Every finding on record at Dupage Care Center

Based on observation, interviews, and record review the facility failed to change a wound dressing as ordered by the physician and the facility failed to prepare medications per facility policy. This applies to 4 of 35 residents (R134, R165, R177, R195) reviewed for quality of care in the sample of 35. The findings include:1. R134's EMR (Electronic Medical Record) states R134 is 93 years-old who has multiple medical diagnoses including unspecified open wound, right lower leg, initial encounter. On September 8, 2025, at 11:25 AM, R134 was in her bedroom sitting on her wheelchair. R134's right leg was covered with elastic bandage which was stained with red and brown color discharges on the lateral area of her right leg. V23 (4th Floor Head Nurse) stated R134 has venous stasis ulcer on her right leg. On September 9, 2025, at 10:51 AM, V21 (Wound Care Nurse) rendered wound care to R134 venous stasis ulcer in the right leg. R134's Unna Boot dressing was stained with new and old dry discharge which overflowed to the elastic bandage. The stain size was about 5 centimeter (cm) in length by 5 cm in width 5 on the elastic bandage. R134 stated that it was last changed on Sunday (September 7). On September 9, 2025, at 11:00 AM, as V21 was changing the dressing, V21 said the wound was a venous stasis ulcer, they change the dressing every Tuesday, Thursday, and Saturday and as needed when the dressing is soiled like this. V21 said the wound has sero-sanguinous discharges. V21 cleansed the wound with normal saline, wrapped the leg with Unna boot and secured with elastic wrap bandage. V21 also stated that he changed the dressing on Sunday because the dressing from Saturday was very soiled. R134's POS (Physician Order Summary) report shows: Right lateral leg wound- cleanse with NS (normal saline), apply Unna boot secure with elastic wrap three times a week, every Tuesday, Thursday, Saturday, and as needed for wound care. R134's care plan shows R134 has Venous Stasis Ulcers of the right lower extremity related to venous insufficiency, chronic kidney disease (CKD), and Obesity. The same care plan shows multiple interventions including administration of treatment as ordered. On September 10, 2025, at 12:21 PM, V2 (Director of Nursing/DON) stated that a wound can't be left with a soiled dressing. If the discharge was already seeping out, then the dressing should be change. 2. R165's EMR (Electronic medical record) showed R165 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and vascular dementia unspecified severity with anxiety. 3. R177's EMR showed R177 was admitted to the facility August 15, 2025, with diagnoses mild protein calorie mild nutrition, depression unspecified and chronic kidney disease. 4. R195's EMR showed R195 was admitted to the facility September 14, 2017, with diagnoses Cerebral Palsy, Parkinsons disease without dyskinesia, without mention of fluctuations, Unspecified abnormality of gait and mobility, and unspecified mental disorder due to known psychological condition On September 10, 2025, at 1:40 PM, V16 (RN, Registered Nurse) V16 was preparing medications in the medication room. V16 proceeded to pull out a medication cup and placed it on the top of the medication cart. V16 then opened a drawer pulled a package of medication for a resident and poured the medication into a medication cup and wrote R165's last name on the cup. V16 threw the package in the garbage. V16 opened another drawer pulled out another package of medication opened it, poured it into another medication cup and wrote R177's name on the outside. She then threw the package in the garbage. V16 went to another drawer for a different resident and pulled out the medication package and poured the contents in the medication cup into a different cup writing R195's last name on the cup discarding the package in the garbage. V16 took all three cups and placed them in an empty drawer and put them to the side. V16 was asked the names of the residents and what medications were poured in the medication cups. R165 was administered Depakote 125mg tab, order to be given one time a day. R177 was administered Magnesium Oxide 400mg tablet, order to be given one time a day. R195 was administered baclofen 10mg tablet, Carbidopa Levodopa 25-100mg tablet, and Gabapentin capsule 300mg, order to be given three times day. On September 10, 2025 at 2:45 PM, V2 (DON/ Director of Nursing) stated her expectation for a medication pass was that the nurse takes the medication cart to the resident's room, the nurse is to check the EMAR (Electronic Medication Administration Record), pull the medications out of the drawer, check the five rights of medication administration, check any parameters (ex. blood pressure, pulse) and give the medication. V2 said she does not recommend the nurses prepare multiple resident's medications at the same time because there be some confusion. V2 said the nurses are not to pre-pour the medications. The facility provided their policy titled Medication Administration with a revision date July 2024, showed Preparation of medication.2. Tablets/capsules a) Tear open individual packets and place directly into souffle cup at time of administration. Pre-pouring is a practice that puts patient at risk for med error that may cause actual harm. Pre-pouring is not allowed.

Based on observations, interview and record review, the facility failed to provide residents their meal trays with others seated at the same table. This applies to 6 of 9 residents (R25, R62, R116, R153, R161, and R165) observed for dining in the sample of 35. The findings include: On September 8, 2025, at 12:09 PM during lunch meal observation on the first floor, 1 (one) North dining room, several residents were noted eating their meal when others on the same table had not received their meal tray. R160 was fed by V9 CNA (Certified Nursing Assistant) and had almost finished her meal, whereas R161 and R25 who were seated at the same table and had not received their meal trays. On a separate table in the same dining room, R68 was eating her lunch and R165 and R116 who were seated at the same table were looking on. On inquiry why R25, R116, R161, and R165 did not get their trays at the same time as other residents on the same table, V10 (Certified Nursing Restorative Aide) stated that these residents' trays are on the second cart, and it has not yet arrived. On September 8, 2025, at 12:29 PM, on another table, R90 was fed by V11 (CNA). R153 and R62 who were seated at the same table were looking at R90 being fed. When asked if she had finished eating, R62 stated that she has not received her tray. On September 8, 2025, at 12:32 PM, when R68 received her tray from the second cart, R90 had finished his meal. On September 10, 2025, at 10:51 AM, V12 (Food Service Manager) stated that the first cart should be delivered to the 1 North unit at 11:25 AM and the second cart delivered at 11:57 AM. V12 stated that the kitchen sends the second cart later so that the residents eating at the second seating can get hot food. V12 stated that the nursing communicates with the dietary via email on which residents to put in the first cart so that the residents can eat together. On September 10, 2025, at 11:59 AM, V2 (Director of Nursing) stated that her expectation is that the residents seated at the same table should be served together. V2 added that this is because How would you feel if the other person is eating when you are not. V2 stated that the nursing staff has to coordinate with V12 to change the meal trays that are placed in the first cart. Facility policy titled Tray Delivery Schedule (revised May 2025) included-Purpose: To communicate a tray delivery schedule aiding interdepartmental planning. Procedure: 1 North 11:25 [AM], 11:57 [AM]. Facility Census Roster showed that R25, R62, R68, R90, R116, R153, R160, R161, and R165 resided in the 1 North unit.

Based on observation, interview, and record review, the facility failed to implement feeding interventions to ensure safety for a resident (R173) while eating meals. This applies to 1 (R173) of 35 of residents reviewed for accidents and supervision in the sample of 35. The findings include:R173's electronic medical record showed R173 has diagnoses that include dementia, anxiety, retention of urine, depression, cochlear implants, and dysphagia, oropharyngeal phase. R173 Minimum Data Set showed R173 to be severely cognitively impaired and dependent on staff for eating and all activities of daily living (ADL). R173's care plan dated February 11, 2025, showed that R173 has a need for hands on feeding assistance. R173 ADL care plan dated 2/26/2024 showed that R173 required purple swallow assistance- pureed diet with thick liquids, and standard swallow precaution as follows: eat only when alert, sit upright, small sips/bites, eat drink slowly.On September 8, 2025, at 11:40 AM, R173 was observed sleeping in the dining room. On September 8, 2025, at 12:37 pm observed still sleeping then V19 (Registered Nurse/RN) wheeled R173 to table and at 12:40 PM began feeding resident a pureed diet. R212 had to constantly tell R173 to wake up, open eyes, and swallow. Spoons of food put in resident's mouth were just sitting in R173 mouth as R173 stopped swallowing and working food through her mouth. Food streamed out of resident's mouth at these times and resident pocketed food. V19 kept telling resident to wake up, swallow, and to open her mouth. At times R173 head slumps to the side and V19 tells R173 to wake up and rubs R173. R173's eyes were closed, and she did not speak during the feeding. V19 stated R173 is always sleepy, but sometimes she is alert. On September 9, 2025, at 12:35, V22 (Certified Nursing Rehab Assistant) was feeding R173. On September 9, 2025, at 1:02 PM, V22 stated that R173 is always sleepy and sometimes they can't get R173 out the bed because R173 is so sleepy. On September 10, 2025, at 9:19 AM, V8 (Speech Language Pathologist) stated R173 doesn't take a spoon of food well. V8 stated R173 is always sleepy and never opens her eyes. V8 stated when feeding R173 the resident should stay alert. V8 stated food can remain in R173's mouth and there is a risk of aspiration if she is fed while not awake and alert. V8 stated Purple Swallow is a program the facility has implemented to identify those residents who are a high aspiration risk and R173 is on the Purple Swallow program. On September 10, 2025, at 9:30 AM V7, (Medical Director) stated he was not aware resident was sleeping a lot. V7 stated the staff told him that R173 is a quiet person. V7 stated it is basic nursing care knowledge not to feed someone who is sleeping for risk of aspiration. On September 10, 2025, at 2:50 PM, V2 (Director of Nursing) stated that staff should not feed R173 if she is sleeping. R173's diet meal tickets alert staff that she is on the Purple Swallow program. R173's Tasks ADL Log showed the following: Purple Swallow-Diet Mechanical solids/nectar thick liquids. Individual Instruction-no straws. Double swallow. Swallow support level: Assistance. Standard Swallow Precautions: eat only when alert, sit upright, small sips/bites, eat drink slowly.

Based on observation, interview, and record review, the facility failed to provide a device or equipment for a resident with a limited range of motion to prevent potential further decrease in the range of motion (ROM). This applies to 1 of 8 residents (R9) reviewed for range of motion in the sample of 35. The findings include:R9's Face sheet shows that R9 is 75 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, aphasia following cerebral infarction, vascular dementia without behavioral disturbance, and weakness. MDS (Minimum Data Set) dated July 25, 2025, shows that R9 is cognitively impaired and totally dependent on staff for ADL (activities of daily living) care. On September 8, 9, and 10, from 9:30 AM through 1:30 PM, R9 was observed multiple times. R9 was in bed and non-verbal. R9's left hand noted in one position, it was slightly closed with the index and middle fingers in straight position while the ring and other fingers were bent to the joints. There was no splint or palm protector on her hand. V23 (4th Floor Head Nurse) stated that R9 is confused and requires total assistance with activities of daily living care. On September 10, 2025, at 11:33 AM, V20 (Physical Therapist/PT) assessed R9. V20 said that R9 has locked-in syndrome related to CVA (Cerebrovascular Accident). V20 tested the range of motion of R9's left fingers and stated that the metacarpal phalanges (MCT) were within normal limits, her wrist and thumb were good, the index and middle fingers were good but slightly stiff because of the dystonia, while the fourth and pinky fingers has tightness. V20 also said that R9 may benefit from a palm protector or a carrot, to open the hand and fingers and prevent skin irritation.Restorative notes dated September 10, 2025, at 12:26 PM shows: Resident assessed by PT for hand contracture management with new recommendation of Left-hand protector to be applied at bedtime for 6 hours daily, perform PROM before and after application. noted and carried out. Granddaughter updated (1st contact person) left message to voice mail. Physician Order summary (POS) report dated September 10/2025 shows: Palm protector on the Left hand for 6 hours Apply at bedtime for Left hand Perform PROM before and after application for contracture management and remove per schedule.

Based on interview and record review, the facility failed to put nutrition interventions in place in a timely manner for a resident with significant weight loss.This applies to 1 of 5 residents (R14) reviewed for nutrition in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including sequelae of cerebral infarction, vascular dementia, and chronic obstructive pulmonary disease.R14's MDS (Minimum Data Set) dated June 13, 2025, showed R14 had severe cognitive impairment. The MDS continued to show R14 did not have a behavior of refusing care. R14's nutrition care plan dated September 26, 2023, showed [R14] has potential nutritional problem related to vascular dementia, depression, anxiety may affect meal intakes. Diagnoses sequelae of cerebral infarction, hypertension. Diagnosis chronic obstructive pulmonary disease. Diagnosis hypothyroidism. The care plan continued to show multiple interventions dated September 26, 2023, including Monitor weight per facility protocol and record. Notify physician, registered dietician of significant weight changes, sudden weight loss. The care plan showed an intervention dated August 27, 2025, for Provide and serve supplements as ordered: super cereal with breakfast, super potatoes with lunch and super pudding with dinner daily.R14's EMR showed the following weights:July 2, 2025, at 11:59 PM, 172 pounds;July 5, 2025, at 12:52 AM, 172 pounds;August 2, 2025, at 12:01 PM, 154.9 pounds;August 2, 2025, at 3:46 PM, 154.9 pounds and;September 5, 2025, 2:59 PM, 154 pounds.R14's weights showed R14 experienced a significant weight loss of 9.94% (percent) in one month from July 2, 2025, to August 2, 2025. A Nutrition/Dietary note dated August 27, 2025, at 9:52 AM, by V14 (DTR/Dietetic Technician Registered) showed Nutrition High Risk Note: [R14] had an August weight completed, a re-weigh was requested, no re-weigh available at this time. Using her recorded August weight of 154.9 pounds, this is noted to be a 9.9% weight loss in one month, a 9.9% weight loss in three months, and a 9.9% weight loss in 6 months; prior to the August recorded weight, her weight had been stable from January to July. Will add super cereal to breakfast, super potatoes to lunch, and super pudding to dinner daily for additional calorie intakes. Will review with September weight. She continues on the pureed diet texture for impaired swallowing and chewing abilities, continues with no straws. She is now fed by staff during meals.On September 10, 2025, at 10:42 AM, V14 said a resident's monthly weight should be obtained by the fifth of the month. V14 said if a resident's monthly weight showed a significant weight loss, then V14 asks for a reweight to be obtained for the resident. V14 said she requested R14 be reweighed when R14's August weight showed a significant weight loss. V14 said she did not get a reweigh for R14 so on August 27, 2025, V14 implemented fortified foods as a nutritional intervention for R14's weight loss. V14 said she notified V24 (Registered Dietician) about R14's significant weight loss this week when V24 returned after being off of work from August 26, 2025, until September 8, 2025.On September 10, 2025, at 1:28 PM, V2 (DON/Director of Nursing) said if a resident's monthly weight shows a significant weight loss, then the resident should be reweighed. V2 said R14's EMR showed R14 was reweighed on August 2, 2025, and the reweigh showed R14's significant weight loss was an accurate weight. V2 said interventions to prevent R14 from experiencing further weight loss should have been implemented sooner than 25 days after the reweigh was obtained.The facility's policy titled Heights and Weights dated July 2025, showed Purpose: To provide objective data to assist in the assessment of resident nutrition status. Policy: it is the policy of [the facility] that admission weights and heights will be documented for all new residents. Subsequently, weights will be documented monthly, and heights measured annually, unless ordered at different intervals by the physician. Scope/Eligibility: All clinical staff and residents. Procedure: . 5. 5. Significant weight change of greater than 5% times 30 days, greater than 7.5% times 60 days, and greater than 10% times 180 days will be reviewed and assessed by the Clinical Nutrition Staff. Individualized intervention will be provided as needed. Physician order as needed. The Dietician will review each month.

Based on observation, interview, and record review, the facility failed to follow physician order for medication administration. There were 25 medication opportunities with 2 errors, resulting to 7.69% error rate. This applies to 2 of the 8 residents (R9, R13) reviewed for medication administration in the sample of 35. The finding include:1. On September 9, 2025, at 9:44 AM, V17 (Nurse) administered multiple medications to R13 including Esomeprazole via gastric tube (g-tube). The Esomeprazole cup remained with decent amount of medication residuals after V17 completed the medication administration. R13's Medication Administration Record (MAR) dated September 2025 shows to give Esomeprazole 20 mg via g-tube once daily for GERD (gastroesophageal reflux disease). 2. On September 9, 2025, at 1:39 PM, V18 (Nurse) administered Rifampin oral suspension to R9. The thick Rifampin liquid suspension was mixed with water when V18 administered it to R9 via g-tube. However, V18 did not give the full dose of this antibiotic because there were still residues of this medication left from the medicine cup. R9's MAR dated September 2025, shows Rifampin Oral Suspension 10 mg/ml (milligrams per milliliter) to administer 60 ml (600 mg) via g-tube one time only for prophylaxis. On September 10, 2025, at 12:15 PM V2 (Director of Nursing/DON) stated that when the nurses administer medication, it is expected that they will follow physician orders, and the 5 rights principles of medication administration such as the right time, dose, patient, medication, and route.

Based on interview and record review, the facility failed to provide a resident with a pneumococcal vaccine.This applies to 1 of 5 residents (R34) reviewed for immunizations in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R34 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, type 2 diabetes mellitus, chronic kidney disease, and ventricular tachycardia.R34's Pneumococcal Vaccine Consent/Declination Form showed on June 23, 2025, R34's POA (Power of Attorney) consented for R34 to receive the pneumococcal vaccine.R34's Immunization Report dated September 10, 2025, showed R34 did not receive the pneumococcal vaccine until September 9, 2025.On September 10, 2025, at 1:17 PM, V2 (DON/Director of Nursing) said R34 received the vaccine on September 9, 2025, after V5 (ADON/Assistant Director of Nursing) started compiling the requested vaccination information, V5 saw R34 did not receive the pneumococcal vaccine so the facility administered the vaccine at that time. V2 said R34 should have received the vaccine sooner since the consent was obtained in June 2025.The facility's policy titled Pneumococcal Immunization Program reviewed July 2025, showed Purpose: The purpose of this policy is to provide guidelines for the initial administration, series updating, monitoring, documentation, data collection and analysis of pneumococcal vaccines used to prevent and reduce the incidence of pneumonia. Policy: Prior to or upon admission to facility documentation is to be provided about the resident's pneumonia vaccination staties i.e. which vaccine received and date received. Determination of which vaccine is to be administered as well as any series requirement, will be based on the information provided. Pneumococcal vaccine is provided to residents as part of the facility immunization program. A physician's order is required. All residents are offered the pneumococcal vaccine and on a recurring basis when revaccination is needed based on resident prior vaccination status CDC (Centers for Disease Control and Prevention), clinical criteria and the physician's recommendations.

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and perform hand hygiene while in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 211 residents. On [DATE] at 1:16 PM, V39 (ADON/Assistant Director of Nursing) said there are 6 NPO (Nothing by Mouth) residents; all other residents eat from the facility kitchen. On [DATE] starting at 10:19 AM, V23 (Chef) was observed pureeing lunch items. After V23 pureed the chicken, she removed her gloves, pulled the garbage can out from under the counter with her bare left hand (while touching the rim of the garbage can) and threw away her gloves with her right hand. V23 then put on a new pair of gloves and did not wash her hands after touching the garbage can. V23 then put some of the roast beef and gravy into the blender to puree it. After V23 pureed the first batch of roast beef, she scooped out the rest of the not yet pureed roast beef with her gloved left hand and moved it into another silver container. V23 then grabbed a spoon, and with her gloved left hand she pulled down her face mask to taste test the consistency of the roast beef from the spoon in her right hand. After taste testing the roast beef consistency, V23 then pulled her mask back up over her nose and mouth with her gloved left hand and proceeded to puree the rest of the roast beef. V23 then poured the rest of the pureed roast beef into the silver container and covered it in plastic wrap while using her same gloved hands to touch the blender, the plastic wrap, and the steamer door handle. V23 did not wash her hands throughout the process of pureeing the chicken and roast beef after touching the garbage can and her face mask. On [DATE] starting at 10:40 AM, the facility kitchen was toured in the presence of V22 (Dietary Manager). The following was found: In the dry storage: 1. A large undated and unsealed bag labeled crispy onions. 2. A large undated and unsealed bag labeled croutons. In Cooler #2: 3. A 4 ounce package of sliced roast beef deli meat with a use by date of [DATE] and a handwritten date of [DATE]. V22 (Dietary Manager) said he was not sure why the kitchen staff wrote [DATE] on the package and he would find out when the roast beef was served. On [DATE] at 10:16AM, V22 said the roast beef was served to residents on [DATE]. V22 said the roast beef was labeled with the wrong date. On [DATE] at 12:43 PM, V22 said all food items in the kitchen should be labeled, dated, and sealed to keep the food fresh and safe to feed the residents. V22 said unsealed items are a concern because they can become contaminated by environmental contaminants. V22 said deli meat is safe in the refrigerator for 7 days, and if the package is unopened, the deli meat should be thrown away on the use by date. V22 said the unopened roast beef deli meat should have been discarded on [DATE]. V22 said it is a concern to have deli meat improperly dated because of the risk of serving it to the resident past the use by date with the potential to make the residents ill. V22 said the kitchen staff should wash their hands with soap and water after touching the garbage can to prevent food contamination. V22 said the kitchen staff should wash their hands with soap and water after touching their face mask to prevent cross contamination. V22 said staff should never touch the food with their gloved hands and should always use a utensil to prevent food contamination. The facility's policy titled Hand Hygiene last reviewed on ,d+[DATE] states, Purpose: To provide guidelines for hand hygiene and prevention of infections. To promote compliance with regulatory guidelines for hand hygiene. Policy: All healthcare workers and visitors will follow facility guidelines for hand hygiene .Procedure: Traditional soap and water method. Hand hygiene is the single most effective procedure for reducing the spread of infectious organisms and cross-contamination .Following is a list of some situations that require hand hygiene: Before & After: .Eating/handling food (hand wash with soap & water) . After: .Handling soiled equipment or utensils . Removing gloves or aprons The above lists do not include all opportunities to wash your hands, Remember to follow the hand hygiene guidelines anytime you question if contact with a source of contamination did occur. The facility's policy titled Labeling, Dating, and Storage of Food Items last reviewed ,d+[DATE] states, Purpose: To ensure food is labeled, dated, and stored properly. Policy: Dining staff will label, date, and store food items properly per standard sanitation procedures. Procedure: .2. All food items will be labeled with a receiving date that correlated with the month and day received. 3 .a. Any package opened for food production will be labeled with an open date and sealed airtight prior to it being placed back into food storage locations .5. All food storage areas will be monitored regularly to discard any outdated food items from inventory stock.

Based on observation, interview, and record review, the facility failed to date and discard as indicated insulin vials when opened. The facility failed to store medications in their original packaging until they were administered. This applies to 8 of 8 residents reviewed (R104, R96, R160, R197, R75, R121, R146, R73) for medication storage in the sample of 37. Findings include: 1. On 8/20/2024 at 3:40 PM, V9 (RN/Registered Nurse) was asked to check the fourth floor's medication room for medication storage. V9 said R73's opened and filled Levemir insulin vial was not dated with the open date. V9 said R146's opened and filled Fiasp insulin vial was not dated with the open date. V9 said R121's opened and filled Lantus insulin vial was not dated with the open date. V9 said R75's opened and filled Fiasp and Glargine insulin vials were not dated with the open dates. V9 said insulin vials should be dated when they are opened for proper medication storage. On 8/20/2024 at 4:40 PM, V11's (Licensed Practical Nurse/LPN) medication cart was checked for medication storage. V11 said R197's opened and filled Lantus insulin vial package said do not use after 8/12/2024. V11 said R160's opened and filled Humalog insulin vial package said do not use after 8/12/2024 and opened and filled Lantus insulin vial package said do not use after 8/18/2024. V11 said insulin vials should be discarded after the indicated do not use after date and new insulin vials should be obtained. 2. On 8/20/2024 at 4:07 PM, V10's (RN) medication cart was checked for medication storage. V10's cart had 9 pills that were loose in a clear medication cup. V10 said she removed R104's scheduled 5 PM and 9 PM medications from their packages and poured them into a medication cup. V10's cart had another 5 pills that were loose in a clear medication cup and another medication cup with a loose white powdery substance. V10 said she removed R96's scheduled 9 PM medications and Miralax powder dose. V10 said she should have not removed R104 and R96's medications from their packages before their scheduled administration times and should have not stored them in the medication cart. On 8/20/2024 at 5:00 PM, V12 (Assistive Director of Nursing/ADON) said nurses are expected to label insulin vials once opened and discard them accordingly to ensure safe medication storage and administration. V12 continued to say medications should be prepared when scheduled, administered once prepared, and not be stored in the medication carts once removed from their packages to ensure safe medication storage and administration. The facility's policy titled Medication Administration with a revised date 10/2023 said Purpose: The purpose of this policy is to assure that all medications are administered safely .Standard of Practice 8. Medications will be destroyed or disposed of in accordance with facility policy and regulatory guidelines .Procedure 6. a. Check multi-dose vials for dates: When it was first opened, and what is the last date it may be used. b. If label does not contain these 2 dates, return medication to pharmacy .Storage of Medications 1. Medications are stored in manufacturer's containers until repackaged by pharmacy .

Based on observation, interview, and record review, the facility failed to use appropriate PPE (Personal Protective Equipment) for a resident on EBP (Enhanced Barrier Precautions) and failed to do proper hand hygiene to prevent the spread of infection. This applies to 5 of 5 residents (R68, R41, R155, R364, R365) reviewed for infection control in a sample of 37. The findings include: 1. On 8/20/24 at 11:23 AM, V27 (CNA/Certified Nurse Assistant) was providing personal hygiene and incontinence care for R68. R68 was on EBP due to having a G-Tube (Gastrostomy Tube). V27 applied a gown and gloves and provided incontinence care to R68, who had stool and urine in her disposable brief. V27 wiped the urine and stool off R68, then took a new incontinence brief and applied it under R68. V27 did not change her gloves or perform hand hygiene when going from the dirty brief to the clean brief. At 11:48 AM, V27 left R68's room without removing the PPE to throw the dirty linen bag in a container in the hallway. At 11:49 AM, V27 returned to the room and applied new PPE and entered R68's room, and then left the room again with all the PPE on. V27 returned with the same PPE on, washed her hands, and assisted V28 (CNA) with personal care for R68. On 8/21/24 at 1:48 PM, V25 (CNA) was providing personal hygiene and incontinence care to R68. V25 was not wearing a gown during personal care for R68. R68 had a soiled incontinence brief, and V25 provided incontinence care, and when going from dirty to clean, did not change her gloves or perform hand hygiene. On 8/21/24 at 2:40 PM, V25 said R68 was on EBP, and she should have worn the gown, gloves, and a mask when providing care. On 8/21/24 at 2:19 PM, V29 (RN/Registered Nurse) said R68 was on EBP due to having a G-Tube and so the staff needed to wear a gown and gloves for high contact activities. On 8/22/24 at 1:01 PM, V33 (CNA) said the staff should wear a mask, gown and gloves when giving care to a resident in EBP. V33 said the used PPE needed to be removed when you are about to leave the room. On 8/22/24 at 1:16 PM, V35 (RN) said when providing care for residents under EBP, staff need to wear a gown and gloves before entering the room, and before leaving the room, all the PPE needed to be removed, and hands needed to be washed. On 8/22/24 at 9:39 AM, V2 (DON/Director of Nursing) said if a resident is on EBP and the staff are providing care, the staff needed to wear a gown and gloves. V2 said the PPE should not be worn outside the rooms, and should be taken off while in the room, and handwashing needed to be performed. R68's face sheet showed she was admitted to the facility with diagnoses including gastrostomy status. R68's MDS (Minimum Data Set) dated August 14, 2024 showed R68 had severe cognitive impairment and was dependent on staff for all activities of daily living. The facility's Enhanced Barrier Precautions policy dated August 2023 showed EBP as a routine approach to infection control is based on the recognition that Standard Precautions, which requires the use of gown and glove in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes, often have not been successfully implemented in nursing home settings. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. EBP should be maintained for the entire resident's stay or until 1) Wound(s) have healed; 2) Indwelling medical devices are no longer present. In addition to following Standard Precautions gowns and gloves should be worn during the following: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs, or assisting with toileting, Device care or use, and Wound care. 41384 2. On 8/20/24 at 1:53 PM, V15 and V16 CNAs (Certified Nurses' Assistants) were providing incontinence care for R155. V15 and V16 with gloved hands, used a mechanical lift to assist R155 to a standing position and transport her to the toilet. They then lowered R155's pants and removed her soiled brief. R155's brief was soiled with stool and urine. V15 with gloved hands wiped R155's buttocks 5 times with the same wet towel and did not turn or fold the towel as he attempted to clean her buttocks of stool. After V15 was done cleaning R155's buttocks, he left the bathroom with his dirty gloved hands and opened R155's bedroom door, left the room, returned back to the room with plastic bags. V15 then put the soiled brief and towels in the bags, attached a clean brief and pulled R155's pants back up and then used the mechanical lift control to bring R155 back to her wheelchair. After getting R155 in her wheelchair V15 then untied R155's call light from her bedrails, moved R155's wheelchair closer to her call light and then took the plastic bags out of the room, all while still wearing his dirty gloves. V15 then put the plastic bags in 2 different containers in the hall and then removed his gloves and threw the dirty gloves in one of the containers in the hall and then cleaned his hands using the hands sanitizer on the wall next to the container. On 8/22/24 at 11:19 AM, V2 (DON) said that it is her expectation that during incontinent care staff will change their gloves and clean their hands when going from a dirty area to a clean area. It is her expectations that staff will wipe from front to back and after wiping fold the towel before wiping again. V2 said that this is to be done to prevent infections, UTIs (urinary tract infections), and cross contamination for infection control. 46380 3. On 8/20/2024 at 10:41 AM, V36 (CNA-Certified Nurse Assistant) was providing bladder and bowel incontinence care to R41. After V36 cleaned R41's feces, V36 did not change her gloves and continued to apply a fresh incontinent brief. With the same soiled glove, V36 continued to assist R41 with putting on clothes. Using the same soiled gloves, she combed and flatten R41's hair. When V36 was done assisting R41 with grooming, V36 took off her gloves and did not perform hand hygiene. R41's MDS (Minimum Data Sheet) documents a BIMS (Brief Interview for Mental Status) of 6 which means R41 had severe cognitive impairment. R41 is also dependent on staff for toileting, personal hygiene, and upper and lower body dressing. R41 is always incontinent of bowel and bladder. R41's care plan dated 3/28/2024 documents that she is at risk for infection with intervention to educate resident/representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition, and avoidance of crowds. 4. On 8/21/2024 at 9:13 AM, with bare hands, V37 (CNA) was observed inside R364's room tying a garbage bag with soiled incontinent pad . V37 took the garbage out of R364's room. In the hallway, V37 proceeded to double bag the garbage and put the garbage in a bin. Without performing hand hygiene, V37 proceeded to go inside R364's room and took out her meal tray, opened the meal cart which was in front of the nurse's station and put the meal tray inside the cart. R364's face sheet documents diagnosis of ESBL (Extended Spectrum Beta Lactamase) resistance in urine. R364 was on contact isolation. MDS dated [DATE] documents R364 is frequently incontinent of bowel and bladder and is dependent on staff for personal hygiene. R364's care plan did not address what staff should do to prevent infection. 5. On 8/21/2024 at 9:40 AM, R365 was observed being wheeled into the therapy room. On 8/22/2024 at 10:33 AM, R365 said she goes out to therapy early in the morning every day. She said she does not wash her hands before heading out with therapist. She said staff does not help her wash her hands before she goes to therapy. She said maybe staff thinks her hands are clean. R365's face sheet documents diagnosis of enterocolitis due to CDIFF (Clostridium Difficile) and is currently on contact isolation. R365's MDS dated [DATE] documents her BIMS score is 15 which means that she has intact cognitive functions. She is occasionally incontinent of bowel and bladder and needs partial or moderate assistance with toileting hygiene and personal hygiene. On 8/22/2024 at 10:58 AM, V32 (Therapy Program Manager) said R365 goes to the gym for therapy daily. On 8/22/2024 at 11:10 AM, V12 (ADON-Assistant Director of Nursing) said residents on contact isolation are permitted to go out of their rooms as long as incontinent care is rendered before going out of the room and residents wash their hands before going out of the room. R365's care plan did not address what staff should do to prevent infection. On 8/22/2024 at 1:14 PM, V38 (IP-Infection Preventionist) said she expects staff to perform hand hygiene before going inside a resident's room and before coming out of the room and in between providing care for patients. She said there are five steps staff needs to follow for hand hygiene. Steps are hand hygiene, put on gloves, do task, remove gloves, hand hygiene. She said hand hygiene can either be washing hands with soap and water or applying hand sanitizer. She said during peri care, staff should change gloves from dirty to clean and clean to dirty because it puts resident on higher risk for infection. She said when proper hand washing is not done on a resident with CDIFF before going out of room, there is a good chance of the CDIFF spore to spread. She said if proper handwashing is not done when needed during care, bacteria might spread to other residents. Facility's Contact Isolation Policy dated 7/2002 and reviewed 9/2023 states the following: .Policy: .Contact Isolation is an isolation category designed to prevent transmission of highly contagious or virulent infections that may be spread by direct contact. These precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to interrupt transmission in the facility. Procedure .3. Hand washing is indicated before and after resident contact. Hand hygiene should be performed after glove removal before leaving the resident's environment. Use an antimicrobial agent or waterless antiseptic. Facility's Hand Hygiene Policy dated 5/11/2010 and reviewed on 3/2024 states the following: . Hand hygiene is the single most effective procedure for reducing the spread of infectious organisms and cross contamination. Following is a list of some situations that require hand hygiene.Upon and after coming in contact with resident's intact skin . before moving from work on a soiled body site to a clean body site of the same resident . after handling soiled or used linens, dressings, bedpans, catheters, and urinals.After emptying garbage cans, waste baskets.

Based on observations, interviews, and record reviews, the facility failed to properly monitor, assess and treat a resident who is at risk for potential pressure ulcers. The facility also failed to properly monitor, and assess 1 resident who is unable to reposition themselves. This applies to 2 of 2 residents (R104 and R155) reviewed for quality of care. Findings include: 1. R104 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including chronic kidney disease stage 3, type 2 diabetes, unspecified mental disorder, schizoaffective disorder, urinary tract infection, E coli, altered mental status, ataxic gait, difficult in walking, history of falls, pressure ulcer of sacral region stage 3, pressure ulcers of left buttock unstageable, metabolic encephalopathy, depression, cognitive communication deficit, hyperlipidemia, muscle spasms, acquired absence of digestive tract, artificial right hip and anxiety. On 8/20/24 at 11:31 AM, R104 was observed in her bed on her back and again at 12:10 PM she was observed on her back when V17 (Wound Nurse) and V18 (Wound Doctor) came into the room to provide wound care to R104's stage 3 pressure ulcer to her coccyx wound. R104's dressing to her coccyx wound was found with brown substance on it, and an area on R104's left buttock was found with redness and the skin was blistered in some areas. The doctor assessed the area and said that it was a new open wound 3cm X 3cm caused by incontinence of urine and stool. V17 then cleaned both wounds and applied the medicated ointment as prescribed by the doctor. On 08/22/24 at 11:30 AM, V2 DON (Director of Nursing) said that her expectation is that staff provide incontinent care every 2 hours and as needed to prevent skin breakdown. V17 said that R104's wound to her left buttocks is a MASD (moisture associated skin damage) from incontinences of urine and feces. V17 said that he expects the nursing staff to change the residents and keep them dry. V17 said that he provided wound care to R104 coccyx wound on 8/19/24 and the wound to R104's left buttock was present and look the same as it did on 8/20/24. R104's electronic record did not show any record of a wound to R104's left buttock on 8/19/24. R104's 8/20/24 skin/wound note showed wound assessed and measured. Treatment done on sites. No complaints of pain made. New treatment order made and carried out. R104's 6/4/24 order showed coccyx - cleanse with normal saline, pat dry period apply calcium alginate and cover with gauze island dressing daily and PRN everyday shift for wound care. R104's 5/2/2024 order showed nurse to evaluate residence wounds for treatments. R104's 8/6/24 MDS (Minimum Data Set) shows that R104 is dependent for toileting hygiene, and she is totally dependent on staff to roll from left to right. R104's 8/6/24 care plan showed that R104 has an ADL self-care performance deficit related to activity intolerance, limited mobility, limited range of motion, and poor endurance secondary to multiple medical chronic diagnosis such as kidney disease, diabetes mellitus, lipidemia, tachycardia, ataxia, and behaviors related to schizoaffective disorder and anxiety. R104's interventions included toileting hygiene physically dependent check and change large brief. R104's 5/24/24 care plan showed she has a potential for pressure ulcer development related to impaired mobility, activity intolerance, secondary to diagnoses of diabetes mellitus 2, anxiety, schizoaffective disorder, depressive type, muscle spasms, and incontinence. The goal is that the resident will have intact skin free of redness, blisters, or discolorations. The interventions or tasks include apply skin protectant after incontinent episodes, follow facility policy protocols for prevention or treatment of skin breakdowns, monitor nutritional status, provide assistance to turn or reposition at least every two hours more often as needed or requested, monitor bed pressure relieving air mattress, and monitor-skin observation. R104's 7/26/24 care plan also showed a returned status post hospitalization for hydronephrosis, UTI (urinary tract infection), with pressure ulcer to the coccyx stage 3 (5/7/24). The goals included the resident's pressure ulcer will show signs of healing and remain free of infection. the interventions and tasks include administer treatments as ordered and monitor for effectiveness, assess, record, and monitor wound healing, daily measure length width and depth where possible. Assess and document status of wound perimeter wound bed and healing progress. Report improvements and declines to medical doctor. Avoid positioning the resident on her back, monitor nutritional status, and monitor - skin observations. R104's 8/20/2024 wound evaluation & management summary showed Site 7 etiology (Quality) moisture associated skin damage. Duration - greater than 1 days, wound size 3 x 3 x 0.1 centimeters, surface area 9.0 centimeters. cluster wound open ulceration area of 4.50 centimeters, & skin 50%. Additional wound detail - patient has new irritation to left inferior buttock with overlapping area from previous pressure site. patient is at high risk for skin breakdown due to previous wound site and this skin integrity is weakened from scar tissue as well as urinary and fecal incontinence. Dressing treatment plan - zinc ointment apply once daily as needed for 30 days. Recommendations reposition per facility protocol, & offload wound. R104's 8/20/24 skin & Wound Evaluation MASD (moisture associated skin damage) acquired in-house, left gluteus 9.0cm X 3.0cm x 3.0cm Erythema: Redness of skin - may be intense bright red to dark red or purple, additional care: incontinence management, moisture barrier, moisture control, turning repositioning program, education of off-loading and repositioning. 2. R155 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including cerebral ischemia, vascular dementia, depression, panic disorder, essential hypertension, difficulty walking, arteriosclerotic heart disease, lower back pain, and a history of falling. On 8/20/24 at 1:42 PM, R155 was observed in her wheelchair leaning to her right side with her right arm hanging over the right armrest and she was crying. R155 said that her right arm was caught and when she tried to move it, it would cause her pain. R155's wheelchair had a large bolster on her right arm rest and a lateral support to the right upper back of the wheelchair. There was an open area on the right side of the wheelchair where the 2 adaptive pieces did not meet. This opening is where R155's right arm had fallen through, and she was unable to get her arm back out. The surveyor asked her if she could use her call light to call for help and she said no. R155's call light was observed at the head of the right side of her bed tied around the top bedrails and R155 was in her wheelchair on the left side of the bed behind the foot of the bed. The call light was out of reach. The surveyor turned R155's call light on and V14 (Nurse) came to assist R155 to get her arm out. V14 attempted to bring R155's arm back over the armrest but was unable to. R155 continued to cry out in pain when she would move her arm. V14 then was observed removing the right bolster/adaptive device from R155's wheelchair so that she could get R155's arm released. On 8/21/24, V14 said that R155's arm was trapped because of the bolster on her wheelchair. V14 said that she saw that R155 could not call for help because her call light was out of reach. On 8/21/24 at 10:46 AM V21 (R155's husband) said that on 8/20/24 he visited his wife from 10:45 am until 12:50 pm. V21 said that during that time R155's call light was tied to the bedrails at the top of the bed as it is every day, and he did not move it. V21 said that the call light is never in R155's reach and he visits her every day. V21 said that his wife's arm is trapped in her wheelchair every day and it causes her pain when she tries to move it out. V21 said that the staff are aware of this because they move her arm out of being trapped every day to put the sling for the mechanical lift on her so that they can toilet her. V21 said that this has been like this for a year ever since they put the bolster on her armrest. V21 said that it causes her pain, and it is every day. On 08/22/24 at 09:15 AM, V44 (Manager of Rehabilitation Services) said that R155's has diagnoses of dementia, history of falls, and weakness and that is what causes R155 to lean. V44 said that on 7/10/2023 R155 was given a high back wheelchair with a bolster on the right armrest, and on 5/2024, R155 had increase weakness and leaning, and the facility added the right lateral support to her wheelchair. V44 said that since R155 has had the increased leaning she has been unable to reposition herself. V44 said that when R155 comes down for services at physical rehab she is leaning, and they have to reposition her. V44 said that she had not received any reports that R155's arm was being caught between the cushion on the armrest and the lateral support on her wheelchair. On 08/22/24 at 11:51 AM, V2 (DON) said that her expectations are that call lights are within reach, resident are being closely observed and frequent rounding if needed. V2 said that she expects the staff to report if a patient is falling through the adaptive devises. V2 said that this should be done so the patient can be comfortable, without pain, and free to move. R155's electronic health record showed on 1/25/24 R155's cognition is severely impaired, and she needs substantial to maximal assistance for eating, toileting, sitting to standing, and personal hygiene. R155's 4/24/21 physician order showed she is on fall precaution every shift. R155's 5/13/24 care plan showed ADL self-care deficit related to impaired mobility, cognitive deficit, generalize weakness related to a diagnosis of dementia, and a history of falls. Interventions include monitor document and report as needed any changes, any self-care deficit declines in function, encourage to use bell to call for assistance. R155's 1/23/2024 care plan showed a risk for falls related to impaired mobility, cognitive deficit, generalized weakness related to dementia and history of falls. The interventions included anticipate and meet the residents needs, be sure that the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs to be in a safe environment. R155's Wheel Chair System - Patient Evaluation information showed that on 7/10/2023 a high back chair with foam and a bolster to the right side was given to R155, and on 5/2/2024 a lateral support was added to the right side of the wheelchair due to increased lean.

Based on observation, interview, and record review, the facility failed to offer hydration fluids for a resident at risk for dehydration. This applies to 1 of 2 residents (R30) reviewed for hydration in the sample of 37. Findings include: R30's EMR (Electronic Medical Record) showed R30 had multiple diagnoses including recurrent urinary tract infections, a disorder of the kidney and ureter, neuromuscular dysfunction bladder, urinary retention, constipation, and parkinsonism. R30's MDS (Minimum Data Set) dated 5/09/2024 showed she was cognitively intact. R30's MDS continued to show she was dependent on facility staff for assistance with feeding including drinking liquids. On 8/20/2024 at 10:57 AM, R30 was in bed and said she was not getting enough water. R30 said she was having urinary discomfort and was waiting for her urine results. R30 had no water at the bedside but had a tub of thickener mixing powder. On 8/21/2024 at 11:30 AM, R30 was in bed with no water at the bedside. At 12:30 PM, R30 said she wanted to have water to drink. R30 said she was fed lunch and drank one cup of milk but did not have water. R30 did not have water at the bedside. On 8/22/2024 at 9:50 AM, R30 said she was still not receiving enough drinking water and wanted more. R30 said she only receives a small cup of lemon-thickened water with her medications. R30 said she would like to be given more lemon-thickened water throughout the day. R30 did not have water at the bedside. On 8/22/2024 at 9:53 AM, V13 (Head Unit Nurse) said staff should be offering fluids to residents between meals. V13 said residents who are in their rooms should have a water pitcher at the bedside. V13 said for those with thickened liquids they have available premade thickened liquid drinks. V13 said R30 had frequent recurrent urinary tract infections and needed more fluids. V13 said they would place lemon-thickened water at R30's bedside and offer her more fluids. On 8/22/2024 at 11:12 AM, V12 (Assistive Director of Nursing/ADON) said all residents who can drink oral fluids should be offered fluids because they are all at risk for dehydration. V12 said R30 should have been offered fluids and staff should assist her because of her swallowing precautions. R30's Care Plan dated 8/22/2024 showed multiple focus problems including a potential nutritional problem and an actual impaired urinary elimination problem. R30's care plan showed multiple interventions including Offer preferred foods/fluids within diet recommendation when possible and Encourage fluids during the day to promote prompted voiding response. R30's Annual Nutritional assessment dated [DATE] said R30's diet included moderately honey thick liquids. R30's assessment showed R30's estimated fluid needs were 2050-2100 milliliters and should be encouraged to consume moderately honey-thick liquids. R30's urinalysis lab result dated 8/20/2024 showed an abnormal urine result. The facility's policy titled Hydration Plan with a revised date of 3/2024 said Purpose: To provide residents with adequate water and fluids throughout the day to maintain proper hydration. Policy: It is the policy of DPCC to maintain resident's health at the highest level. The procedure contained in the policy will ensure that all residents will have access to ample water and liquids to maintain the proper levels of hydration required .Procedure: A. 1. The Nurses will: Offer residents/patients a full glass of water with the medication pass .Monitor residents that are acutely ill that require increased hydration due to possible elevated temperatures or infections that demand more fluids to improve their conditions .

Based on interview and record review the facility failed to report allegations of verbal abuse within 24 hours. This applies to 1 of 2 residents (R141) reviewed for abuse in a sample of 37. Findings include: R141 admitted to the facility on [DATE] with diagnoses that includes paraplegia, neuralgia, cramp / spasm, diverticulosis, hypertension, depression, anxiety, and insomnia. R141's MDS (Minimum Data Set) dated 7/17/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status Score) of 15. On 8/20/24 at 11:48 AM, R141 stated V40, CNA (Certified Nurse Aide) verbally abused him by saying he was a bother and no other CNAs wanted to work with him. R141 stated, V2 DON (Director of Nursing) and V5 Social Services Manager were aware of his allegations from the previous week. On 8/20/24 at 12:10 PM, V5 stated she spoke to R141 on 8/17/24 regarding removing V40 CNA from his care team. V5 stated R141 did not like the way V40 positioned him in the wheelchair. V5 stated she did not ask R141 details as to why he no longer wanted to receive care from V40. V5 stated she informed R141 she was aware a service recovery (attempt by the facility to find a resolution for a dissatisfied resident) had been initiated by V6 Social Worker in the previous week. On 8/20/24 at 12:20 PM, V6 Social Worker stated she had spoken with R141 the previous week regarding V40 being mouthy and not placing him in his wheelchair correctly. V6 stated she did not ask R141 what he meant by V40 was mouthy. V6 stated she could not recall specific details of her conversation with R141. V6 stated on 8/19/24 V5 Social Services Manager informed her R141 claimed V40 was being abusive. On 8/20/24 at 3:48 PM, V2 DON (Director of Nursing) stated R141 left her a voice mail over the weekend accusing V40 of verbal abuse. V2 stated she reviewed the message on Monday 8/19/24. V2 stated V5 followed up with R141 regarding his allegation of abuse. V2 stated R141 had a service recovery regarding the care he received from V40 CNA the prior week. V2 did not know details regarding the service recovery. V2 stated staff doing a service recovery will ask the resident what their specific concerns are and attempt to address them. On 8/21/24 at 2:45 PM, R141 stated he had spoken to V6 Social Worker regarding his allegations against V40 the prior week. On 8/21/24 at 10:17 AM, V5 Social Services Manager stated she spoke to R141 on Saturday 8/17/24 while manager on duty. V5 stated R141 told her he no longer wanted V40 to provide his care. V5 stated R141 informed her V40 places him in his wheelchair in an uncomfortable position and told him he was a bother. On 8/22/24 at 9:34 AM, V40 CNA stated he was informed on Monday 8/12/24 that R141 complained and no longer wanted him to provide his care. V40 stated on Monday 8/19/24, V39 ADON (Assistant Director of Nursing) informed him of R141's allegations of abuse and suspended him. On 08/22/24 11:37 AM, V4 Assistant Administrator / Abuse Coordinator stated anyone in leadership can file a report for an abuse allegation including on the weekend as there is a manager on duty. V4 stated abuse allegations are to be submitted to the department of health within two hours. V4 stated verbal and mental abuse is a gray area. We file a report based on the allegations. We try to get details of a concern and if we can't get to the bottom of the concern within 2 hours, we file the report with the state. It is better for us to over report allegations rather than under report. R141 makes a lot of false allegations, and it has been a challenge for us. V4 stated the word bother isn't a word that is necessarily a trigger, but it is the perception of the individual. If someone says they are being abused, it should be reported. The voicemail V2 DON received on 8/19/24 is what triggered us to file the report of abuse. The facility service recovery report submitted by V6 Social Services states R141 expressed frustration with his CNA on the morning of Sunday 8/11/24. Immediate follow up / action take was to provide active listening and apologize to R141. Nursing to follow up as appropriate. A facility provided document dated 8/13/24 from V6 Social Services interview with R141 states V40 told him you're starting to bother me. An email dated 8/16/24 from V8 Head Nurse to V6 Social Services stated CNA was reeducated on customer service and removed from resident's care list. The initial report was submitted to IDPH (Illinois Department of Health) on 8/19/24. The facility policy Resident Abuse & Theft Prevention dated 10/2023 states the Administrator, abuse prevention coordinator or designee will be notified immediately of any reports of alleged mistreatment, neglect or abuse. The Administrator, Abuse Prevention Coordinator, Nursing Administration or designee will immediately send an initial report to IDPH.

Based on observation, interview, and record review, the facility failed to place call lights within reach of residents. This applies to 3 of 3 residents (R145, R168, R155) reviewed for accommodation of needs in a sample of 37. The findings include: 1. On August 20, 2024 at 12:46 PM, R145 was brought back to her room with the assistance of V24 (CNA/Certified Nurse Assistant). V24 wheeled R145 towards the foot of the bed and left the resident in her wheelchair at the foot of the bed. R145's call light was lying across the center of the bed, out of reach of the resident. When asked, R145 said she needed to press the call light to ask for help. R145 tried to propel herself to reach the call light but was not able to reach her call light. R145 asked R168 to reach for her call light, and R168 was not able to reach the call light. At 12:54 PM, R145 was still attempting to reach for her call light but was unable to. R145's face sheet showed R145 was admitted with diagnoses including repeated falls, wedge compression fracture, cerebral ischemia, generalized anxiety disorder, age-related osteoporosis, and weakness. R145's POS (Physician Order Set) showed R145 was on Fall Precaution. R145's MDS (Minimum Data Set) dated July 5, 2024 showed R145 had moderate cognitive impairment. R145 needed substantial assistance from staff for toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. R145's July 9, 2024 care plan showed she had an ADL (Activities of Daily Living) self-care performance deficit [related to] limited physical mobility, gait and balance impairments from dementia .with an intervention to Encourage the resident to use call button to call for assistance. R145's care plan also showed R145 was at high risk for falls [related to] cognitive impairment, musculoskeletal impairment from recent multiple fracture [status post] orthopedic surgery; psychotropic drug use; [history] of repeated falls, with an intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 2. On August 20, 2024 at 12:42 PM, R168 was sitting in her wheelchair with the tray table in front of her. R168's call light was on the bed but out of reach of the resident. At 12:46 PM, R145 asked R168 to reach for her call light, and neither resident was able to access their call lights. R168's face sheet showed she was admitted to the facility with diagnoses including hypertension, osteoarthritis, depression, and dementia. R168's MDS dated [DATE] showed R168 had severe cognitive impairment. R168 required moderate assistance from staff for personal hygiene, substantial assistance for toileting hygiene, shower/bathing, upper and lower body dressing, and was dependent on staff for putting on/taking off footwear. R168's care plan dated May 18, 2023 showed Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On August 22, 2024 at 1:01 PM, V33 (CNA) said the call light should be within reach to the resident. V33 said he clips it to their clothes or blankets, and it be in a place where they can press it. On August 22, 2024 at 1:04 PM, V34 (CNA) said the call lights should be within reach as well as within sight to the resident, and he usually clips the call light onto them. On August 22, 2024 at 1:09 PM, V25 (CNA) said the call light needs to go near the resident so they could reach it. On August 22, 2024 at 1:11 PM, V26 (RN/Registered Nurse) said the call lights should be in a place the resident could reach. On August 22, 2024 at 1:16 PM, V35 (RN) said the call light should be where the resident could reach, and some of the residents even tell the staff where to place the call light. V35 said the staff should clip it on top of the sheets within reach of the resident. On August 22, 2024 at 9:39 AM, V2 (DON/Director of Nursing) said the call light should be within the resident's reach for those who can move their hands. V2 said the call light should be clipped on their clothes or the sheets in a place that is accessible to the resident. V2 said the staff do call light assessments as needed and if there is a change in condition. V2 said the call light should still be within reach if the resident is alert but not oriented. The facility's Call Light Protocol reviewed February 2021 showed A working call light is to remain within reach of the resident at all times when they are in their room; if they are in bed, a wheelchair, a geri chair, the toilet or a commode. 41384 3. On 8/20/24 at 1:42 PM, R155 was observed in her wheelchair leaning to her right side with her right arm hanging over the right armrest and she was crying. R155 said that her right arm was caught and when she tried to move it, it would cause her pain. The surveyor asked her if she could use her call light to call for help and she said no. R155's call light was observed at the head of the right side of the bed tied around the top bedrails and R155 was in her wheelchair on the left side of the bed behind the foot of the bed. The surveyor put the call light on so staff could come and assist R155. V14 (nurse) came in and had to remove the adapted device on R155's armrest to release R155's trapped arm. On 8/21/24 V14 (Nurse) said that on 8/20/24 at 1:42 PM, when she came to assist R155, R155's arm was trapped in her wheelchair and her call light was out of reach. On 8/21/24 at 10:46 AM, V21 (R155's husband) said that on 8/20/24, he had visited his wife from 10:45 am - 12:50pm and her call light was out of reach the whole time as it is every day. V21 said that R155's call light was tied to the bedrail at the top of the bed as it is every day and he did not move it.

Based on observation, interview, and record review, the facility failed to change, date, and label a feed tubing for an enteral feed for a resident with a gastrostomy tube (G-tube). This applies to 1 of 1 (R68) resident reviewed for gastrostomy tubes in a sample of 37. The findings include: On August 20, 2024 at 11:23 am, R68 was connected to her feeding via the gastrostomy tube and was receiving it at a rate of 50 milliliters per hour. R68's bottle of formula was dated August 19, 2024 at 4 PM and the tubing was dated August 15, 2024 at 9:53 PM. On August 21, 2024 at 11:32 AM, R68's feed tubing was not labeled or dated. On August 22, 2024 at 11:34 AM, V26 (RN/Registered Nurse) said the G-tube pump tubing was changed whenever a bottle was opened. V26 said the tubing should not be used for more than 24 hours. V26 also said the tubing needed to be dated and labeled. On August 22, 2024 at 1:16 PM, V35 (RN) said when the staff start a feeding, all the equipment needs to be brand new. V35 said the tubing and bottle need to be changed every 24 hours, or more frequently, depending on when the bag is changed. V35 said the tubing should also be dated. On August 22, 2024 at 9:39 AM, V2 (DON/Director of Nursing) said the gastrostomy feed tubing should be dated, but said for changing the tubing, she would need to double check the policy for when the tubing should be changed. As of August 23, 2024 at 3:30 PM, V2 was unable to provide a policy regarding when the tube feeding tubing should be changed. R68's face sheet showed she was admitted to the facility with diagnoses including gastrostomy status. R68's MDS (Minimum Data Set) dated August 14, 2024 showed R68 had severe cognitive impairment and was dependent on staff for eating. R68's POS (Physician Order Sheet) showed Enteral Feed Order Check tube placement before initiation of formula, medication administration, and flushing tube. The Manufacturer Guidelines for Ready-To-Hang Prefilled Enteral Feeding Containers provided by the facility, dated 2010, showed Proper identification and dating are essential for patient safety. Use formula, container, and tubing for 24 hours, or up to 48 hours after initial spike, when clean technique and only one new feeding set are used.

Based on interview and record review the facility failed to provide documentation of monthly medication reviews and obtain a documented physician response to pharmacy recommendations. This applies to 1 of 5 residents (R141) reviewed for unnecessary mediations in a sample of 37. Findings include: R141 admitted to the facility on [DATE] with diagnoses that includes paraplegia, neuralgia, cramp / spasm, diverticulosis, hypertension, depression, anxiety, and insomnia. R141's MDS (Minimum Data Set) dated 7/17/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status Score) of 15. On 8/21/24 at 3:47 PM, V7 Pharmacy Manager stated he did not have documentation of the medication review done on 3/16/24 or 6/24/24. Pharmacy recommendations made on 11/27/23 did not have a physician response. On 8/22/24 at 9:53 AM, V7 Pharmacy Manager stated pharmacy recommendations are sent to the units for the physician to address when they round. Nursing is responsible for following up with the physician to address our recommendation. We do not have a policy to address the time frame in which the physician should respond to our recommendations. Pharmacy will send a follow up by the next review if we have not had a physician response. The pharmacy recommendation on 11/27/23 for Citalopram Hydrobromide continue at a reduced dose: maximum dose in the elderly (those over [AGE] years) is 20mg per product labeling due to the risk of QT prolongation. Please consider a dose reduction to 20mg if possible. V7 Pharmacy Manager stated a prolonged QT can cause arrhythmias in the heart if R141 has risk factors. The physician response provided by V43 Psychiatrist on 12/4/23 states not followed by me. Please refer to V42 PCP (Primary Care Physician). V7 Pharmacy Manager did not provide documentation of V42 PCP response to recommendations from 11/27/23 or documentation of pharmacy follow up with V42 PCP regarding recommendations. On 8/22/24 at 1:14 PM, V2 DON (Director of Nursing) stated the pharmacy delivers the monthly medication review to the head nurse or the charge nurse who should present it to the physician for review. V2 DON stated policy directing the time frame in which a physician should address pharmacy recommendations. V2 DON stated the physician or nurse practitioner make their rounds in the facility daily. V2 stated her expectation is that if the physician has not made rounds or addressed the pharmacy recommendations the nurse should contact him within a week. R141's current physician's orders show an increase of Citalopram Hydrobromide from 30MG (Milligrams) daily to Citalopram Hydrobromide 20MG twice daily. The facility provided policy Prescribing of Medications dated 8/2022 states if there is a question regarding an order, the pharmacist may contact the physician directly for clarification and, if necessary, may write a clarification on the patient's medical record. All current residents will undergo a monthly drug regimen review. Completion of review will be documented by the pharmacy manager or designee.

Based on observation, interview, and record review, the facility failed to safely transfer residents using a gait belt. This applies to 2 of 2 residents (R68, R191) reviewed for mobility in a sample of 37. The findings include: 1. On August 21, 2024 at 2:11 PM, V25 (CNA/Certified Nurse Assistant) and V41 (Restorative Aide) assisted R68 from a lying to a sitting position. V25 applies a gait belt around R68's waist and then V25 and V41 assists R68 into a standing position, with V25 pulling R68 up by her pants. At 2:11 PM, V25 pulled R68 further back into her wheelchair using her pants instead of the gait belt. R68's face sheet showed she was admitted to the facility with diagnoses including dysphagia, gastrostomy status, failure to thrive, cognitive communication deficit, osteoporosis, and a history of falling. R68's MDS (Minimum Data Set) dated August 14, 2024 showed R68 had severe cognitive impairments and was dependent on staff to transfer from lying to sitting on side of bed, sit to stand, and bed to chair transfers. R68's care plan revised on August 7, 2024 showed Resident will require 2 [Gait Belt] total dependent assist from staff. 2. On August 21, 2024 at 11:47 AM, R191 was being assisted into the wheelchair by V31 (CNA). R191 was sitting at the edge of her bed and V31 applied the gait belt around her and brought the wheelchair close to R191. V31 then pulled and pivoted R191 using her pants into the wheelchair. At 11:51 AM, R191 was taken to the bathroom, and V31 used R191's pants to pull her up instead of the gait belt and placed her on the toilet. At 11:55 AM, V31 pivoted R191 with one hand on the gait belt and the other hand on her pants. R191 face sheet showed she was admitted with diagnoses including abnormalities of gait and mobility and repeated falls. R191's MDS dated [DATE] showed R191 had moderate cognitive impairment. R191 required substantial assistance for sitting to stand, bed to chair transfers, and toilet transfers. R191's care plan dated April 1, 2024 showed The resident has an ADL (Activities of Daily Living self-care performance deficit [related to] cognitive deficit and mobility impairment .with an intervention including bed to chair 1 person assist to Give her time to participate in holding the side rails and let her pull herself to stand and pivot to the chair. On August 21, 2024 at 2:40 PM, V25 (CNA) said the staff should use a gait belt to transfer residents for safety. V25 said staff need to make sure it was placed tightly and then the resident should be pulled up by the gait belt, not by their pants. On August 22, 2024 at 1:04 PM, V34 (CNA) said the residents should be transferred using a gait belt and they should not be pulled by their pants. On August 22, 2024 at 1:16 PM, V35 (RN/Registered Nurse) said the staff should be transferring the resident using a gait belt and should not be pulling them by their pants. V35 said the gait belt was in place to use and pulling them by their pants could hurt them. On August 22, 2024 at 12:56 PM, V32 (Physical Therapy Program Manager) said ideally, the staff should only be holding the resident by the gait belt and should not be pulling them by their pants. On August 22, 2024 at 9:39 AM, V2 (DON/Director of Nursing) said the staff should use the gait belt to lift and transfer the residents. The facility's Transfer-Gait Belt Policy reviewed August 2023 showed Place your hands toward the back of the resident and grasp the belt by inserting your thumbs downward. Fingers are to be curled under belt and next to thumbs. The belt is to be snug enough to allow your hands only enough space to grasp the belt.

Based on record review and interview, the facility failed to ensure two staff assisted in transferring a resident safely while using a mechanical lift. This failure resulted in R2 falling from the mechanical lift to the floor, sustaining a right tibia fracture and an occipital contusion and transfer to the emergency department. This Applies to 1 of 5 residents (R2) reviewed for falls and accidents in a sample of 9. A care plan initiated on 10/30/2023 showed that R2 needs two staff members to assist with ADLs (Activities of Daily Living), including transfers from bed to wheelchair and vice versa. The MDS (Minimum Data Set), dated 11/22/2023, showed that R2 is cognitively intact and dependent on ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, and bathing. A review of R2's face sheet and physician's progress notes dated 01/24/2024 showed R2 was an [AGE] year-old admitted to the facility initially on 05/01/2023 with diagnoses including muscular dystrophy, osteoarthritis, history of falls, disease of the spinal cord, history of multiple traumatic fractures, lack of coordination, vitamin D deficiency, progressive weakness, wheelchair-bound, and chronic obstructive pulmonary disease. On 06/13/2024 at 01:04 PM, R2 was in bed, alert, oriented to person, place, and time, and was interviewable. R2 said, V12 (Certified Nursing Assistant) put him in a mechanical lift by herself, and the sling was smaller to him. R2 said when she lifted him from the bed, his groin hurt, and he told V12 to take the sling off. R2 said V12 played around with the sling and took the mechanical lift near the door where his power wheelchair was, and he fell from the mechanical lift and broke his right leg and blood was coming from the back of his head. R2 said V12 ran outside the room and told other staff that she had dropped him and staff had come to assist him. Nursing progress notes dated 01/21/2024 showed that at 8:40 AM, R2 had a witnessed fall during transfer, causing injury to the head (occipital region) and right knee pain. The nursing progress notes further showed that R2 was sent to the emergency department for evaluation. R2's hospital emergency department Physician history and physical dated 01/21/2024 showed [AGE] year-old R2 presented to the hospital on 1/21/2024 with a complaint of a fall from the mechanical lift with an injury to the right leg below the knee with pain and side of the head lacerations. X-ray of the right tibia fibula lateral view on the same day showed medial tibial plateau fracture and treated with knee immobilizer 24/7 for three weeks and Neosporin antibiotic cream dressing for scalp after cleaning. On 06/13/2024 at 2:00 PM, V2 (Director of Nursing) said R2 uses a mechanical lift with two staff members assisting, and he fell from the mechanical lift while V12 (Certified Nursing Assistant-Agency) was transferring R2 from bed to his wheelchair. V2 said V12 should have waited for another staff member to help R2 transfer. V2 said the facility is not using V12 anymore, investigated, educated staff on the mechanical lift transfer, and reported to IDPH. On 06/13/2024 at 2:10 PM, V6 (Certified Nursing Assistant) said he is a regular staff member in that unit and that they should always use two or more staff to transfer residents from the mechanical lift. V6 said R2 is a dependent resident for ADLs, and V12 should have called for help to transfer R2 using the mechanical lift. A facility's policy titled Transfers-EZ Lift/EZ Stand stated, in part, that each resident will be assessed to determine the mode of transfer and the level of staff involved.

Based on observation, interview, and record review, the facility failed to provide dignity for 5 of 5 residents (R19, R61, R72, R79, R128) reviewed for dignity in the sample of 36. The findings include: On 10/26/23 at 10:00 AM, V16 (unit secretary) was observed paging call light assistance over an intercom. She announced the room and bed number. At 10:22 AM she announced bathroom assistance with the room number. The Admission record for R128 shows he was admitted to the facility 6/29/16. His 8/24/23 quarterly assessment shows him to be cognitively intact. On 10/26/23 at 11:21 AM, R128 said the overhead paging has been brought up before, and he was told it was going to be phased out. It is embarrassing when someone says toileting assist and their room number or their name. All of the shifts use the paging system. He said the secretary will announce who needs bathroom assistance and it is embarrassing for those that are incontinent or in the bathroom, everyone does not need to know that information. The Admission record for R19 shows she was admitted to the facility on [DATE]. Her 10/9/23 quarterly assessment shows she is cognitively intact. On 10/26/23 at 11:41 AM, R19 said the intercom has always been used by the staff, they announce the room and what you need. When you put on the call light, they will use the phone to ask what you need. If you ask to use the bathroom, they will announce it overhead with the room number, and sometimes they will use the resident's name. She said it makes me think now everyone knows you went to the bathroom or pooped, it is embarrassing. On 10/25/23 at 1:26 PM, during the resident council meeting, R128, R19, R79, R72, and R61 said it is about 20-30 minutes waiting for call lights to be answered. The light is on so long that the nurse will get on the intercom and page 1137 needs bathroom help. R19 said they can just say that we need assistance, but they call it over the intercom what kind of help is needed, and it is embarrassing. Each said it was a dignity issue. R79 said sometimes the staff will answer the call light using the phone system and will ask the person what they want, then will announce it over the intercom. He said some of that should be private. R72 said she does not like the overhead paging. They should just say someone needs help and not what kind of help. They should not say someone has to go to the bathroom. On 10/26/23 at 12:07 PM, V2 DON (Director of Nursing) said the units have always had paging, it is not used after night time but during the day. The staff should only be announcing needing assistance. V2 said she could possibly see the bathroom announcement as a dignity issue. The facility's 8/2023 Resident Rights policy documents it is dedicated to promoting the highest quality of life for their resident's. The Center strives to ensure that these rights are protected and respected by the resident, staff, volunteers and visitors at the Center.

Based on Observation, Interview and Record Review the facility failed to serve residents trays at an appetizing temperature for eight residents (R5, R12, R128, R119, R19, R79, R72, & R61) outside of the sample. The findings include: On 10/24/23 at 11:17 AM, the first tray cart containing lunch trays was delivered to the third floor. Residents were sitting in the common area at tables. Staff were not passing any of the lunch trays. At 11:37 AM, the second tray cart containing lunch trays was delivered to the third floor. V7 CNA (Certified Nursing Assistant) took a rolling cart over to the first tray cart, opened the doors to look for certain trays and placed them on her rolling cart. V7 went to the second tray cart, opened the doors to look for certain trays and placed them on her rolling cart. V7 took 4 resident trays and walked down the hall. At 11:42 AM, V8 CNA started serving lunch trays. V9 CNA opened the first tray cart, removed a couple of trays, left the doors open and went to the second cart to look for additional trays. At 11:48 AM, there were 5 trays left sitting on the racks of the first cart that had the door left open. V7 CNA, V10 CNA, and V11 CNA removed lunch trays from the side of the first cart that had the door left open. At 11:50 AM, the last tray was removed from the first cart on the side with the door open. The tray was for R5. V13 (Dietary Manager) took temperatures of the food on R5's tray. The salmon was 116 degrees Fahrenheit and the potatoes were 119 degrees Fahrenheit. V13 stated when they temperature test for test trays the food temperatures should be 120 - 125 degrees Fahrenheit. V13 stated the reason they do two tray carts to the floor is so the first cart will come up and trays will served before the second cart comes up. V13 stated this was done so staff can serve food at the temperature it needs to be. V13 stated it was important to serve food at the appropriate temperature because it tastes better for the residents. V13 observed the staff leaving the doors open on the tray carts while searching for residents lunch trays. V13 stated that leaving the doors open on the tray carts contributes to cold food. At 12:10 PM, forty-three minutes after the first tray cart was delivered to the floor, the last meal tray on that cart was ready to be served to R12; she had a mechanical soft diet. V13 took the following temperatures in degrees Fahrenheit of R12's lunch tray: pork - 108 degrees, rice 105 degrees, and carrots 106 degrees. V13 stated the food was too cold. V13 stated he noticed staff spend a lot of time searching for trays in the carts while other staff go up and down different halls delivering lunch trays. At 12:12 PM, V12 (Registered Dietician) stated the tray carts don't go up at the same time so nursing staff can pass trays from one cart before the other cart comes so the food doesn't get cold. On 10/25/23 at 1:26 PM, during the group meeting R128, R119, R19, R79, R72 and R61 stated the food is served cold. R128 and R72 stated when the tray carts are brought up the staff is busy and they can't get the food trays out fast enough so the food is served cold. R72 stated two carts will come up to the floor and staff will sometimes wait for both of the food carts to come up before they start serving the food. R61 stated staff leave the doors open on the food carts and the food gets cold. On 10/26/23 at 10:40 AM, R5 stated the food is always cold and tastes awful. R5 stated, I don't know why it's cold all of the time; but it doesn't taste good like that. I can have it warmed up if I ask them to do that and if I can get someone to do it. The Face Sheet dated 10/26/23 for R5 showed medical diagnoses including spina bifida, paraplegia, disorder of adrenal gland, gastroesophageal reflux disease, absence of other parts of digestive tract, deficiency of other vitamins, obstructive and reflux uropathy, hypertension, and kidney stones. The Dietary Note dated 10/25/23 for R5 showed she has had an 8 percent weight loss in three months with variable appetite. R5 is provided select menus for lunch and dinner to choose her meals. R5's food preferences were updated. The Care Plan dated 8/10/23 for R5 showed she has a potential nutritional problem. Regular diet; provide and serve diet as ordered. The Minimum Data Set (MDS) dated [DATE] for R5 showed no cognitive impairment; set up only needed for eating; extensive assistance needed for bed mobility, dressing, and toilet use; total dependence on staff for transfers. The facility's Dining Services policy (no date) showed, Meals shall be prepared using quality ingredients and standardized recipes, and served in a palatable, attractive and at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for Covid-19 resident room. The facility failed to have the required PPE for airborne/droplet isolation available outside the resident room to prevent possible exposure to Covid-19, for 4 of 4 residents (R150, R280, R281, and R282) reviewed for transmission based precautions (TBP) in the sample of 35. This failure has the potential to infect high risk residents with Covid-19 and spread the disease of Covid-19 to negative residents. The facility failed to perform hand hygiene and change gloves during incontinence care to prevent cross contamination for 1 of 5 residents (R108) reviewed in the sample of 35. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/2/2021 at 12:15 PM when it was determined staff were not wearing an N95 mask into the rooms of residents considered to be PUI and on airborne/droplet precautions to rule out Covid-19.The Immediate Jeopardy was identified on 8/2/2021 at 12:15 PM. V2 (Assistant Administrator) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on 8/3/2021 at 1:30 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/3/2021 However noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility provided list on 8/2/2021, shows the following two residents are on airborne/droplet transmission based precautions and considered to be PUI, to rule out Covid-19. (R280 and R282). The facility provided list on 8/2/21 shows R150 was admitted to the facility on [DATE] and R281 was admitted to the facility on [DATE]. Outside the rooms of the above four identified residents there were isolation carts and a sign posted on the doors. The signs show anyone entering the room is required to wear a gown, N95 face mask, gloves, and a face shield when entering their rooms. The list provided by the facility on 8/2/2021 shows that 92.31% of residents and 85.13% of staff have been fully vaccinated against Covid-19. On 8/2/2021 at 12:28 PM, V7, Unit Secretary, said people who are admitted here from the hospital who are not vaccinated for Covid-19 are on TBP for 14 days, they are not PUIs. V7 said it is his understanding only residents with known exposures to Covid-19 are PUIs. V7 provided a list indicating the residents on TBP; the residents marked were R150, R280, R281, and R282. On 8/2/2021 at 12:10 PM, V5, Certified Nursing Assistant (CNA), said staff wear a N95 mask only if they are not vaccinated; if the staff member is vaccinated, they can choose not to wear an N95 mask. On 8/2/2021 at 12:15 PM, V4, Occupational Therapist (OT), was in R281's room wearing a surgical mask and a face shield. V4 exited R281's room and said R281 is on isolation since she was not vaccinated for Covid-19. V4 said she is required to wear a gown, gloves, a face shield and a surgical mask in R281's room. On 8/2/2021 at 12:38 PM, V10, Registered Nurse (RN) was observed going into R281's room with a surgical mask, face shield, gown, and gloves. V10 said all residents not vaccinated for Covid-19 are on contact/droplet TBP for a total of 14 days. V10 said no N95 mask is required for TBP rooms except for staff members who are not vaccinated. On 8/2/2021 at 12:42 PM, V11, CNA, was observed delivering a meal tray to R280 wearing only a surgical mask, gown, face shield and gloves. On 8/2/2021 at 12:32 PM, V9, RN said she is not required to wear an N95 mask in any of the isolation rooms. Contact isolation requires staff to wear a gown, gloves, and face shield with a surgical mask and the same PPE for residents on TBP. V9 said residents on TBP are those residents not fully vaccinated for Covid-19 that have come from the hospital or new admissions. V9 said she wears a regular surgical mask unless the resident has Covid. On 8/2/2021 at 12:21 PM, V6, Secretary, said she goes into resident rooms to deliver clothes or the newspaper. V6 said she is required to wear full PPE in isolation rooms which includes a gown, surgical mask, and foot covers for any isolation room. V6 said she does not have to wear an N95 mask in isolation rooms, just the surgical mask. On 8/2/2021 at 10:11 AM, V8, Registered Nurse (RN), said residents are on TBP for 14 days after returning from the hospital. Currently, R150, R280, R281, and R282 are on TBP. On 8/2/2021 at 1:01 PM, V3, Infection Prevention Nurse, said staff are require to wear all the garb including an N95 mask, gown, gloves, and face shield for residents in TBP rooms. On 8/2/2021 at 2:42 PM, V1, Assistant Administrator, said that is not our policy, staff absolutely have to wear the N95 masks in the PUI rooms. On 8/3/2021 at 8:30 AM, V2, Director of Nursing (DON), said, I don't know how we missed the guidance on this one. They have been wearing surgical masks and face shields, not N95s in the PUI isolation rooms. The facility provided Resident Vaccine Tracker shows the following residents (R90, R173, R283, R144, R150, R25, R75, R282, R101, R88, R284, R281, R280, R31, R110, and R226) have either refused the Covid-19 vaccine or are considered not fully vaccinated against Covid-19 per CDC criteria. On 8/2/2021 at 9:54 AM, the 1 East Unit isolation carts outside the residents' rooms were checked by the surveyor. The carts contained, gowns, surgical masks, and cleansing wipes for face shields. There were no face shields, gloves, or N95s in the carts. Staff on the floor, V4, V5, V6, V7, V8, V9, V10, and V11, were observed to be wearing surgical masks and not N95s. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The Centers for Disease Control Preparing for COVID-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory mask, eye protection, gloves, and gown when caring for new admissions and readmissions. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, Appendix: Additional Information about Airborne Infection Isolation Rooms, Respirators and Facemasks: Filtering Face piece Respirators (FFR) including N95 Respirators: A commonly used respirator in healthcare settings is a filtering face piece respirator (commonly referred to as an N95). FFRs are disposable half face piece respirators that filter out particles. To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. Three key factors for an N95 respirator to be effective: 1. The respirator must be put on correctly and worn during the exposure. 2. The respirator must fit snugly against the user's face to ensure that there are no gaps between the user's skin and respirator seal. 3. The respirator filter must capture more than 95% of the particles from the air that passes through it. The facility Infection Control Covid-19 Policy revised 6/2021 shows the facility will implement all three types of TBP, contact, droplet, and airborne, with resident's who are suspected or confirmed with Covid-19. Specifically, respirators will be used when available . The Immediate Jeopardy that began on 8/2/2021 was removed on 8/3/2021, when the facility took the following actions to remove the immediacy: 1.The facility conducted re-education on August 2, 2021, for staff when working on the unit where the PUI residents reside to include the donning of gown, shield, gloves and N95/P100. 2.The facility required staff to complete re-education prior to assignment to the care of PUI residents and before the beginning of each shift by the Director of Nursing or Designee. 3.The facility has conducted audits on August 3, 2021. Audits will be ongoing on all three shifts. Audits will be conducted daily for 3 days, then weekly for 3 weeks, then monthly for 3 months to ensure compliance. The audits will be reviewed during the Quality Assurance Performance Improvement meetings and recommendations or changes will be made accordingly. 2. On 8/2/21 at 11:53 AM, V12 CNA (Certified Nursing Assistant) and V13 CNA performed incontinence care for R108. R108 had a large amount of liquid stool in his incontinence brief, incontinence pad, and bed sheet. There was stool to R108's left hip. V12 had her right hand on the stool on R108's hip and then touched R108's urinary device tubing, and R108's shirt without changing her gloves or performing hand hygiene. At 12:32 PM, V13 CNA pulled the soiled with stool washcloths from under R108's backside and placed the soiled linen in a garbage bag. V13 touched R108's new incontinence brief, R108's clean shorts, urinary drainage device tubing, the mechanical lift controls, and R108's motorized wheel chair controls without performing hand hygiene or changing his gloves. On 8/4/21 at 11:00 AM, V22 CNA said hand hygiene should be performed and gloves should be changed after each step of incontinence care. Hand hygiene and glove change should be done before a new incontinence brief and clean clothes are placed on the residents to avoid contamination and infection. The facility Hand Hygiene Policy revised on 8/2020 shows, To provide guidelines for hand hygiene and prevention of infections. To promote compliance with regulatory guideline for hand hygiene. Wash hands when visibly soiled; show dirt or contamination from proteinaceous material; blood; or, other body fluids (i.e. fecal material or urine.). Hand hygiene should be done before and after assisting residents with personal care, assisting residents with toileting, and before moving from work on a soiled body site to a clean body site on the same residents.

Based on interview and record review, the facility failed to immediately assess and provide treatment to a resident with burn injuries after spilling coffee. This failure resulted in R1 (who is paraplegic) having a delay in treatment to his second degree [CONDITION(S)] requiring surgical debridement. This applies to 1 of 4 residents (R1) reviewed for incident/accidents in a sample of 11. Findings include: The review of R1's EHR (Electronic Health Record) shows R1 a [AGE] years old was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated 4/21/21 showed R1 required extensive assistance of one staff with bed mobility, transfer, and toilet use. The MDS shows R1 with impairment to one part of the upper extremities. On 5/7/21 at 8:55 A.M., R1 stated on 4/26/21, he spilled hot coffee on himself because the coffee mug lid was not properly screwed to the mug. R1 stated on 4/26/21 he was assisted by V5 (Certified Rehab Nursing Assistant, CRNA ) in his room during breakfast. R1 stated V5 brought coffee to him in his mug that he has used for over two years. R1 stated as he picked the mug up from his bedside table and was about to drink the coffee, the lid came off and the hot coffee spilled out of the mug. R1 stated the entire coffee spilled over his right lower abdomen and thigh area. R1 stated he did not realize how bad the burn was immediately following the coffee spill. R1 stated he could not feel from his waist down related to his [CONDITION(S)]. R1 stated V9 (CRNA) removed his shirt, mopped his right upper abdomen area. R1 stated V5 brought linen to change his bed later. R1 stated no treatment was received to the burn area until the next day. According to the MDS (Minimum Data Set) dated 4/21/21, R1 is cognitively intact. Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: apply ice pack for 20 minutes, loose clothing, apply [MEDICATION(S)] cream to open area, right upper lateral leg twice daily until healed. R1's medical record dated 4/26/21 shows R1 obtained secondary degree [CONDITION(S)] to his right lower abdomen and right lateral thigh around 9 A.M., R1's skin was not assessed for injuries until around 8:30-9:00 P.M. (approximately 12 hours after the incident). The facility also failed to inform the physician about R1's incident until 9:00 P.M. (12 hours after the incident). R1 did not receive any treatment to the burn areas until 11:00 P.M., on 4/26/21 (14 hours after the incident). Review of R1's initial daily wound documentation dated 4/27/21 shows R1 with burn to right lateral lower abdomen that measured 22cm (centimeter) in length (L) x 15.00cm in width (W) x 0.00cm in depth (D). The wound base was noted with 1.5cm x 1.5cm collapsed blister. The second burn wound site was the right lateral thigh which measured 38cm (L) x 20cm (W) x 0.10cm (D) with 100% granulation tissue. R1's wound treatment order was changed on 4/28/21. The new wound treatment shows to clean the right upper lateral thigh with normal saline, pat it dry then apply Vaseline gauze and a thin layer of [MEDICATION(S)] and cover it with gauze and ABD (Army Battle Dressing) pad daily in the morning. Change only ABD pad if saturated in the evening shift and as needed. Clean the right lower lateral abdomen with normal saline, pat it dry then apply [MEDICATION(S)] and cover with ABD pad daily. Review of R1's wound evaluation and management summary dated 5/5/21 shows R1 with burn wound to the right hip that measured 24.0cm (L) x 14.0cm (W) x not measured (D) with 50% slough and 50% granulation. The report shows R1's wounds were noted with heavy serous exudates. The report also shows R1 had surgical excisional debridement procedure done to the burn wounds. The report also shows to administer multivitamins once daily, vitamin C 500mg twice daily, and [MEDICATION(S)] 220mg once daily for 14 days. On 5/7/21 at 11:20 AM, V10 (Wound Care Nurse) stated she saw R1 on 4/27/21 and did a skin assessment. V10 stated redness and lots of drainage were noted from R1's wound sites and due to the amount of drainage coming out of R1's wounds, she called V17 (Wound Care Doctor) to inform her of the findings. V10 stated V17 changed R1's treatment orders to reflect the current condition of R1's wounds at the time. V10 stated there was a debridement done on 5/5/21 by V17 to R1's right lateral thigh. On 5/7/21 at 10:15 AM, V5 (CRNA) stated she filled R1's mug with coffee during breakfast. V5 stated she was in another resident's room when she heard R1's scream. V5 stated she went to R1's room and found R1 had spilled the coffee on himself. V5 stated V9 (CRNA) was also present in the room. V5 stated R1's shirt was removed by V9 while she went out of R1's room to obtain linen. V5 stated she did not inform V3 (Nurse) right away because R1 asked her not to inform V3. V5 stated she went back to R1's room about two hours later to change his linens and got R1 up. V5 stated she informed V3 in the afternoon before the end of her shift but V3 stated she would see R1 later. On 5/7/21 at 10:30 A.M, V9 (CRNA) stated she was taking R3's breakfast tray out on 4/26/21 when R1 screamed out. V9 stated she went to R1's side and found out R1 had spilled the entire coffee on himself. V9 stated V5 rushed into the room and they both removed R1's shirt. V9 stated R1 was very upset and started cursing out. V9 thought V5 went to get the nurse (V3) but V3 did not come into R1's room before V9 left R1's room. On 5/7/21 at 12:55 P.M., V3 (Nurse) stated she cared for R1 on 4/26/21 (during the day shift). V3 stated she was alerted by V5 around 2:00 P.M., that R1 had spilled coffee on himself earlier during the shift. V3 stated she was told by V5 that there was no injury and that R1 did not want her informed. V3 stated she went to see R1 later around 3:15 P.M., but R1 was in an activity program. V3 stated she did not perform a skin assessment on R1 nor relate the incident to oncoming nurse or the supervisor on duty. V3 stated she took V5's words that R1 had no injuries, so she went home. V3 stated she should have done a thorough skin assessment on R1. V3 further stated she should have informed the oncoming nurse about the incident and should have documented the incident. V3 stated she was made aware of R1's injuries the next day. On 5/8/21 at 3:06 P.M., V8 (Evening Supervisor) stated he was called on 4/26/21 at around 8:30 P.M., by V21 (Nurse) about the coffee spill on R1 that occurred during the day shift. V8 stated he was informed by V21 that it was a burn and it was big. V8 stated he immediately went with V12 (Supervisor) to assess R1. V8 stated R1's abdominal skin was noted with redness and blisters, the thigh area was also noted with open wounds and blisters. V8 stated he called V19 (Doctor) to inform him. V8 stated he obtained treatment orders for the wounds. V8 stated he did not personally do the initial treatment on R1's wounds. On 5/10/21 at 1:38 P.M., V22 (Evening Nurse) stated that on 4/26/21 at around 8:30 P.M., she was called by V23 CNA (Certified Nursing Assistant) to see something important with R1. V22 stated when she arrived in R1's room, she saw a huge redness to R1's lower abdomen and right thigh. V22 stated she called V8 right away to report the incident. V22 stated V8 obtained treatment orders for R1's burn wounds. V22 stated R1 refused the ice pack application but she went back to apply [MEDICATION(S)] on R1's right thigh while R1 was sleeping. V22 stated she did not get any assistance from staff to turn R1 for proper application of the [MEDICATION(S)] cream because it was close to 11:00 P.M., and staff was getting ready to go home. V22 stated she informed V8 that R1 refused the ice pack but was not sure if R1's physician was informed. On 5/7/21 at 3:02 P.M., V2 (Director of Nursing, DON) stated she expected the nursing staff to notify the nurse on duty immediately after the coffee spill. V2 also stated when the nurse was eventually notified, the nurse should have performed a visual assessment of R1's skin, administered first aid treatment, notified the physician, and passed the report to the oncoming nurse. On 5/10/21 at 2:15 P.M., V17 (Wound Care Physician) stated she was asked to see R1's wounds on 5/5/21 because they were not getting better. V17 stated R1's burn wounds had lots of superficial layer of slough and would not heal. V17 stated a debridement was needed and carried out to the right thigh burn wound to help promote wound healing. V17 stated she modified the initial physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 stated she added multivitamin regimen and [MEDICATION(S)] sulfate to help improve wound healing. On 5/10/21 at 2:35 P.M., V19 (R1's Attending Physician) stated he was notified of R1's incident on the night of 4/26/21. V19 stated he was informed that the incident occurred during the day. V19 stated he would have preferred to be notified of the incident immediately and he would have instructed nursing staff to loosen R1's clothings, apply cool compress and use [MEDICATION(S)] treatment on the wounds. V19 stated the cool compress would have decreased the burn area of the skin. V19 further stated he was not informed R1 refused the ice packs but he saw R1 the following day after the incident with second degree [CONDITION(S)]. The facility's policy titled, Accident/Incident Reporting dated 10/03/2019 showed: To ensure prompt and appropriate treatment to any resident sustaining an incident or accident .Report event/occurrence to supervisor, head nurse, or department manager .complete appropriate documentation on the shift that the accident or incident occurred and provide this information to the supervisor. Further review of the policy showed: The license nurse shall examine all accident/incident victims .assess the extent of the injury .administer first aid for minor cuts or abrasions

Based on observation, interview and record review, the facility failed to assess and monitor a resident during heat pack therapy in the rehabilitation department. This failure resulted in the resident sustaining bilateral knee full [MEDICAL CONDITION] by infection which required a schedule of intravenous antibiotic therapy. This applies to 1 of 5 residents (R1) reviewed for rehabilitation therapy and receiving heat pack therapy. The Findings Include: The Face Sheet documents R1 is [AGE] years old with the following pertinent Diagnosis: [REDACTED]. Brief Interview for Mental Status assessment dated [DATE] rates R1 with a score of 15 indicating R1 is cognitively intact. On 1/14/2020 at 10:00AM, R1 was sitting in a wheelchair with a [MEDICATION NAME] Lock to the lower right forearm. There was an intravenous therapy machine in the room. R1 said I like rehabilitation/physical therapy except when the hot packs burned both of my knees in (MONTH) of 2019. R1 pulled up both pant legs and showed dressings to both knee caps dated 1/13/2020. R1 said I am getting the IV antibiotic because of my knee burns. On 1/14/2020 at 10:10AM, V3 (Nurse) said the physician will examine both of R1'[MEDICAL CONDITION]. V3 said R1 sustained [MEDICAL CONDITION] heat packs used in therapy. V3 said R1 is getting IV antibiotics because [MEDICAL CONDITION] infected. On 1/14/2020 at 10:38AM, V4 (Unit Nurse Manager) propelled R1 from the dining room to his room for the physician to examine R1. V5 (Medical Director/Medical Doctor) examined R1 while V4 (Unit Nurse Manager), V3 (Nurse) and V8(Treatment Nurse) were present. V5 measured both wounds; the right knee burn was 2.5 cm in length by 1 cm in width black eschar surrounded by redness, the left knee burn was 3 cm in length by 2 cm in width, black eschar surrounded by redness. V5(Medical Doctor) said, R1 got the wounds, first noted as blisters, because the therapist kept the hot packs on too long. The blisters collapsed with subsequent eschar. The [DIAGNOSES REDACTED]. [MEDICAL CONDITION] complicated by [MEDICAL CONDITION] and R1 required intravenous antibiotic therapy. The left knee is worse than the right knee. My colleague diagnosed both wounds as full thickness burns, earlier. The wounds are improving now partial to full thickness burns. On 1/14/2020 at 12:52PM, V6 (Rehabilitation Aide) said R1 came down for therapy on 12/26/19 and said his legs were sore. That is usual, he gets hot packs for arthritis. V6 said he kept the hot packs on for 10 minutes (R1's allotted time) and used a timer. V6 said all R1 said was his legs were sore. After the heat packs were removed R1 began therapy. V6 said he did not check R1's legs during or after the hot pack use. V6 said he has used hot pack therapy several other times and nothing happened. I don't know what happened this time. V6 said residents are supposed to tell us when the packs are too hot and we will remove them. V6 said residents with cognitive impairment, we check the skin after 5 minutes of use. On 1/14/2020 at 12:57PM, V10 (Rehabilitation Manager) and V11 (Assistant Administrator) said R1 was re-evaluated for therapy on 10/16/2019 due to complaints of knee pain. Hot pack therapy was added. R1 had hot pack therapy 5-6 times prior to that last hot pack therapy which resulted in burns. Temperatures were taken and the [MEDICATION NAME] machine temperatures were fine. V6 (Rehabilitation Aide) was interviewed and said there was nothing unusual. As a result of the burn, we have been doing return demonstrations with the therapist on hot pack therapy. We are trying to determine the root cause analysis. When asked what were possible reasons for the burns, if temperatures were checked and all were within normal limits and R1 received this hot pack therapy 5-6 other times without burns, the surveyor received no response. On 1/14/2020 at 3:12PM, V7 (Nurse) said on 12/26/2019 between 8 to 8:30PM, R1 was noted with fluid filled blisters to both knees. R1 said he received heat pads to his knees in therapy earlier today. V7 said the measurements were documented. V7 said the medical doctor was notified and ordered dry sterile dressings until the blisters erupt. V7 said he is familiar with R1 and that R1 is pleasant and soft spoken and should have informed the therapist about the heat from the packs, but R1 is soft spoken and needs encouragement. V7 said R1 did not experience any change in condition prior to therapy on (MONTH) 26, 2019. On 1/15/2020 at 9:12AM, R1 was interviewed again. R1 said V6 (Rehabilitation Aide) put the heat pads on when I got the burns. R1 said V6 kept the heat pads on for about 30 minutes and it started to burn terrible. R1 said I could feel the heat, I did not tell V6. R1 did not respond as to why he did not tell V6 about the burning. R1 said after V6 removed the heat pads, I got on the exercise bike and participated in therapy. R1 repeated 3 times that V6 kept the heating pads on for 30- 35 minutes. On 1/15/2020 at 12:35PM, V1 (Administrator) and V13 (Manager of Social Services) said they were just made aware that R1 did not communicate the heat from the hot packs to V6. V1 said she went to R1's room to see if R1 could quantify time and there were concerns. Due to R1's [DIAGNOSES REDACTED]. Progress Note dated 12/26/2019 at 10:23PM says, R1 noted with a 4.5 cm in length by 2.5cm in width fluid filled blister on his right knee and a 4.5cm in length by 4.5 cm in width fluid filled blister on his left knee. No drainage noted. R1 verbally denies experiencing any pain/discomfort. R1 verbalized that he had heating pads applied to his bilateral knees while attending therapy earlier during the day. Medical Doctor made aware, receiving new order for dry sterile dressings to bilateral knees daily. Physician Note dated 1/3/2020 says knee breakdown on both sides that started after heat therapy, recently. Currently, treatment is just dressings, was a blister before, but popped today. Left knee is blanchable, opened skin no discharge, or pus, top layer of skin is missing. Right knee is excoriated around and non-blanchable in middle but on outside. R1 is oriented to person, place and time and slow to respond. Deep tissue injury related to heat on both knees, will start [MEDICATION NAME] cream daily with kerlix and follow-up in a few days to make sure wounds are not getting worse. Physician Note date 1/7/2020 says left knee 3.5cm in length by 2.4 cm in width burn with eschar, right knee 2.6 cm in length by 1.0 cm in width eschar. Bilateral partial [MEDICAL CONDITION] possible full [MEDICAL CONDITION] left knee. [MEDICATION NAME] twice daily, recheck 1/10/2020. Physician order [REDACTED]. Physician Note dated 1/7/2020 states Intravenous antibiotic for infected 2nd [MEDICAL CONDITION] knees. Physician Note dated 1/8/2020 says 2nd [MEDICAL CONDITION] knees complicated by [MEDICAL CONDITION] start [MEDICATION NAME] IV. Physician Note dated 1/9/2020 says the wounds progressed to bilateral full thickness burns. Physical Rehab Treatment Logs Forms were reviewed from (MONTH) 2019 to (MONTH) of 2019. R1 received Hot pack therapy on the following days: 10/24/2019, 11/21/2019, 12/1/2019, 12/9/2019, 12/13/2019 and 12/26/2019. V6 applied hot packs therapy for R1 on 12/26/2019, other therapist performed the hot pack therapy on the other days. The Daily Hot Pack Temperature Log was reviewed for (MONTH) of 2019. All Temperatures were within normal limits of [MEDICATION NAME] Master Heating Units Operation Manual undated. [MEDICATION NAME] Packs Procedure undated says, patient should be checked on regularly during treatment, [MEDICATION NAME] may be too hot, making it necessary to add more towels between hot packs and area of application. Check area that has been treated, skin should be pink, not red. On 1/15/2020 at 11:40AM, V4 (Rehabilitation Manager) said the manufacturer Guidelines for the [MEDICATION NAME] does not tell how much time heat packs should be applied. We assess residents by applying the heat packs for tissue tolerance. V4 said the standard time frame is 10 to 20 minutes. V4 said residents with cognitive impairment are assessed ,with observation, more frequently when using hot packs. R1's assessment was requested. R1's assessment for heat pack tissue tolerance was not presented.

Based on interview and record review the facility failed to follow speech therapy recommendations for intermittent supervision while eating. The facility also failed to follow safe swallow precautions (taking small bites, alternating solids and fluids) while eating for a resident identified as having swallowing concerns and not independent with follow through on swallow precautions. This failure resulted in R1 experiencing a fatal choking incident. This applies to 1 of 3 residents (R1) reviewed for altered diets and supervision while eating in the sample of 8. The Findings Include: The facility's final incident report dated (MONTH) 4, (YEAR) shows on (MONTH) 27, (YEAR) at approximately 3:00 PM, R1 took a peanut butter sandwich from the snack cart at the nurse's station. R1 started to experience a choking episode and staff initiated the [MEDICATION NAME] maneuver and airway clearance efforts via suctioning. 911 was called and arrived several minutes later. (R1) stopped breathing and lost consciousness, but EMS (Emergency Medical Services) personnel did not initiate advanced resuscitative efforts due to resident's DNR (Do Not Resuscitate) status. Resident expired. On (MONTH) 10, (YEAR) at 12:20 PM, V16 (Deputy Coroner) said R1's final death certificate has not been released pending the autopsy report from the forensic pathologist. The preliminary cause of death is aspiration of food bolus throughout the airway, secondary to the medical history of [REDACTED]. During the autopsy, actual food was present in the trachea with extensive aspiration of food material throughout the airway. The food content consisted of peanut butter sandwich. The EMR (Electronic Medical Record) shows R1 was a [AGE] year old male resident, admitted to the facility on (MONTH) 28, (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 4, (YEAR) showed R1 had severe cognitive impairment and impaired hearing. R1 required extensive assistance with bed mobility, transfers, dressing, bathing and toileting, and required supervision with eating. R1's POS (Physician order [REDACTED]. R1's Yellow Spoon Information sheet dated (MONTH) 30, (YEAR) showed R1's diet texture as mechanical soft, and nectar thick liquids. The sheet showed R1 required swallow precautions and was not independent with follow through on swallow precautions. R1 required intermittent supervision during meals for physical and/or verbal cuing, and was on standard swallow precautions including encouraging small bites of food, eating slowly, alternating solids/liquids, and taking one bite at a time. Facility documentation shows the Yellow Spoon Program is used as a method of providing staff, visitors, and volunteers the ability to identify residents with special swallowing needs, diet texture modifications or fluid restrictions. R1's Speech Therapy Discharge Summary dated (MONTH) 17, (YEAR) shows: Impact on Burden of Care/Daily Life: The patient requires verbal and visual cues for A/C (auditory comprehension) due to safety reasons and HOH (Hard of Hearing). Pt benefits from use of white board for communicative exchanges. Precautions: Recommended diet of mechanical soft solids and nectar thick liquids with safe swallow precautions. Small bites/sips, slow rate, upright at 90 degree angle. Unable to follow commands and express basic needs/wants. Deaf, double vision in R (right) eye. On (MONTH) 6, (YEAR) at 9:52 AM, V13 (RN- Registered Nurse) said, I am the head nurse, I know all the residents. On (MONTH) 27, (YEAR) around 2:58 PM, I walked out of my office to go home. I saw (R1) eating a sandwich in his wheelchair facing the nurse's station. I shook my head at (R1) and mouthed are you okay and (R1) gave me a thumbs up. (V8, Nurse) and (V6, Nurse) were having a conversation and looking at paperwork, not at the resident. The pillar blocked their view of (R1). Sandwiches are at the nurse's station but aren't continuously monitored. Not to my knowledge was anyone monitoring the resident while he was eating the sandwich. Usually a CNA (Certified Nursing Assistant) was always sitting next to him during meals. I did not tell anyone he was eating a sandwich or to monitor him before I left for the day. On (MONTH) 10, (YEAR) at 3:25 PM, V13 said, R1 did not have any liquids to drink while eating the sandwich as instructed by speech therapy. V13 also confirmed that she did not offer any fluids to R1. V13 said thickened liquids are not usually kept on the floor for the residents. We would have to call the kitchen to send up nectar thick liquids for (R1). To my knowledge, no one obtained liquids for (R1) to drink with his sandwich. On (MONTH) 6, (YEAR) at 11:13 AM, V10 (Speech Therapist) said, (R1) required intermittent observation during meals. This does not mean you can watch him and then walk away and come back five minutes later. Intermittent observation means the resident should have always been in the direct line of sight of a staff member while he was eating. Even though the resident was allowed to eat peanut butter sandwiches on his diet, he would require observation. He also should have had fluids to drink while eating, alternating bites of food with fluids. On (MONTH) 10, (YEAR) at 2:50 PM, V10 (Speech Therapist) said, We train the staff on the floor regarding swallow precautions and specific residents. Intermittent does not mean leave the floor or the room while the resident is eating. Doing so would mean the resident would be eating at an independent level, which (R1) was not able to do. Intermittent supervision means that you intermittently cue the resident only in the event the resident wasn't following safe swallowing strategies at the time. In other words physical or verbal cuing as needed. V6 (APN- Advanced Practice Nurse) documented on (MONTH) 28, (YEAR): Visit (MONTH) 27, (YEAR) 3:00 PM - Choking episode - Approximately 3:05 PM, (R1) was seen choking, coughing and pounding his chest while eating a peanut butter sandwich while sitting in wheelchair at the nursing station. On (MONTH) 5, (YEAR) at 10:17 AM, V6 said, I was sitting at the nurse's station the date of (R1's) choking incident, but I did not see him eating and did not actually visualize him raising his arm or pounding on his chest. The nurse told me she heard him coughing and saw him pounding his chest, so that is what I wrote in my note, but I did not observe those things. My view of (R1) was obstructed by the large pillar at the nurse's station. Prior to the choking incident, I was not informed by any facility staff to monitor the resident because he was eating a sandwich. I was not aware he was eating. I attempted the [MEDICATION NAME] maneuver on the resident and another nurse got the suction equipment. There was no outlet at the nurse's station to plug into, so we had to take the resident to the closest room. I attempted to suction food from his mouth using a [MEDICATION NAME] suction tip, and a 16 French catheter, but both were unsuccessful. We put him on oxygen and put him in bed. I attempted to listen for heart sounds and breathing. There was no palpable pulse. EMS arrived and hooked him up to the monitor. The nurse brought over his POLST form. EMS couldn't do anything at that point due to the DNR status of (R1). R1's POLST (Practitioner Order for Life-Sustaining Treatment) Form dated (MONTH) 29, (YEAR) showed: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of [REDACTED]. Request transfer to hospital only if comfort needs cannot be med in current location. V7 (RN) documented on (MONTH) 27, (YEAR): 3:05 PM. I heard coughing in front of the nurse's station and when I checked, I saw (R1) sitting in his wheelchair raising his arm and pounding his chest. I asked him if he was choking and he nod his head. I initiated [MEDICATION NAME] maneuver right away. I smell peanut butter on resident's breath. I yelled for help. 911 was called, and (V6) took over [MEDICATION NAME] maneuver. I started oxygen on resident. 911 came and took over. Resident was pronounced dead by 911 and APN. On (MONTH) 5, (YEAR) at 12:39 PM, V7 said, The incident with (R1) happened at the beginning of my shift. I was sitting at the nurse's station getting report. I was just starting. I could not see (R1) from where I was sitting. I heard coughing near the nurse's station. (R1) was raising his hand and I initiated the [MEDICATION NAME] maneuver. We found peanut butter in his mouth but we couldn't remove it. I'm not sure where the sandwich came from. I did not see any staff near him or helping him eat. On (MONTH) 6, (YEAR) at 10:10 AM, V7 said, No staff member told me to monitor or observe (R1) because he was eating. I never knew he was eating a peanut butter sandwich. I was not watching him. V8 (RN) documented on (MONTH) 27, (YEAR): 3:05 PM. I heard someone coughing. I looked over and saw (R1) coughing near the nursing station, and hitting his chest. I went to him and could smell peanut butter on his breath. I realized he was choking. On (MONTH) 5, (YEAR) at 1:00 PM, V8 said, On the date of the choking incident, (V7) went over to the resident first. (R1) had been coughing. (V7) asked if he was choking. The resident had the smell of peanut butter on his breath. No sandwich was in front of him. There are a variety of sandwiches at the nurse's station. No staff member was near him to provide feeding assistance or observe him prior to his choking. At lunch we have someone out there watching him. We did the [MEDICATION NAME] maneuver and suctioning. Neither was successful. There was a point where he became unresponsive. I was not in the room when (R1) expired. I was not aware the resident was sitting by the nurse's station eating a sandwich. No staff was watching him while he was eating. It was shift change. On (MONTH) 5, (YEAR) at 1:45 PM, V9 (Dietitian) said extra peanut butter sandwiches are sent to the unit where R1 resided in case residents become hungry between lunch and dinner. On (MONTH) 5, (YEAR) at 3:15 PM, V12 (CNA) said she took care of R1 on (MONTH) 27, (YEAR). V12 said she frequently worked with R1 and she was usually assigned to watch him during meals and ensure he took small bites of food. V12 said she brought R1 to the nurse's station before 3:00 PM on (MONTH) 27, (YEAR) but did not give the resident a sandwich. R1's care plan dated (MONTH) 28, (YEAR) showed R1 had Impaired breathing pattern, shortness of breath on exertion related to: dysphagia,[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus). Multiple interventions on the care plan included the following: Encourage to take small bites. Monitor during meals to provide assist in case of choking. Report episodes of choking. Observe for signs/symptoms of aspiration. R1's care plan dated (MONTH) 29, (YEAR) showed R1 had Nutrition problem, actual or potential, related to [DIAGNOSES REDACTED]. Yellow Spoon Protocol. Intermittent supervision. On (MONTH) 6, (YEAR) at 1:00 PM, V15 (MDS Coordinator) said she was responsible for entering R1's respiratory care and dysphagia care plan into the EMR. The interventions put in place were standard for residents with a dysphagia diagnosis. During meals staff should have monitored that he was not taking too much food at one time. On (MONTH) 6, (YEAR) at 2:20 PM, V5 (Physician) said, I would expect facility staff to follow (R1's) care plan interventions and the speech therapy recommendations put in place.

Based on observation, record review and interview the facility failed to ensure staff monitored residents (R1 through R4) to prevent from sustaining injuries when staff transferring residents who are dependent on staff for their safe transfer from bed to chair and or from chair to bed. The facility also failed to implement interventions per their plan of care. As a result: (1) R1 sustained a laceration to her scalp and fractured left proximal tibial metaphysis and fibular neck when staff transferred her on March 13, 2017 from bed to motorized chair with total mechanical lift. (2) R2 sustained left intertrochanteric hip fracture when staff transferred him on March 12, 2017 from bed to wheel chair with a sit to stand mechanical lift. (3) R3 sustained left 4th toe fracture when staff transferred her on March 20, 2017 with a total mechanical lift from wheel chair to bed. This applies to 4 of 4 dependent residents (R1 through R4) evaluated for injuries sustained when the staff transferred these residents. The findings include: (1) R1's Nurses Notes on March 14, 2017 showed she was being transferred with sit to stand mechanical lift on March 13, 2017 at 6:00 AM and accidentally hit her head on the mechanical lift where she sustained a laceration to the posterior right occipital area. The laceration required seven staples and she also sustained a 3.0 cm (centimeter) x 2.0 cm bruise to her right ear. R1's Nurses Notes on March 15, 2017 at 11:10 AM showed, she complained of left leg pain during her transfer, noted bruise on her left lateral knee 3.0 cm x 3.0 cm and left lateral leg 10.0 cm x 5 cm. March 15, 2017 X-Ray showed subacute slightly displaced fracture involving the left proximal tibial metaphysis and fibular neck. The fracture may represent pathologic fractures due to unspecified lucency. The facility on March 13, 2017 6:00 AM documented the incident towards end of transfer to chair using mechanical lift with two Certified Nurse Aides (CNAs) R1's upper body unexpectedly moved and R1 hit head onto part of the mechanical lift machine, sustained 1.5 cm laceration to back of head with moderate amount of bleeding and bruise to right ear. The incident investigation report noted E3 and E4 (CNAs) were involved in transferring R1 on March 13, 2017. The facility's investigation of the incident did not determine the cause of the incident. On March 19, 2017 E3 gave written statement to the facility as part of the incident occurrence. In the statement E3 stated E4 assisted to transfer R1. E4 operated the mechanical lift and E3 guided R1's feet towards her chair. R1 suddenly flipped upside down and R1 was hanging down. E3 and E4 managed to put R1 back in the bed. R1 hit her head on the bottom of the mechanical lift when she was hanging. E3 stated all four sides straps of the sling still attached to the mechanical lift and not sure what went wrong. E4's written statement also confirmed E3's statement. The facility per her February 20, 2017 Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score of '15,' meaning R1 to be alert and oriented to time, place and person. On March 21, 2017 at 3:30 PM R1 stated there was only one CNA (E3) who transferred her. On March 22, 2017 at 12:20 PM in the presence of E10 and E11 (Nurses) R1 stated it was only E3 who transferred her. On March 23, 2017 at 9:00 AM in the presence of E8 and E15 (CNAs) R1 stated E3 transferred her and after she fell , E4 came to help to put her back on the bed. The facility incident investigation documents that R1 stated E3 and E4 transferred her. R1's CNA care guide for transfer showed to use mechanical lift with two person assist. According to the (mechanical lift) Manufacturer's guide line and the facility mechanical lift policy and procedure, it shows to use medium size sling for a person whose weight is between 90 - 220 pounds. R1's weight record showed she weighs 144.5 pounds. R1 falls into medium sling range. The intervention of using medium size sling is not documented in the CNA care guide or on her plan of care for fall prevention. On March 23, 2017 9:00 AM E8 (Restorative Aide) and E15 (CNA) transferred R1 from bed to motorized chair with mechanical lift using medium size sling. E8 stated they could use medium or large for R1. It is unknown what size sling the staff used when transferring R1 on March 13, 2017 when the incident occurred. On March 23, 2017 at 11:25 AM, Z2 (direct care physician and Medical Director of the facility) per telephone stated that R1 has [DIAGNOSES REDACTED], contractures to upper and lower extremities and has [DIAGNOSES REDACTED]. Z2 said, sometimes when position is changed spastic movements may trigger, but the staff has to monitor her movements. Z2 said, R1 may have had a spastic movement, another reason could be the way the aides hooked the sling to the mechanical lift. They may have hooked it wrong. (2) R2's March 12, 2017 9:44 AM nurses notes showed E6 (CNA) heard 'pop' sound when he transferred resident from bed to wheel chair with a sit to stand mechanical lift. R2 complained of pain to his left knee. X-Ray of left knee was negative for fractures. On March 13, 2017 change of condition report for R2 showed he was in severe pain to left leg, hip, unable to move, positive for external rotation, guarding site, sent to the hospital for evaluation and treatment. On March 13, 2017 at the hospital X-Ray of left hip showed R2 sustained acute left femoral neck fracture with lateral and anterior angulation of distal fracture fragment. On March 14, 2017 at the hospital R2 underwent open reduction and internal fixation of the left hip. The facility documented the incident of March 12, 2017. E7 (Nurse) in the incident documented 'per CNA (E6), while transferring R2, he was yelling and kicking. After transferring, R2 complained of left knee pain. During the facility investigation of the incident E6 gave a written statement stating during resident care and transfer R2 was uncooperative and resistive with the process of care and transfer. E6 transferred R2 with sit to stand lift. During the process of hooking R2 up to the machine he was pushing and kicking the machine several times, and after the completion of the transfer to his wheel chair he started complaining of left knee pain. R2's March 7, 2017 fall injury care plan interventions included when R2 show signs of agitation and being resistive to care, allow R2 time and re-approach at later time. This intervention was not followed on March 12, 2017. On March 21, 2017 at 2:45 PM E6, Restorative CNA stated the unit is usually supposed to have three CNAs plus himself (E6) for day shift and evening shift. On March 12, 2017 day shift, two CNAs called in sick and there was only one CNA plus himself for 18 residents. E6 transferred R2 with mechanical sit to stand from bed to chair. R2 has Dementia, was resistive to care and transfer, he kicked and pushed the mechanical sit to stand, resisted to apply the harness. E6 said with much difficulty was able to apply the harness, but E2 continued to push and kick the sit to stand lift and E6 heard a 'pop' sound on his left leg. E6 managed to complete transferring R2 from the bed to wheel chair. E6 also stated, he could not wait and re-approach or get extra help due to being short of help. On March 24, 2017 at 10:45 AM E6 and E13 (CNA) transferred R2 from bed to wheel chair with a mechanical lift. R2's CNA care guide showed transfer with one person assistance. E13 stated prior to R2's injury it was one staff transfer and the care guide needs to be updated. On March 23, 2017 Z2 stated R2 has Dementia and Anxiety. The staff should allow time when R2 is resistive to care and re-approach later. It is normal for someone to point to their knee when they have hip injury. The staff should have done X-Ray of leg, knee and hip, in this case the hip X-Ray was done a day later. Z2 assured he will work with the staff, it is quite unusual for the facility to have such incidents. (3) The facility documented an incident involving R3, when the staff (E5 and E14 both CNAs) transferred her with a mechanical lift from her wheel chair to the bed. Her foot was caught on the mechanical lift which resulted in a laceration to R3's left 4th toe. The X-Ray showed left 4th toe fracture. On March 22, 2017 at 3:10 PM E5 stated E14 was driving the mechanical lift machine, she (E5) was at the foot end. When E14 lifted R3 with the mechanical lift, R3's foot bumped into the machine. E5 said, she should have been careful, especially R3 being unable to help and totally dependent on staff. R3's current physician orders [REDACTED]. On March 23, 2017 at 11:25 AM Z2 stated the aides should be more careful and monitor residents during transfer, so the injuries could be prevented. (4) On March 22, 2017 at 2:30 PM R4 stated on March 19, 2017 early in the morning (Z1) an agency CNA got her (R4) up from bed with a gait belt and dropped (R4) on the floor and Z1 fell on top of her. R4 said, she is supposed to be up with a sit to stand lift mechanical lift, due to her (R4) left sided weakness from Cerebral Vascular Accident (CVA). R4 said that Z1 insisted she can do by herself. R4's March 16, 2017 CNA care guide showed she is supposed to be transferred with a sit to stand lift with one staff assistance. On March 19, 2017 Z1 did not follow the CNA care guidelines to transfer R4 from bed to wheel chair. On March 23, 2017 at 4:30 PM E2 (Director of Nurses) stated Z1 is a CNA from the agency and she was not sure if Z1 was tested for competency for the use of the mechanical lift. R4's admission record showed she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R4's January 24, 2017 fall risk care plan showed she has a history falls and was found on the floor 14 times (December 8, 9, 18, 20, 21, 23, 2016; January 1, 15, 31, 2017; February 4, 6, 12, 23, 2017; and March 8, 2017.)

Based on interview and record review, the facility failed to provide supervision to R 2 and R 3, identified as high risk for falls. The facility also failed to revise the plan of care and implement individualized interventions to address their specific needs and to follow staff recommendations for R 2. These failures resulted in R 2 sustaining fractures of the left Humerus and a left Hip fracture for R3. This applies to two (R2 and R3) of three residents reviewed for falls with injuries. The findings include: R2 's Admission Face Sheet showed R 2 has a [DIAGNOSES REDACTED]. R2 's MDS (Minimum Data Set) of February 17, 2016 showed R2 needs extensive assistance of one person during transfers and ambulation. R2 's Fall Assessment on February 11, 2016 showed High Risk for fall due to Parkinson's, dementia, depression and anxiety with a score of 18. The facility's Incident report log and R2 's Nurse 's Notes showed R2 had two incidents of falls within two months. On April 25, 2016 and May 2, 2016. On May 5, 2016 at 3:10 PM, E3 (Registered Nurse) said on those two occasions, the bed alarm sounded but by the time staff got to the resident's room, the resident was already on the floor. E3 stated on May 2, 2016, he (E3) was in another room when the alarm sounded. As soon as he got to R 2's room and turned on the light switch, R2 's curtain was closed around her bed so he did not see anything but just heard a thud sound. E3 said he saw R2 on the floor on her left side and noted a bruise on R2 's left shoulder and complained of pain to the area. The facility Accident/Incident report dated April 25, 2016 and signed by the CNA and Nurse (Insight Report) showed a recommendation to move R 2 closer to the nurse's station to prevent another fall incident. This recommendation has not been followed. On May 10, 2016 at 4:08 PM during a phone interview, E5 (Assistant Director of Nursing) said there was no available room closer to the nursing station, that's why this recommendation was not implemented. E5 stated, We just try to respond as soon as possible. R 2's fall care plan was not revised after R 2's fall on April 25, 2016. No specific interventions were implemented to address R2 's fall or to prevent R 2 from sustaining additional falls. On May 10, 2016 during a phone interview, E13 (RN, Care Plan Coordinator) explained and faxed a copy of R 2's care plan dated March 8, 2016 and was not revised until May 2016. On May 2, 2016 R 2 had another fall and was admitted to the hospital with [REDACTED]. On May 11, 2016 at 9:57 AM during a phone interview, Z1 (R2 ' s Attending Physician) said that R2 has agitation, marked mobility dysfunction and sustained a fracture from a second fall while in the facility. Z1 stated that he agreed with the staff 's recommendation after the first fall, to place R2 closer to the nurse's station. Z1 stated that would have helped prevent the second fall that caused the fracture. Z1 stated, I will make that recommendation myself to the Director of Nurses. R3 's Physician order [REDACTED]. R3 's MDS of April 19, 2016 showed supervision and set-up for transfer and limited assistance of one person during ambulation off the unit, hygiene and bathing. R3's Fall Assessment Risk for February 27, 2016 was high at 10 related to fall history prior to admission, antidepressant use and slight impaired mobility secondary to Parkinson's disease. On May 06, 2016 at 9:25 AM, E14 (RN) said that R3 needed a standby assistance of one person during shower before the April 25, 2016 fall incident. E15 (CNA) stated R3 needed a one person assistance with showers and limited assistance and supervision with ADLs and transfers. The facility's Incident Report Log and R3 's Nurse's Notes showed R3 had fall incidents on April 21, 2016, April 25, 2016 and May 4, 2016. R3 was sent out to the hospital after the April 25, 2016 fall with the [DIAGNOSES REDACTED]. R3 ' s nurse's notes showed On April 25, 2016 at 7:40 PM, found on floor in shower room semi-sitting position. Stated she bent over to fix her slippers and got off balanced and ended up on the floor close to her wheelchair. Able to move left leg but said it hurts when she steps on it .sent to ER (emergency room ) and admitted for left hip fracture. R3 's last care plan review date was prior to the fall incidents was February 2, 2016. R3's fall care plan showed interventions such as Bed and chair alarm, transfers one assist, ambulates with assist, staff provides oversight for safety due to short term memory, easily distracted thought process, bathing/grooming/personal hygiene/shower weekly by CNA-assist upper and lower body. R3 ' s April 21 and April 25, 2016 documentation did not reflect that any of these interventions were done to help prevent the fall. R3 ' s latest fall care plan review date was May 2, 2016. There were no changes made to the fall interventions since the last review date of February 2, 2016 even after the two fall incidents.