] 3. The facility gathered statements regarding the incident. The Director of Nursing also discussed this incident with the Medical Director. Completed: [DATE] 4. The facility's Restorative Nurse completed a facility-wide audit for any/all residents who have dentures regarding, specific denture information, current diet, date of last Speech Evaluation, if a new Speech Evaluation was needed. Resident Care Plans were reviewed/revised based on the outcome of this audit. Completed: [DATE] 5. The facility initiated an ongoing facility-wide resident meal ticket audit (completed by the Dietary Supervisor(s) or designee). Ten audits will be completed each week for two months. This was regarding meal ticket accuracy for resident specific diet. The Administrator or designee will report the results of the audit(s) to the Quality Assurance (QA) committee. The QA committee will follow up as necessary. 6. The facility's Director of Nursing met with ADON (Assistant Director of Nursing), Rehabilitation Nurse, and Director of Therapy to discuss the process of screening, evaluating, residents for Speech Therapy, during the Assessment Reference period(s). The Therapy Rehab Screening Form was also reviewed as well as R4's last three screenings. Completed [DATE] 7. The facility reviewed the facility policies regarding resident meal time for necessary revisions (on [DATE]). Policies were reviewed/revised as necessary. Facility staff will be re-educated (by Education Nurse or designee) on any policy changes beginning [DATE] and training will be completed by [DATE]. Completion Date: [DATE] 8. The facility's Director of Nursing implemented (on [DATE]) Dining Room/Hallway Float duties (to enhance dining room supervision). Nursing staff will be educated on these staffing assignments by the education Nurse or designee beginning [DATE] and training will be completed by [DATE]. Completion Date: [DATE] 9. The facility's Director of Nursing revised/updated the Nursing Shift Assignment sheet to include Dining Room/Hallway Float assignment. Completed [DATE] 10. The facility's Director of Nursing revised/updated the facility Oral/Hearing Assessment. This is completed, by the Restorative Nurse or designee, at least quarterly for each resident. Completed: [DATE] 11. The facility's Dietary Supervisor revised/updated the facility Dietary Interview resident assessment. This is completed, by the Dietary Supervisor or designee, at least quarterly for each resident. Completed: [DATE] 12. The facility's contracted Speech Language Pathologist, V21, arrived at the facility on [DATE]. V21 completed Speech and Language Pathology worksheet (screens) for eight (8) residents. V21 provided staff training/education on safe swallow/compensatory strategies, feeding technique, placement of dentures when appropriate, performance of oral care after meals, completed [DATE]. Completed: [DATE] 13. The facility implemented a new Dining Room Form and Stop and Watch form. The Education Nurse or designee is providing staff with education on the use of this new form. Training for staff beginning [DATE] and training will be completed by [DATE]. These forms are to be completed by any CNA or Nurse as needed. To be Completed: [DATE] 14. The facility has scheduled inservices for all staff regarding Dentures, Oral Care, Swallowing, Speech, Diet, and Meal Time Safety. This is being presented by a contracted Speech Language Pathologist, V21, on [DATE], (7:15 AM, 2:15 PM, and 3:15 PM). To be completed: [DATE] 15. The facility implemented an ongoing audit to assure that dining rooms are supervised (as assigned) during resident meal times. This audit is to be completed by the Nursing House Supervisor or designee. Twenty (20) audits will be completed each week for two months. The Director of Nursing or designee will report the results of the audit(s) to the Quality Assurance Committee. The Q.A. committee will follow up as necessary. Initiated [DATE] 16. The facility will ensure a Speech Language Pathologist screens each resident, at least quarterly, or as needed related to changes in the use of dentures. Initiated: [DATE] 17. The facility will assure that if a resident's dentures are missing/lost/etc. a facility Nurse will assess the resident for safety of resident's current diet, prior to the resident's next meal, and if appropriate may downgrade diet until a Speech Therapist evaluates the resident. Initiated: [DATE]

Based on observation, interview, and record review, the facility failed to protect a resident from theft of their personal property, for 1 of 3 residents (R1) reviewed for misappropriation of resident property, in the sample of 10. This failure resulted in the resident becoming distressed, crying, refusing to eat meals, and not wanting to be around other people. The findings include: R1's Admission Record, printed by the facility on 6/21/23, showed she had diagnoses including Parkinson's disease, generalized anxiety disorder, dementia, osteoarthritis, malignant neoplasm of pharynx, secondary malignant neoplasm of brain, major depressive disorder, and personal history of antineoplastic chemotherapy and irradiation. R1's ADL (activities of daily living) care plan, with a revision date of 6/14/23, showed she required limited one assist of staff for dressing, personal hygiene, toileting and transferring to and from bed, wheelchair, and toilet. R1's facility assessment dated [DATE], showed she was cognitively intact and required extensive assist of one staff member for dressing, toileting and personal hygiene. R1's Progress Note, dated 5/24/23 at 9:00 AM, showed, Patient voiced concern this morning, POA (Power of Attorney), MD (Medical doctor) notified. DON (Director of Nursing) and Administrator aware for further follow up. R1's Progress Noted, dated 5/24/23 at 4:06 PM, showed, Resident is very distressed, crying, refused both meals related to missing items. R1's Missing Item Report, dated 5/24/23, showed at 7:10 AM that morning, R1 reported a diamond ring and a $50.00 gift card from a local store missing. The form showed R1's room was checked, the wing was checked. The bathroom and shower room, the dining room, the soiled laundry room, and the room and unit garbage were checked. The form showed dietary, laundry and housekeeping staff were notified. The form showed the items were not found. A note in R1's medical record, initialed by V24 (CNA/Ward Secretary) showed V23 (R1 significant other) gave R1 a ring that was silver with a green stone on 5/12/22. The facility's investigation into R1's missing items was reviewed. The investigation showed the ring, and the $50.00 gift card were not found, no staff member admitted to taking the missing items, and the police were notified. The facility's Visitor's Register was reviewed showing R1 did not have any family or other visitors from 5/21/23 until 5/24/23 at 10:01 AM (after the items were reported missing). On 6/20/23 at 9:43 AM, R1 was in her room, sitting in her wheelchair. R1 was alert and oriented. R1 had a spiral band around her left upper arm that had a key attached to the spiral band. R1 said she went to bed one night and when she woke up the next morning, her ring and her $50.00 gift card from a local store were missing out of the top drawer of her nightstand. R1 said the ring had a diamond and an emerald in it. R1 said her partner of [AGE] years gave her the ring, and her family gave her the gift card. R1 said she used to wear the ring on her hand, until she almost lost it in the sink one day. After that, she started keeping it locked in her nightstand. R1 said she always kept the ring and the gift certificate locked in the top drawer of her nightstand and the key on a band around her arm, even when she was sleeping. R1 pointed to the spiral band around her left upper arm with the key attached. The key ring was made of a sturdy metal-like material that would not easily come off the band. R1 said she never takes the key off the spiral band. R1 said the night before the items were missing, she had the band around her arm and the key chain was on the band. R1 said the day she reported the ring and gift card missing, she woke up and she was in the bathroom getting ready. R1 said the CNA (Certified Nursing Assistant) that helped her get ready kept going in and out of the bathroom, to R1's room (which R1 thought was weird because no one has ever gone in and out of the bathroom so many times while getting her ready). R1 did not know the name of the CNA. R1 said after she got cleaned up and dressed, she noticed the key was not on the spiral band around her arm. R1 said every morning she would check in her top drawer of her nightstand to make sure the ring was still in there. R1 said she reported to staff that she could not find her key. R1 said they found her key on her bedside table next to her box of tissues. R1 said she looked in the top drawer of her nightstand, and that morning the drawer was not locked, and her ring and the gift card were not in there. R1 said she reported the ring and gift card missing. R1 said no one from the facility has talked to her about the missing items since she spoke to the police officer, the day she reported them missing. As R1 was telling what happened, she appeared upset, and tears were [NAME] up in her eyes. R1 removed the spiral band from around her left arm and unlocked the top drawer of her nightstand. The box that used to have the ring in it was in the top drawer. The box was empty. The cardboard that the gift card used to be attached to was also in the top drawer. The gift card was not attached to the cardboard and was not found in the top drawer of R1's nightstand. After showing the empty box and cardboard, R1 locked the top drawer of the nightstand and was observed pulling on the top drawer to ensure it locked correctly. R1 said she always checked to make sure it locked correctly. On 6/21/23 at 9:45 AM, R1 repeated the process of unlocking the top drawer, locking it back and checking to ensure it locked correctly when she was showing the earrings that matched the ring she was missing. On 6/20/23 at 12:10 PM, V1 (Administrator) said he interviewed staff, and no one admitted to taking R1's missing items. V1 added he has never had an employee admit to taking a resident's items, in all the places he has worked. V1 said the police were called regarding R1's missing items. V1 said the police officer spoke with him and with R1. V1 said the police officer did not interview any staff members. V1 said the officer filed a report and told him if any of the local pawn shops report a ring with that description being pawned, he would let V1 know. On 6/20/23 at 12:20 PM, V8 (Certified Nursing Assistant-CNA) said she was informed by third shift staff about R1 missing a couple dollars. V8 said she told them they needed to report it to the nurse. V8 said she talked to R1 that day, and she was really upset and depressed about the missing ring, and did not want to be around anyone. V8 said she told R1 to let her know if she needed anything. V8 said R1 kept everything that was important to her locked up, and the key on a key ring that she took everywhere with her. V8 said she has never seen R1 try to take the key off the key ring. On 6/20/23 at 12:42 PM, V9 (Registered Nurse-RN/House Supervisor) said she was told by a CNA about R1's missing items. V9 said she went to R1's room and filled out the missing item form, then notified the DON (Director of Nursing), Administrator, R1's POA (Power of Attorney), R1's doctor and the police. V9 said R1 said she keeps the drawer to her nightstand locked. V9 said that morning, the scrunchie (spiral band) was on her arm, but the key was on her bedside table. V9 said R1's family verified they bought her a gift card for her birthday, and R1's significant other verified he bought her a ring. V9 said R1 is alert and oriented and answers questions appropriately. V9 said she had no idea what might have happened to the missing items. On 6/20/23 at 1:08 PM, V11 (RN) said R1 reported the missing items to her. V11 said no staff reported it to her. V11 said R1 said it happened on the overnight shift that worked 5/23/23-the morning of 5/24/23. V11 said she reported it to V9 (House Supervisor) right away. V11 said she was not aware R1 had these items until she reported them missing. On 6/20/23 at 2:19 PM, V15 (CNA) said she worked the night shift into the morning on 5/23/23-5/24/23, the day R1 reported the ring and money missing. V15 said R1 takes herself to the bathroom, staff help dress her and make her bed. V15 said V14 (CNA) went into R1's bathroom and got her ready. V15 said she went in and made R1's bed and took R1's trash out of her room, while R1 was in the bathroom getting ready. V15 said about 10 minutes later, V14 told her R1 said she could not find the key to her nightstand, and the key was not on her bracelet (spiral band). V15 said she went into R1's room to check, and the key was on R1's bedside table. V15 said V14 had gone back into R1's room after because R1 had turned her light on again. V15 said she asked V14 why R1 had turned her light on again, because that was unusual for her to turn her light on that often in the morning. V15 said V14 told her R1 said she could not find her ring and three dollars. V15 said V14 told her the three dollars was found, but not the ring. On 6/20/23 at 2:04 PM, V14 (CNA) said when she went into R1's room on the morning of 5/24/23 to help her get dressed, R1was already in the bathroom, sitting on the toilet. V14 said she helped R1 put her shirt on and her deodorant on. V14 said the scrunchie band was on R1's arm when she assisted her, however, she does not know if the key was on the band or not. V14 said she did not leave the bathroom to go into R1's room, because R1's clothes and everything she needed was already in the bathroom when she went in. V14 said she went into R1's room after that because R1 had turned her light on. V14 said R1 told her she was missing three dollars and a ring. V14 said R1 told her she found the three dollars, but did not find the ring. On 6/21/23 at 8:38 AM, V23 (R1's significant other) said he gave the ring to R1 about a year prior for her birthday. V23 said it was an emerald ring with a diamond in it. V23 said he bought it from a local jeweler. V23 said the facility has not spoken to him about the missing ring. V23 said R1 kept the ring in her locked nightstand. On 6/21/23 at 10:21 AM, V22 (R1's daughter/POA-Power of Attorney) said R1 received the gift card for her last birthday. V22 said V23 gave R1 the ring last year. V22 said R1 used to wear the ring all the time. V22 said no one from the facility has spoken to her regarding any updates on the missing items since they first informed her that they were missing. On 6/21/23 at 9:01 AM, V24 (CNA/ [NAME] Secretary) said V23 told her over a year ago he gave R1 a silver ring with a green stone. V24 said she wrote it down on a piece of paper and put it in R1's medical record. V24 said she also informed the nurse on duty about the ring. V24 said R1 is with it and faithful about keeping it locked in the top drawer of her nightstand. V24 also said R1 always keeps the key with her. V24 said V22 and R1 are very honest and good on their word. On 6/21/23 at 10:17 AM, V20 (CNA that worked the second shift on 5/23/23) said R1 requires a lot of help getting dressed in the morning, however in the evening, unless R1 asks for help, staff do not do much for her to help get her ready for bed. V20 said she is not aware if the key was on the spiral band around R1's arm when she laid down on 5/23/23 because she did not ask for help. At 1:30 PM, V25 (CNA) said she worked the second shift on 5/23/23. V25 said she did not assist R1 with getting ready for bed because R1 was independent. V25 said she does not recall if the band was around R1's arm or not when she went to bed. On 6/21/23 at 9:32 AM, V16 (CNA) said R1 always kept the top drawer of her nightstand locked and the key on her spiral band. The band was always on her arm. V16 said she has never seen R1 take the key off the band. On 6/21/23 at 9:40 AM, R1 said she got into bed about 6:00 PM on 5/23/23. R1 said she always gets into bed around that time. R1 said she would lay in bed and watch television for a while before she went to sleep. R1 said the top drawer of her nightstand was locked that night and the key was on the band around her arm. R1 said she always checks the drawer to make sure it locks correctly. On 6/22/23 at 3:08 PM, V1 (Administrator) said R1 is sharp. V1 said R1 did all the right things by keeping the drawer that her valuables were in locked, and always keeping the key with her. The facility's Abuse Prevention /Detection Program policy and procedure, with a review date of November 2021, showed II Resident Treatment: A. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property. The policy defines misappropriation of resident property as follows: Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to serve liquids at a safe temperature to prevent burns, and failed to supervise residents at risk for burns and with poor safety awareness for 3 of 9 residents (R9, R32, R33) reviewed for safety and supervision in the sample of 23. These failures resulted in R32 sustaining a partial thickness burn to his right foot. The findings include: 1. R32's face sheet showed a [AGE] year-old male with diagnosis of hemiplegia and hemiparesis following a subarachnoid hemorrhage affecting the right dominant side, major depressive disorder, history of malignant neoplasm of bladder and hypertension. R32's 8/24/22 incident report showed staff noted a wound to his right dorsal foot and the resident stated he spilled coffee on his foot yesterday. The right foot had a 6 centimeter (cm) X 3 cm blister and a 2.5 cm X 2.5 cm X less than 0.1 cm wound. The report showed the interventions initiated was blank. R32's 8/24/22 progress note showed resident has new wounds on right foot from coffee burn. There is no wound assessment or other data regarding the incident. A late entry note showed there was partial skin loss and blistering noted to the right foot. Again, there were no measurements or other data noted in the record. R32's 1/1/23 facility assessment showed moderately impaired cognition. This assessment showed R32 was totally dependent on two plus persons physical assistance for toilet use, transfer, and bathing. Bed mobility, dressing, and personal hygiene required extensive assistance of two plus persons to physically assist but once up in his electric wheelchair R32 was independent to move around the facility. R32's safety and skin care plans have no interventions to prevent additional burns. An intervention present showed-if I refuse assistance to get a cup of coffee, provide education on the possible consequences (resident is moderately cognitively impaired). There is no plan to add a cup holder to R32's wheelchair. There is no mention of the 8/24/22 burn incident in R32's care plans. R32's 2/14/23 incident report showed he was transporting a hot cup of coffee from the dining room to his room holding the cup between his thighs. The coffee spilled onto his feet. The right foot had burns from the inner ankle on to the bottom of the foot. The wound measured 14.5 cm X 9.5 cm with partial skin loss and partial blistering. The report showed R32 needed a cup holder on his electric scooter. R32's 2/14/23 progress note showed R32's daughter was updated about the resident spilling coffee onto his feet causing a burn onto his right foot. The note showed the resident returned to the dining room, obtained another cup of coffee and spilled that one as well. Per the note, R32's daughter told the facility he used to have a cup holder on an electric wheelchair and that helped him transport cups of coffee as he has a weak right side. R32's 2/17/23 Wound Physician note showed two wounds to the right foot. Wound #1 showed an etiology of trauma/injury to the right proximal, medial foot measuring 7.8 cm X 3 cm X 0.1 cm. Wound #2 showed an etiology of a burn to the right dorsal foot measuring 13.5 cm X 4.9 cm X 0.1 cm. R32's 2/22/23 incident report showed the resident spilled hot coffee on his left thigh. The area was reddened with a broken blister area that measured 25 cm X 2 cm. On 2/23/23 at 8:40 AM, R32 was in bed. There were 3 empty coffee cups on the bedside table next to him, and the blanket over him had a large coffee stain on it. R32's electric wheelchair was in the room. There was no cup holder attachment on the wheelchair. Access to hot liquids in R32's dining area is not restricted or monitored. On 2/23/23 at 9:43 AM, V4, Wound Nurse, removed the dressing to the wound on R32's right medial foot. There was a large open blister that extended down the side and then the bottom of the right foot. There was another bandage over R32's left knee area. On 2/22/23 at 1:03 PM, V9, Dietary Manager, said a safe temperature for liquids to be served to residents is 165 degrees Fahrenheit. V9 said, I know residents have had burns (from hot beverages). That's why we started putting ice in the hot drinks after (R9) was burned (1/29/23). On 2/23/23 at 9:48 AM, V5, Registered Nurse, said the dressing to R32's left knee area is another burn from his coffee. V5 described the area on R32's left knee as approximately 6 inches long with a blister. R32's new burn wound was not observed as the dressing was not due to be changed. V5 said the burn to his left leg happened 2/22/23. A list of resident burns from hot beverages was requested. The handwritten list received did not include R32's 2/14/23 burn. (This list was received prior to R32's 2/21/23 burn). The National Institute of Health website (nih.gov) showed a burn takes place when the skin comes into contact with a heat source. The most common sources that cause burns are fire/flame, scalds, hot objects, electrical, and chemical agents, respectively. The skin location, the degree of temperature, and duration are contributing factors to the severity of the burn. There is a synergistic effect between the temperature and duration of exposure. Skin exposure to 140 degrees Fahrenheit (F) (60 degrees Celsius) for 10 seconds can cause a full-thickness burn. Some burns, especially partial-thickness, may progress over 2 to 4 days, peaking at day 3. Partial Thickness superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days. Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring. Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present. The facility's 9/2015 Skin Injury Policy showed any resident injury of skin must be addressed as follows: 2. Nurse must assess injury, 4. Injury must be documented in the care plan, 8. Update care plan interventions to prevent further injuries. The facility's 2017 Food Safety: preventing Burns Policy showed hot and food and beverages will be served at a safe temperature to prevent burns. Staff will monitor hot beverages on a regular basis at the point they are served. Appropriate supervision to obtain hot beverages will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds. This policy showed water temperatures at 150 degrees take less than a second to cause second degree burns. Hot liquids at 140 degrees may cause second degree burns in 3 seconds. 2. R9's face sheet showed an [AGE] year-old female with diagnosis of dementia with psychotic disturbance, need for assistance with personal care, weakness, and chronic kidney disease. R9's 8/4/22 facility assessment showed R9 had severe cognitive impairment. R9's 12/11/22 facility assessment showed she required extensive assistance of two plus persons to physically assist with bed mobility, dressing, toilet use, and personal hygiene. This assessment showed R9 required limited assistance of one person to physically assist her to eat. R9's 1/29/23 incident report showed the resident spilled her full cup of hot cocoa onto her left breast, left side of her abdomen and left arm resulting in three blisters to the left arm. Blister #1 measured 5 cm X 0.3 cm. The second blister measured 12 cm X 3 cm. The third blister measured 10 cm X 2.5 cm. There was a red mark to the left side of the abdomen measuring 6 cm X 4 cm. The intervention initiated for this incident was to put ice into cocoa before it is given to the resident and to move the resident to the feeder table. R9's 1/29/23 progress note showed no wound assessment. The wounds size, color, location, peri wound and other pertinent data. The facility's January 2023 Incident/accident log showed on 1/29/23, R9 had a burn/blister to the left arm from spilled hot cocoa. R9's incident notes and skin/wound notes in her medical record are blank. There was no wound assessment in R9's nursing progress notes and no scanned wound documents. R9's care plan had no interventions to prevent future burns from hot liquids. R9's safety care plan showed she was unaware of her safety needs and forgets her functional limitations due to progression of dementia. R9's activity of daily living care plan showed a deficit related to impaired mobility/cognition due to a history of a stroke with right sided hemiplegia and hemiparesis. R9's cognition care plan showed impaired cognition impairments are evidenced by decreased memory and orientation. On 2/21/23 at approximately 1:50 PM, R9 was in the dementia unit dining area visiting with family. R9 was in a wheelchair. Her left antecubital area was reddened, and had scarred residual of the burn wound. The area was open to air and closed. On 2/22/23 at 11:25 AM, V16, Community Staff Aide, poured hot water into individual cups on the dementia unit. The temperature of the water was 169 degrees Fahrenheit. Hot cocoa mix and ice cubes were added to each cup ,then mixed and served to the residents. At 11:30 AM, V16 said they never check the temperature of the hot liquids before serving them to the residents. On 2/21/23 at 1:50 PM, V15, R9's daughter said R9 was burned from hot chocolate. Why would they even serve hot chocolate that hot. She had blisters. 3. R33's face sheet showed an [AGE] year-old female with diagnosis of cerebral infarction, vascular dementia, bilateral optic atrophy, left eye esotropia (deviated toward the nose), head contusion, and aphasia. R33's 5/12/22 facility assessment showed severe cognitive impairment. This assessment showed R33 resided on the dementia unit. R33's 5/12/22 facility assessment showed she required extensive assistance of one-person physical assist for eating, bed mobility, transfer, dressing, toilet use, and personal hygiene. R33's care plan showed she was unaware of her safety needs, overestimates her functional ability and had poor spatial awareness. R33's medical record showed no skin, wound, or incident notes. The facility's May 2022 incident/accident log showed no mention of R33's 5/20/23 burn incident. The facility's 5/20/22 incident report showed R33 spilled hot cocoa in her lap. The report showed bilateral upper thigh redness. The intervention suggested was to put ice cubes to hot liquids. No measurements or complete wound assessment were on R33's record. R33's 5/31/22 wound assessment flowsheet provided by the facility and not part of her electronic record showed diffuse redness. R33's 5/20/22 progress note showed no wound assessment or other data regarding the burn incident circumstances. R33's safety and skin care plans have no mention of the 5/20/22 burn incident and no interventions to prevent additional burns.

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the local health department and the Centers for Disease Control regarding isolation of COVID-19 residents, and the facility failed to ensure staff were knowledgable in the use of personal protective equipment. This failure has the potential to spread COVID-19 disease to negative residents. This applies to five of five residents (R1, R5, R6, R8, and R10) reviewed for infection control practices in the sample of 11. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/18/21 when R1, R5, R6, R8, and R10 were not separated from their COVID-19 positive roommates during the facility's current outbreak. The Immediate Jeopardy was identified on 1/20/21. V1 (Administrator) was informed of the Immediate Jeopardy on 1/22/21 at 11:35 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/22/21; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. On 1/20/21 at 9:05 AM, V1 (Administrator) stated the building was currently in a huge COVID-19 outbreak with 47 positive residents. V1 said the first resident tested positive on 1/11/21 after being sent out to the local hospital and it has just exploded since then. V1 said the entire A-unit is on isolation with some positive and negative residents remaining together in the same rooms. On 1/20/21 at 10:05 AM, V2 (Infection Control Preventionist) stated COVID-19 positive residents were being moved to the south wing of the A-unit until it became full on 1/18/21. V2 said after the south wing filled up, all residents were placed on transmission based precautions and left in their same rooms. On 1/20/21 at 12:40 PM, V1 stated negative residents have been left in the same room as their positive roommate because they have been exposed to [MEDICAL CONDITION]. V1 said they haven't been separated for fear of spreading COVID-19 to other areas of the facility. V1 said all four hallways on the A-unit have COVID-19 positive residents and it would be a huge task to move so many residents around. V1 said there is a plan in formation to move the COVID-19 negative residents to a separate, closed off hall but that has not been done yet. V1 said that would be a team decision, it is not fully thought out yet, and the idea is just forming this morning. V1 said a separate unit for the negative residents would be a sanctuary and would protect those residents from the known positive residents. On 1/20/21 at 1:05 PM, V2 stated the COVID-19 positive and negative residents have not been room separated yet because we are trying to stop the spread to other areas in the building. V2 said widespread testing was done on 1/18/21 for all residents and resulted in 18 positive and 19 negative residents. V2 said it was decided the best way to mitigate any spread was to leave all A-unit residents in their current room, with their current roommate (regardless of test results). V2 said it felt like there was a greater risk of exposing the negative residents to COVID-19 by moving them versus just leaving them right where they were. V2 said the goal is to separate the negative and positive residents, but there just isn't the physical space right now. The facility's Resident Bed List Reports from 1/18/21 to 1/20/21 were reviewed. The facility's January 2021 COVID-19 Mass Testing Logs were reviewed. The documents showed: R4 tested positive on 1/18 and R1 tested negative on 1/19. Both residents continue to reside in the same room together. R7 tested positive on 1/19/21. R6 tested negative on 1/19. Both residents continue to reside in the same room together. R2 tested positive on 1/18 and R5 tested negative on 1/19. Both residents continue to reside in the same room together. R9 tested positive on 1/18 and R8 tested negative on 1/19. Both residents continue to reside in the same room together. R11 tested positive on 1/18 and R10 tested negative on 1/19. Both residents continue to reside in the same room together. The Resident Bed List Report showed all the residents were located in the A-wing of the facility. On 1/21/21 at 10:00 AM, V5 (Business Office/Census Staff) stated the A-wing has 99 total beds. V5 said the resident census on 1/20/21 was 60 residents and therefore the bed census was 39 open beds. V5 said the 39 beds were only considered available assuming male residents resided with males and female residents resided with female. V5 did not know if the five currently positive residents could be relocated to one of the 39 beds with another positive resident. On 1/21/21 at 1:30 PM, V6 (Communicable Disease Coordinator at local health department) stated her department is in daily communication with the facility. V6 said she was aware the facility was in a COVID-19 outbreak and have been providing guidance. V6 said guidance included moving positive and negative residents to separate rooms in hopes that the negative residents would remain negative. V6 said her department also offered suggestions if room space was limited. V6 said using plastic sheathing to block one hall and setting up a separate unit was suggested as a way to keep positive and negative residents apart. V6 said the goal is to put positive residents with positive residents and negative residents with negative residents. V6 stated she clearly remembered a phone call sometime last week (week of 1/11/21) between facility staff and her communicable disease nurse discussing the plastic sheathing tactic. V6 said the facility staff member mentioned they did have the plastic due to recent construction in the building but opted not to use that suggestion. The facility's COVID-19 Infection Control policy, revision dated 9/11/20, states under the transmission based precautions section: i. (facility) will ensure appropriate space/private room if available. If private rooms are unavailable, the (team) will make room placement decisions balancing risks to other residents; and by cohorting impacted residents. The CDC website Responding to COVID-19 in Nursing Homes, updated 4/30/20, shows under the resident with new-onset suspected or confirmed COVID-19 section: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents .If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission .If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit .Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) .Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. On 1/21/21 at 3:00 PM, V1 (Administrator) and V3 (Director of Nurses) stated two of the five residents (R5 and R6) that were allowed to remain in the same room as their COVID-19 positive roommate have now tested positive. The Immedieate Jeopardy that began on 1/18/21 was removed on 1/22/21 when the facility took the following actions to remove the immedicacy: Removal Plan: Action was underway on 1/18/21 and ongoing to separate Covid-19 positive residents from Covid -19 negative residents. This was completed at 3:00PM on 1/21/21. Residents who tested positive were seperated from resident who tested negative to include R1, R5, R6, R8, R10. Education for transmission based precautions was intitiated on on 1/21/21. Education will be completed by 1/25/21. The faciity will test and assess residents based on symptomatology and testing every 3-7 days for screening of residents previously negative for Covid 19. Room changes are to occur immediately after the identification of a positive test result or symptoms. The facility will continue to assess and test residents for Covid 19 to maintain separtation of positive and negative Covid 19 residents. The Quality Assurance Team will meet weekly and as needed to assess compliance along with daily IDT meeting comminications. 2. On 1/20/21 at 9:05 AM, V1 (Administrator) stated there is currently a huge outbreak of COVID-19 in the building. V1 said the A-unit is designated as the COVID-19 unit. V1 said all positive and potentially exposed residents are being cohorted on the A-unit. V1 said the B-unit does not have any COVID-19 positive residents, but does have one hallway (B-south) for 14 day isolation of new admissions or readmissions. On 1/20/21: At 11:00 AM, the B-south wing had yellow highlighted signage on each end of the hall stating: STOP . Please go through A-(wing) if you are not caring for residents in this hall! At 11:05 AM, V7 (CNA) stated those are old signs and are not correct. They were put up to direct people to not pass through this hall and instead go through the A-unit (COVID-19 unit). We have tons of people with COVID-19 on that unit now so I will take the signs down right now. V7 said the B-south wing is a PUI (Person Under Investigation) isolation unit and no one should be using the hallway as a pass through. At 11:30 AM, V10 (Hospice Nurse) walked through the PUI unit and stated she was not caring for any resident on the hallway and was only passing through. V10 walked past a second sign on the PUI unit door that showed: Please do not enter unless you are needing to care for or see a resident on this unit. This is an added safety measure. At 11:05 AM and 11:20 AM, V7 (CNA) was wearing goggles on top of her head while entering two different resident rooms on the PUI unit. At 11:30 AM, V10 (Hospice Nurse) walked through the PUI unit without eye protection. At 11:10 AM, V8 (CNA) was also wearing goggles on top of her head while caring for residents on the B-west unit. At 11:45 AM, V2 (Infection Control Preventionist) stated eye protection is needed at all times in resident care areas, not just when staff are within six feet of the resident. V2 said COVID-19 can spread through the eyes and protection is necessary to stop the spread. At 11:50 AM, V11 (Housekeeper) was wearing a N95 mask, eye protection, gown, and gloves while exiting the A-wing (COVID-19 unit). V11 went to the clean PPE bin and opened drawers to get a cleaning rag. V11 was carrying a full bucket of sanitizing solution. V11 said he just came out real quick to grab cleaning towels so he left his PPE on. V11 said he was unsure if he needed to remove the PPE to exit the unit. At 12:00 PM, V12 (Cook) was at the A-wing (COVID-19 unit) steam table filling resident lunch trays. V12 was not wearing any eye protection or gown. V12 stated she thought she only had to wear them if she went down a hallway, but she wasn't sure. At 12:05 PM, V14 (Registered Nurse) stated she was not sure what the PPE rules were on the A-wing (COVID-19 unit). V14 said the rules have changed one or two times over the past few days and we are flying by the seat of our pants. V14 said she thinks the rule is to change gowns and gloves after exiting every resident room. V14 said the nurse station is considered a clean area and we can't go behind it with a gown. We have to take it off first. At 12:10 PM, V15 (Nurse Secretary) was behind the A-wing (COVID-19 unit) nurse station wearing a gown. V15 said she didn't realize she was supposed to take if off. V4 (Assistant Director of Nurses) was seated next to her without a gown on and said, Yes, you shouldn't be behind the nurses station in that gown. This is a clean area. At 12:30 PM, V16 (Housekeeper) and V17 (CNA) were on the A-south hall (COVID-19 unit). Neither were wearing gowns or gloves. V16 said I think I am supposed to put them on when I enter the south hall, but I'm not really sure. V17 said she was told to change her gown when entering the south hall but didn't have one available at the unit entry. V17 said she changes her gown between every resident care. At 12:40 PM, V19 (Respiratory Therapist) stated he was told to wear full PPE when entering the A-wing because all the residents were COVID-19 positive and only remove it when exiting the A-wing. At 12:35 PM, V18 (CNA) stated she changes her gown between every resident on the A-south hall. At 12:45 PM, V21(CNA) stated she doesn't change her gown between residents on the A-south hall. At 1:00 PM, this surveyor exited the A-south hall and was instructed by V17 (CNA) to change gowns and gloves before entering the other three A-wing halls. There was no biohazard disposable bin, no clean gowns, and no trash can for sanitizing items outside of the unit. At 1:05 PM, V20 (Restorative Nurse) stated she wasn't really sure how to enter or exit the A-south hall. V20 said she hasn't had the need to go in or out so she doesn't really know. At 1:15 PM, this surveyor exited the main entry to the A-wing (COVID-19 unit). There was no biohazard disposable bin available. At the same moment, V22 (Unit Assistant) exited wearing a gown and pushing a wheelchair. V22 said she has to use the end resident room to throw away her contaminated gowns. V22 said she had just washed the wheelchair at the far end of the COVID-19 unit and was taking it to the therapy department. At 1:20 PM, V23 (Activity Aide) entered the COVID-19 unit without donning any gown or gloves. V23 returned five minutes later with a hot microwavable lunch container and stated he uses the microwave on that unit to heat his lunches. Facility postings on the door outside of the A-wing (COVID-19 unit) showed: Building A (A-wing) is considered to be a Protective Area. Do not enter unless given direction. Staff assigned to building A need to stay on the unit until the end of the shift. Staff assigned to A should only use the A lounge. Staff should bring a change of clothes to change into before leaving for the day. Additional signage from the (CDC) Center for Disease Control showed: PPE must be donned correctly before entering the patient areas (e.g. isolation room, unit if cohorting). PPE must remain in place and be worn for the duration of work in potentially contaminated areas. The sign showed required PPE consisted of eye protection, N95 facemask, gloves, and gowns. At 1:05 PM, V4 (Assistant Director of Nurses), V14 (Registered Nurse), V20 (Registered Nurse), V24 (CNA), V25 (CNA), and V26 (Activity Aide) were on the COVID-19 unit not wearing gowns. Multiple resident room doors were wide open on all four A-wing halls. On 1/22/21 at 9:45 AM, V2 (Infection Control Preventionist) stated PPE in the A-wing (COVID-19 unit) changed overnight and the entire wing is now a (TBP) transmission based precaution unit. V2 said PPE required on a TBP unit includes a N95 mask, eye protection, gown, and gloves. V2 said resident room doors should be closed to reduce the potential for COVID-19 spread outside of resident rooms. V2 said the sign on both entries to the B-south (PUI) unit was old and incorrectly directed staff to pass through the COVID-19 positive unit. V2 said staff receive CDC training in regard to proper PPE use and should be well aware of when and how it is used. V2 said the last training was just last month in December 2020. The facility's COVID-19 Infection Control policy, revision dated 9/11/20, shows: The primary goal of (facility) is to prevent COVID-19 from being introduced within our campus. Prevention include: b.Providing training and education for staff, residents, and visitors on COVID-19, Use of personal protective equipment (e.g. gloves, gowns, masks, eyewear) when there is an expectation of possible exposure to infectious material. Resident room doors will be closed unless there are safety considerations. Removing and discarding the gown in a dedicated container for waste or linen before leaving the resident room or care area.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse/punishment from staff. This failure resulted in R23 experiencing fear, loss of sleep, and mental anguish since December 29, 2017. This applies to 1 of 35 residents (R23) reviewed for abuse in the sample of 35. The findings include: R23's February 2018 physician's orders [REDACTED]. R23's current MDS (Minimum Data Set) documents that R23 scored a 15 on the BIMS (Basic Interview for Mental Status) showing that R23 has no cognitive impairment. On February 6, 2018 at 8:31 AM, R23 was sitting in her wheelchair in her room. R23 was asked about the incident that occurred on December 29, 2017. R23 stated, I still wake up in fear and shaking. Because it scared me so bad. Makes me shiver just to talk about it. It was a while ago, (V8- LPN) made me sit up in my chair all night. (R23 got tears in her eyes) I told her I didn't want the two CNAs that were working to take care of me. They didn't know me. She told me I could train them. I told her that I don't train people. So she told me I would have to stay up in my chair. So I sat up all night. I put my call light on and asked for a blanket, they wouldn't give me one. Then I asked for a pillow and they wouldn't get me one. So I pulled on my blanket and got the pillow off my bed, then I turned my chair around and got my legs up on the bed and I sat there all night. I told the supervisor on Monday and he told (V1- Administrator). On February 6, 2018 at 2:47 PM V1 stated, (R23) is very particular with everything in her care. She was refusing to have anybody put her to bed. Kept saying they don't know my routine. (V9 and V10- CNAs) asked her a couple different times. (V8) talked to her a couple different times. (V8) told R23 you can train her on your routine. (R23) said, I'm not training the staff. (R23) told (V8), Get me a different CNA. (V8) didn't want to take a CNA from another unit and make them short and told (R23) I'm not going to get anyone else. (R23) said she could see the CNAs sitting in the hall. (V9 and V10) said (R23) was refusing care. They said they were respecting her rights. I asked (V8) to write a statement of what happened and (V8) wrote her resignation and left it on my desk. Then I got her to come in and talk to me and I don't think she got it. (V8, V9, and V10) all said it was (R23's) right to refuse and they were not going to force her to do something she didn't want to. V1 was asked what the staff should have done in this situation. V1 stated, I expect the nurse to pull someone from another unit, just to avoid conflict. On February 6, 2018 at 3:17PM V6 (Social Service) stated, (R23) told me that she's had some fear and is having trouble sleeping at night. I don't think it is documented. I have seen her get emotional. The Final Incident Investigation Report dated January 8, 2018 states, (V8) stated that both CNAs assigned to the resident offered the resident assistance but the resident refused their assistance . (V8) stated that she told the resident that the other CNAs in the building were busy with other residents on their hallways . (V8) stated, I did not tell (R23) she had to sleep in her wheelchair. (R23) is alert and oriented x3 and made that choice on her own. (V10) stated (R23) refused, asking if there was anyone else in the building who completely knew her routine that could come get her ready. I told her I would ask the nurse. When I left the room (V8) was on her way down the hall to give (R23) her nightly medication. I stopped (V8) and told her that (R23) refused for us to get her ready because we don't know her routine fully and is requesting another aid from the building that does know her routine. (V8) said No, she'll have to sit up in her chair for the night then. When (V8) came out of resident's room she informed us that resident still refused our care and chose to stay in her chair. (V9) gave a statement. (V9) stated that the resident (R23) refused for either her or (V10) to give her care. The resident wanted someone else but the girl she wanted wasn't there. (V8) told the resident that she couldn't get her a different CNA. This same document states, In conclusion, it was determined that (V8) could have given more effort to find someone different to provide care for the resident, either in a different hallway or another part of the facility. (V9 and V10) could have also persisted in assuring that someone else in the facility (a different CNA or nurse) provided care for the resident on December 29, 2017, or alerting someone in position of authority to resolve the concern. None of the individuals followed (the facility) standards of practice, good customer service, and resident care. R23's Behavior care plan dated February 22, 2016 states, I am impatient and intolerant of others, especially staff, I am selective with whom I interact with on a daily basis per my choice, I am particular in my routine . One approach listed on the care plan states, Convey an attitude of acceptance towards me. The facility policy entitled Abuse Prevention and Management Manual dated November 2016 states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Willful, as used in this definition of abuse, mean the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to remove a tray of food from the vicinity of a resident assessed at risk for choking and with known impulsive eating behaviors. This failure resulted in R1 being found unresponsive in R1's room after taking food off an unmonitored tray of food near the nurse's station. R1 subsequently died . This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. This failure resulted in an Immediate Jeopardy which began on [DATE] when R1 ingested food from an unattended meal tray, causing R1 to choke and subsequently leading to R1's death. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 10:03 AM. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity level 2, due to the need to evaluate the effectiveness of any new policies, procedures, and training provided to staff. The findings include: R1's Face Sheet dated [DATE] shows R1 is a [AGE] year old pt, admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] shows R1 had a score of 99 (unable to complete), moderate cognitive impairment; fluctuating behaviors with inattention and disorganized thinking, and extensive assistance with walking and eating. R1's Physician order [REDACTED]. R1's undated Bed card (quick reference sheet) shows R1 is a total assist with eating, is on thirty minute safety checks, and very quick/impulsive in the notes section. R1's Care Plan dated [DATE], under the category of Nutritional Status, shows R1 to be on a mechanical soft diet, difficulty chewing due to [MEDICAL CONDITION]'s disease, and at times can put too much food in my mouth and take a long time to chew. This same care plan documents that R1 is fed by staff, is quick and impulsive, and at times takes food/liquids from other residents. The approaches to be taken are: Staff will monitor and remove food/drink items in R1's vicinity, to be fed by staff at the nurse's station, monitor for difficulty chewing/swallowing, and monitor (R1's) interactions around others during meal times. R1's Physician Internal Medicine Report dated [DATE] shows R1 being assessed for [MEDICAL CONDITION]'s disease and dysphagia (swallowing difficulties) with a Plan/Orders of aspiration precautions. The facility's Incident Report dated [DATE] showed on the afternoon of [DATE], R1 was observed in R1's room on the floor, V10 Registered Nurse (RN) assessed the resident and noted food particles around R1's hands and mouth. V10 started Cardiopulmonary resuscitation (CPR). Staff contacted the Emergency Medical Services (EMS) department, primary physician, and (R1's) family. EMS arrived and took over the care of the resident. On [DATE], at 4:15 PM, V9 Certified Nursing Assistant (CNA) stated Around 2:10 PM ([DATE]), I did not see any of the other staff in the 2 South hall way. I noticed a tray of food and water pitcher in disarray on the table next to the nurse's station at the beginning of the South Hallway. A trail of food was on the floor from the tray, and it went down the hall towards R1's room. I knew of R1's behaviors of taking food, and went to check on R1. I found R1 on the floor unresponsive, lips were blue, and R1 had food particles (mashed potatoes and meatloaf) in R1's mouth and on R1's hands. I yelled for help while turning R1 onto R1's side to do a finger sweep in an attempt to remove some of the food out of R1's mouth. R1 was unresponsive, not breathing, and had no pulse. I initiated CPR. V7(RN) and V16(RN) Registered Nurses (RNs) came into the room to assist with coding R1. While performing CPR, suction was used to remove more food particles from R1's mouth. On [DATE] at 9:45 AM, V7 stated I entered R1's room. V9 had started CPR already. R1 was cyanotic (blue faced) with ground meat particles around R1's mouth, hands, and on the floor next to R1. Suction was used during CPR to remove more food particles from R1's mouth in attempt to clear R1's airway. EMS arrived, took over CPR, and left with R1 to the hospital. V7 stated the hospital called after 3:00 PM to notify us R1 had expired at the hospital. V7 stated R1 had very impulsive behaviors. R1 would get up quickly to walk down the hall or R1 would grab food and put it into R1's mouth. R1 had swallowing problems, and the way shoved food into R1's mouth R1 was at risk for choking. Staff would place R1 in a chair by the nurse's station so staff could keep an eye on R1. On [DATE] at 9:30 AM, V10 (CNA) stated On [DATE], approximately 2:15 PM, I was in a resident room waiting for assistance with a mechanical lift transfer. I heard someone yell for help. When I looked out of the room I saw staff in R1's room starting CPR. There was a food tray on the table next to the nurse's station and a trail of food down the hall in the direction of R1's room. On [DATE] at 8:50 AM, V6 (Registered Nurse) stated I went to help when R1 was coding. There was a food tray and tipped over water pitcher on the table next to the nurse's station. Food was trailed on the floor down the hall in the direction of R1's room. On [DATE] at 4:15 PM, V9 (CNA) stated R1 needed to be fed one to one because of R1's behaviors of taking food off of other resident's trays, taking water off of the nurse's carts, and shoving large amounts of food into R1's mouth (with hands) without waiting to chew or take a drink. R1 was fed at the table by the nurse's station, outside the dining room, to reduce R1'sbehavior of grabbing other resident's food. R1 was very fast when R1 would grab any food or liquids. R1 could not be left alone with any food because R1's eating habits could easily make R1 choke. On [DATE] at 9:00 AM, V5 (Dietitian) stated R1 needed to be fed one to one by staff for safety due to behaviors of grabbing and stuffing food into R1's mouth. V5 stated on previous visits to the facilityV5 had witnessed R1's behavior of stuffing food into R1's mouth. On [DATE] at 9:00 AM, V4 (Assistant Dietary Manager stated dietary staff is told If R1 is in the dining room redirect her out and let other staff know R1 is there. R1 needed to be fed one on one with staff because of her behaviors which is a safety issue. R1 will quickly grab and shove food into R1's mouth. R1 has [MEDICAL CONDITION]'s disease which causes R1 to have swallowing difficulties. R1 was impulsive and could not be left alone with food. R1 has had these behaviors since R1'sadmission (February 12, 2015). V4 stated the CNA who feeds R1 is responsible for returning the food tray to the nutrition station after R1 is done with meals. R1 is on a general, mechanical soft diet with small portions. On [DATE] at 8:30 AM, V13 (CNA) stated staff would try to direct R1 to the chairs out by the nurse's station to be watched. R1 was ambulatory and would quickly get up and walk. R1 had access to the whole 200 wing. R1 was fed separately outside of the dining room. R1 is fed at the table next to the nurse's station to reduce R1's behavior of taking food off other resident's meal trays. R1 needed to be watched closely so she did not take any food and choke. On [DATE] at 8:50 AM, V11 (CNA) stated R1 was ambulatory with impulsive behavior. R1 would get up and walk all the time. R1 would grab food off of trays with R1's hands and put the food into her mouth. R1's behavior of grabbing food and shoving it into R1's mouth made R1 a choking risk. R1 needed to be fed one to one outside of the dining room. On [DATE] at 9:30 AM, V10 (CNA) stated R1 has a history of wandering and quickly grabbing food and putting into R1's mouth. V10 stated the way R1 would eat made R1 a choking risk. V10 stated we try to monitor R1 by keeping R1 around the nurse's station so there is more staff to watch R1. I have not heard of anyone being 'designated' to watch R1 after meals or during the day. On [DATE] at 9:00 AM, V12( CNA) stated R1 was fed one to one at the table next to the nurse's station to keep R1 from grabbing others food and choking. R1 was a one to one observation after she finished eating to make sure R1 did not walk back into the dining room to get food during meal times. R1 has no history of pocketing food, but would gulp fluids really fast. R1 could not eat or drink without a staff member present. V12 stated last week I walked into R1's room and R1 was opening R1's roommate's chocolates. I just let R1 eat it and made sure R1 didn't choke. On [DATE] at 2:10 PM, V15 (CNA) stated on Saturday ([DATE]) I fed R1 at lunch. R1 ate all of R1's food without pocketing any in R1's mouth. R1's meal tray was returned to the dining room after R1's meal. V15 stated, later on I was in another residents room, I heard V9 yell out in the hall for help. When I went out to look V9 was in R1's room next to R1 on the floor. V9 asked if R1 was a full code. I said yes and went to get a nurse. On the table at the end of the hall there was a food tray and a spilled pitcher of water. V9 stated Earlier that afternoon R4 and V17 (R4 wife) were sitting at the table while R4 ate his lunch. On [DATE] at 8:10 AM, V17 (R4's wife) stated I arrived to the building around 12:30 PM on Saturday ([DATE]). R4 and I sat at the table next to the nurse's station while R4 ate lunch. R4 has eaten meals at that table before. It is easier to position R4's wheelchair with the newer footrests at the table so R4 can eat. R4 only ate about half of the meal which consisted of meatloaf, potatoes, lemonade, and cheesecake for dessert. Just before one o'clock R4 finished his meal, and we went back to his room. The staff was busy so I moved R4 to R4's room in R4's wheelchair. The tray was left on the table next to the nurse's station. V17 stated R1 was sitting in a chair close to the nurse's station when R4 and I returned to R4's room. None of the staff asked to be notified when R4 was done eating. On [DATE] at PM, R4 stated On [DATE], while waiting for my spouse to eat lunch, (R1) walked up to where I was sitting, grabbed my lemonade, and drank it down. On [DATE] at 2:20 PM R5 stated (R1) would walk into my room and drink the water out of my cup from my table. R1's Dietary Care Plan Update dated [DATE] shows R1 is a total assist at side table by nurse's station. Resident is fed by staff for safety of resident. Resident has [DIAGNOSES REDACTED]. R1's Dietitian assessment dated [DATE] shows R1 will find food anywhere and grab it, stuff it in her mouth, and at times begins to cough. R1's Nurses Progress Notes dated [DATE], shows the hospital contacted the facility and noted R1's time of death is at 2:58 PM. R1's Death Certificate dated [DATE], shows R1 expired on [DATE]. The cause of death is listed as [MEDICAL CONDITION] arrest due to aspiration. The facility Administrator was notified of the Immediate Jeopardy on [DATE]. On [DATE], the surveyor confirmed the facility took the following actions to remove the immediacy: 1. The facility reported this incident to IDPH on [DATE]. The facility timely submitted its final Incident Investigation Report on [DATE]. 2. Upon finding R1 unresponsive, nursing staff immediately assisted R1, cleared the airway initiated CPR and called [DATE]. The POA and physician were immediately notified. on [DATE]. 3. Maintenance Staff removed the table that was situated by the nurse's station on [DATE]. 4. The Administrator conducted a thorough investigation of the incident, including interviewing facility staff. R1's roommate was not interviewable. The Administrator discussed this incident with the Medical Director. The investigation was competed on [DATE]. 5. The Nursing Managers reviewed and revised all resident bed cards to include the resident's dietary needs, including texture, liquid consistency, and assistance required for eating. Completed on [DATE]. 6. Staff are to by educated on supervising residents that eat outside of the dining room and immediately remove the food trays upon completion of the meal. Education was initiated on [DATE] For any direct care staff who have not yet participated in this education, the Administrator or designee will provide the educational training before the staff work their next shift. The training was initiated on [DATE]. 7. The administrator reviewed the facility policies regarding resident meal time for necessary revisions. Policies were revised as necessary. Completed on [DATE]. 8. To monitor continued compliance, the DON or designee will be performing weekly audits with staff members for six weeks to ensure that direct care staff are knowledgeable of where to locate information regarding a resident's dietary needs and restrictions. The Administrator or designee will report the results of the audit to the Quality Assurance (QA) committee. The QA committee with follow up as necessary. This was initiated on [DATE]. The next scheduled QA meeting will be held in February 2018.

Based on observation, interview and record review the facility failed to safely transfer a resident. This failure resulted in a fall causing a left femur fracture which needed surgical repair. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The face sheet for R1 shows him to have [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] shows R1 to be cognitively intact and requires two assist from staff for transfers. The bedside care plan for R1 shows two assist was needed for transfers. The resident fall investigation report dated December 9, 2017 shows R1 was being transferred to the bed from his wheelchair by one staff when he fell to the floor. On December 15, 2017 at 1:00 PM, V1 (R1's family member) stated after R1 fell he was taken to the local hospital where it was determined he had a fracture to his left femur. He was then transferred to another hospital to have surgery. V1 stated after the surgery R1 was in alot of pain and was crying out, V1 stated this was very difficult for him to watch. V1 stated R1 said to two family members at different times that R1 had asked the staff to get another person to help with the transfer but the single staff told him they were fine they could do this. On December 19, 2017 at 3:10 PM, V5 CNA (Certified Nursing Assistant) said she was transferring R1 by herself because she had seen other staff transfer R1 by themselves and she felt it was fine to do this. V5 said she never looked at R1's bedside care card until after the fall. V5 said she stood R1 up and went to pivot him when his knee gave out and they both fell to the ground. V5 stated she does not recall the resident asking her to get another staff to help her. On December 19, 2017 at 11:15 AM, V3 restorative nurse stated she does all the assessments for residents to determine the safe number of people or equipment needed to safely transfer a resident. V3 said R1 has always been a 2 person assist transfer. V3 said R1 should not have been transferred by just one CNA. On December 19, 2017 at 12:40 PM, V2 DON (Director of Nurses) stated R1 should not have been transferred by just one CNA. V2 said a fall can be life changing for a resident and can even lead to death. On December 19, 2017 V6, V7 and V8, CNA's, all stated R1 was a two person assist for transfers and if unsure about a residents transfer status they should check the bedside care plan. On December 19, 2017 V4 and V9 RN's (Registered Nurse) stated the CNA's are to check the bedside care cards to determine the number of staff needed to safely transfer a resident. The Safety Risk Data Collection assessment with quarterly review dates of January 20, 2017 and September 20, 2017 shows R1 requires two staff for all transfers. The care plan for R1 dated February 6, 2017 for falls shows I am at risk for falls as I have a fused left hip and cannot bend. I am impulsive and I have poor judgement. The approach dated May 2, 2017 shows two assist using gait belt with all toileting/transfers. The care plan for R1 for ADL (Activities of Daily Living) with a review date of October 2, 2017 shows I need assist from two staff members to transfer to/from bed/chair at all opportunities. The hospital records dated December 10, 2017 for R1 show a displaced angulated mid shaft left femur fracture after a fall during a transfer at the facility. R1 was transferred to another hospital for a left femur fracture intramedullary nailing surgery December 10, 2017. The facility's Fall Policy revised 2017 shows All residents who are assessed as being at high risk for falls will be identified and indivualized fall precautions will be developed for that resident. Preventative measures shall be taken to decrease the number of falls whenever possible . Changes in safety approaches is communicated via log book, care plan, bed card, and unit education inservices.

Based on interview, and record review, the facility failed to identify agitated behaviors for a Dementia resident as an indicator of pain. The facility failed to asses swelling to a residents leg on June 11, 2017. These failures contributed to R1 having a delay in treatment, R1 was found to have a femur fracture and a [MEDICAL CONDITION] on June, 12, 2017. This applies to 1 of 3 residents (R1) reviewed for falls and injuries in the sample of 5. The findings include: R1's [DIAGNOSES REDACTED]. The sheet shows R1 has sustained previous fractures since her admission. On June 27, 2017 at 10:50 PM, R4 (R1's former roommate) said R1 bumped her leg on her wheel chair a couple weeks ago. R4 said R1 sat up real fast and threw her legs over the side of the bed, bumping her legs on the chair. R4 said this occurred the day before R1 was sent to the hospital (R1 went to the hospital on June 12, 2017). R1's Care Plan last updated June 1, 2017 shows R1 requires limited assistance of 1 staff member and gait belt for ambulation. On June 27, 2017 at 4:30 PM, E7 (Registered Nurse-RN) said she was R1's nurse from 3:00 PM-11:00 PM on June 11, 2017. E7 said R1 was yelling and screaming the entire shift. E7 stated, (R1) usually yells out, but I have never heard her scream like that. E7 said after eating supper, R1 was transferred from the wheel chair to the recliner in the hallway near the nurse's station. E7 said R1 was not there for long because she was still screaming, so she had the CNAs transfer her into bed. On June 28, 2017 at 12:58 PM, E9 (Certified Nursing Assistant-CNA) said she worked on June 11, 2017 from 3:00 PM-11:00 PM. E9 said the first shift staff reported to her that R1 had been screaming all day. E9 said When we came in it was more of the same. E9 said R1 was Screaming at the top of her lungs .like in a panic. E9 said R1 was very stiff and could hardly move. E9 said R1 was Very stiff and anxious, panicked. E9 said she was in with R1 for 45 minutes to an hour that night and it did not stop her from screaming. On June 27, 2017 at 3:00 PM, E8 (CNA) said From the moment I walked onto that hall at 2:45 PM (R1) was yelling and screaming. E8 said she has dealt with R1's yelling before but not to this level. E8 said at bedtime R1 was transferred from her wheel chair to the bed for care. E8 said R1 was combative during care. R1 was then transferred from the bed to the wheel chair and then transferred into the recliner in the hallway. On June 27, 2017 at 8:49 AM, Z1 (R1's family member) said on June 11, 2017 the facility called her around 7:00 PM and asked if she could come to the facility due to R1's agitation. Z1 said when she got to the facility R1 was distraught. Z1 said usually she can calm R1, however she was not able to on that date. Z1 said R1 complained that her left leg hurt. Z1 said R1 also complained that her head and her stomach hurt, so she did not know what to make of it. Z1 said she stopped by and spoke with E7 (RN) and asked her to call the doctor and get something for her pain and anxiety. Z1 said R1 had a history of [REDACTED]. On June 27, 2017 at 2:40 PM, E11 (RN) said she worked the overnight shift from 11:00 PM on June 11, 2017 through 6:00 AM on June 12, 2017. E11 said R1 was calling out, complaining of pain in her left arm, her right arm, and her left leg. E11 said she noticed R1's left knee was swollen. On June 27, 2017 at 1:53 PM, Z2 (Agency CNA) said she worked the overnight shift (11:00 PM-7:00 AM) on June 11, 2017. Z2 said around midnight R1 woke up and started yelling out. Z2 said she went to move R1 and R1 screamed out and said her left knee hurt. Z2 said she noticed a cut on R1's leg. R1 was transferred from her bed to her wheel chair and then taken out to the hall and transferred to the recliner. Z2 said as they were transferring her, R1 complained of pain again. Z2 said after R1 had her feet up in the recliner, Z2 said she saw serious swelling to R1's left leg. On June 28, 2017 at 9:11 AM, E12 (CNA) said she worked June 11, 2017 from 11:00 PM-7:00 AM. E12 said Z2 called her into R1's room and she noticed a little blood on R1's sheet. E12 said there was a little scrape on R1's left leg and the leg was swollen from her hip to past her knee. E12 said R1 always complains of pain but this time it was different. E12 said R1 had increased restlessness that shift. On June 27, 2017 at 2:30 PM, Z3 (Agency LPN) said she worked the day R1 was sent out to the hospital (June 12, 2017). Z3 said R1 was complaining of pain in her left leg when she got up that morning and there was swelling in her left leg. Z3 said she received the Physician order [REDACTED]. On June 27, 2017 at 8:00 AM, E3 (Assistant Director of Nursing-ADON) said she received a call about R1 after 11:00 PM on June 11, 2017. E3 said she was informed by E11 that R1 had a bad night and the doctor had been called to get an order for [REDACTED]. On June 28, 2017 at 1:42 PM, E2 (DON) said if the nurse sees swelling on a resident, she would expect them to inform the doctor. On June 28, 2017 at 1:45 PM, E1 (Administrator) said according to the facility's census sheets R1 left the building at 11:10 AM on June 12, 2017 to go to the ER. Nurse's Progress Notes of June 11, 2017 show at 3:30 PM [MEDICATION NAME] (pain medication) given for general discomfort. Resident continued to scream out. Get me out of here over and over. Pt (patient) screamed until dinner. Took offered snacks and fluids yet continued to scream . Screamed out after meal. Pt in recliner screaming. Unable to say what is wrong. When asked Do you hurt? Pt response Yes. The notes show at 9:10 PM [MEDICATION NAME] was given and at 10:00 PM R1 continued to yell out. The Nurse's Progress Notes of June 11, 2017 11:00 PM-7:00 AM shift show resident complained of pain to left lower extremity and bilateral upper extremities. The notes show [MEDICAL CONDITION] to R1's left knee and leg. The Nurse's Progress Notes of June 12, 2017 show at 9:00 AM, pain medication was given and 47 minutes later, R1 continued to complain of pain. The notes show R1's left leg slightly swollen. R1's Minimum Data Set (MDS) assessment of May 7, 2017 shows she had severe cognitive impairment and required extensive assistance of 1 staff member for ambulating and 2 staff members for transfers, dressing, personal hygiene, and bathing. R1's as needed medication record shows R1 went from receiving [MEDICATION NAME] 25-50 milligrams (mg) every 6 hours as needed or Tylenol 650 mg 1-3 times a day to on June 11, 2017 receiving pain medication five times. R1's Hospital History and Physical dated June 12, 2017 shows During initial evaluatioin, emergency department patient has undergone extensive evaluation and she has been diagnosed to have a oblique fracture through the left distal femur extending into the joint space. Venous ultrasound Doppler of the lower extremity was positive for acute [MEDICAL CONDITION] involving left common femoral vein to left posterior tibial and peroneal veins. The notes show R1 had open reduction internal fixation surgical procedure to her left leg for a distal femur fracture. The facility's Employee Action Sheet (form staff fill out regarding incidents) shows prior to 11:30 PM while Z2 and E12's (CNAs who worked June 11,2017 on the 11:00 PM-7:00 AM shift) were transferring R1 they noticed a small cut on her left leg and R1 complained of pain in her left knee. R1's knee and her leg were swollen. The form also shows R4 reported to the CNAs that R1 had fallen about 2 hours earlier. The Employee Action sheet with E8's (CNA who worked June 11, 2017 on the 3:00 PM-11:00 PM shift) statement shows R1 was extremely agitated and restless on June 11, 2017. Calmed for brief periods only. Was one-on-one for several hours. The sheet shows R1's left knee was slightly swollen. A January 22, 2017 Diagnostic Imaging Department report shows R1 suffered a displaced [MEDICAL CONDITION] ischial tuberosity 6 months previously. The report shows R1 had mild [MEDICAL CONDITION] affecting her hips and her bones appear demineralized. The facility's undated Pain Management Guidelines shows The goal of the pain management program is to provide optimal comfort, reduce complications, and enhance each resident's well being. Program goals will be accomplished by timely recognition, assessment, and management of pain. The guidelines shows B. Pain Assessment: c. For cognitively impaired or unconscious residents, utilize nonverbal parameters e.g. agitation, facial grimacing, guarding, moaning, withdrawal, affect, change in mobility or ADL (Activities of Daily Living) functional status, etc.