Every finding on record at Elevate Care Northbrook

Based on interviews and record reviews, the facility failed to follow professional standard of care by not timely reporting a fall accident in the facility. This deficient practice affects one resident (R5) of three residents reviewed for fall accident. During transfer, R5 legs buckled, resulting a sudden loss of weight bearing ability, staff provided support and assisted R5 to the floor to prevent a fall. Staff did not report the unusual event to the nurse during this transfer. This past noncompliance occurred on 6/2/26 to 6/9/26.Findings Include:R5 is a [AGE] year-old female resident with diagnoses of but not limited to: Right Hip Unilateral Primary Osteoarthritis, Hereditary and Idiopathic Neuropathies, and Osteoarthritis.Facility Reported Incident submitted to IDPH (Illinois Department of Public Health) dated 6/5/26, reads in part: Assigned nurse observed bruising to R5's right knee during routine care, upon assessment, R5 reported knee pain rated 6/10 with movement. R5 denied any fall and stated she may have bumped her knee. Pain medication was administered with reported relief. Attending physician was notified and ordered an x-ray of the right knee. The x-ray revealed an acute fracture of the distal femoral condyle. Physician notified and ordered transfer to local hospital for further evaluation. R5 evaluated and returned to facility the same day. R5 family notified and kept informed of the plan of care. A follow-up facility investigation was conducted, including record review and interviews with staff and R5. The investigation determined that R5 had been transferred from bed to wheelchair by two nursing assistants using a stand-pivot transfer technique which is her usual transfer status. During the transfer, R5's legs unexpectedly buckled, resulting in a sudden loss of weight bearing ability. Staff immediately provided support and assisted R5 to the floor on a controlled manner to prevent a fall and minimize injury.Based on facility's investigation, the injury was identified following an assisted transfer during which R5 experienced an unexpected loss of weight bearing ability. Staff responded appropriately by providing support and assisting R5 to the floor in controlled manner. R5 received timely assessment, diagnostic testing and physician notification, hospital evaluation, treatment interventions and follow-up care. Care plan updated accordingly, and all appropriate notifications were completed. Family updated and satisfied with the facility investigation and interventions taken.R5 had an assisted fall accident during transfer on 6/2/26. During transfer from bed to chair, 2 CNAs (V23 and V24) transferring R5, when R5 knees buckled. V23 and V24 assisted and lowered R5 on the floor. Called for another (V25) CNA to help them get R5 up and into the chair. On 7/22/26 at 12:41PM, V23 (CNA) stated she was the assigned CNA for R5. Asked for assistance from V24 (CNA) and during transfer the knees of R5 got weak, and both CNA were holding on the gait belt that was on R5, and assisted R5 down to the floor in sitting position. V23 stated It was not reported to the nurse because they lowered R5 slowly, V23 did not think it was considered a fall accident.On 7/22/26 at 1:05PM, V24 (CNA) stated she was not the assigned CNA for R5 but assisted V23 with transfer. Gait belt in used. R5 knees buckled. V23 and V24 slowly lowered R5 onto the floor. They called for another CNA (V25) for assistance. V24 stayed with R5, while V23 called V25. V24 stated she did not report to the nurse because she assumed that V23 reported it to the nurse on duty.On 7/23/26 at 10:30AM, V2 (DON) stated they started Past Noncompliance. V2 stated there are no concerns with the transfer technique as R5 was transferred as per usual transfer status, stand-pivot. Just that R5's legs unexpectedly buckled, and staff lowered R5 to the floor. The concern was that the 2 CNAs attended to R5 did not report this change of plane from standing to sitting to the nurse. R5's assigned CNA did not consider it a fall accident and was not reported to the assigned nurse that day. V2 defined fall incident is any incident with a change from higher plane to lower plane by gravity. Facility's expectation if for the staff to report fall incident/accident timely. V2 stated that facility started the PNC (Past Noncompliance) so all the staff would know the definition of fall incident. The facility policy and fall interventions, change in condition, notification and reporting in-services were provided to staff. Fall policy (not dated) reads in part: Observed or unobserved and reported by staff member, licensed nurse should conduct assessment immediately, including events leading to the fall to determine when possible and causative factors. CNA: 1. Call for nurse and stay with resident.Prior to the survey date of 7/21/26, the facility had taken the following actions to correct the noncompliance.Facility's action:What actions will be accomplished for identified resident (R5)?6/5/26R5 observed with bruise to her right knee. X-ray completed and with result of an acute fracture of distal femoral condyle.Investigation initiated, on 6/2/26 R5 was assisted to the floor by nursing staff during R5's transfer from bed to wheelchair, as R5 could no longer bear weight on her legs, but fall was not reported to DON/ADON until 6/9/26.6/6/26R5 returned to facility with knee immobilizer in place and outpatient orthopedic follow up. Pain well managed with tramadol hydrochloride.How we will identify other residents having potential to be affected:Residents who have had a fall have potential to be affected.Quality Assurance Process Improvement and actions:Staff education on fall prevention program including but not limited to reporting fall timely to DON/ADON, completing Risk Management Event, thorough assessment, post fall documentation of ongoing monitoring and assessment for sign and symptoms of injury. Staff education on facility Change in Condition Notification Policy including attending physician and family notification and notification of DON/ADON for any delays in notification to ensure proper resident fall follow up.What measure will be put into place or what systemic changes will be made?V23 (CNA) one-on-one education on 6/5/26.V24 (CNA) one-on-one education on 6/6/26.Education provided: the facility definition of fall, including that an assisted lowering to the floor meets the facility reporting criteria. The facility fall prevention and management policy, emphasizing the requirements to immediately report all falls, assisted lowering, and unexpected transfer events to the charge nurse and DON/ADON. Required post-event procedures, including timely completion of incident reporting, resident assessment, and notification of nursing leadership.The importance of prompt communication to ensure timely residence evaluation, physician notification, and implementation of appropriate interventions.V23 and V24 both verbalized understanding of the education provided and successfully demonstrated knowledge of the facility's reporting expectation. Competency was validated by the DON/designee.Education for all Nursing staff on fall prevention program and facility Change in Condition Notification policy including timely reporting of all falls to DON/ADON, POA, and attending physician, completing Risk Management Event, thorough assessment, post for documentation of ongoing monitoring and assessment for signs and symptoms of injury with returned demonstration done on Fall Prevention Program completion and ability to verbalize Fall Prevention Program and facility Change in Condition Notification policy.How the facility plans to monitor the system performance:Audits will be completed by the DON and/or designee 3 times weekly for four weeks, then weekly thereafter until sustained compliance has been determined by interdisciplinary team.Random chart reviews of fall prevention program process completion as well as changing condition notification policy.Education provided to nursing staff where needed on following fall prevention program process completion as well as changes condition notification policy,Random interviews will be completed with nursing staff to ensure they are aware and understand the fall prevention program process and change in condition notification policy.Follow up action will occur immediately for any compliance issue. Completion date 6/9/26.

Based on observation, interview, and record review, the facility failed to follow its Fall Prevention Program by failing to implement appropriate interventions to ensure the safety of fall-risk residents for 1 of 3 residents (R1) reviewed for falls. This failure has resulted in a fall with a right distal femur fracture. The facility also failed to follow its elopement policy by failing to monitor and prevent the departure of an elopement-risk resident for 1 of 3 residents (R7) reviewed for elopement. Findings include:1. R1 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the minimum data set (MDS) dated [DATE].On 6/16/26 at 10:15 AM, R1 was observed in her bed along with R1's nurse (V4). R1 stated, I had a fall last week, and I can't recall how I fell.On 6/16/26 at 10:15 AM, R1's call light was observed hanging from the wall behind the headboard and the bedside table with a water cup and remote on her right side (behind head), and was not within reach.On 6/16/26 at 10:15 AM, V4 stated that the call light should have been accessible to R1, and the bedside table with water and TV remote should be within her reach.On 61/7/26 at 12:45 PM, R1 was observed in her bed with a call light string under her pillow and buried under the linen. The resident was unable to locate the call light upon request.On 6/17/26 at 12:50 PM, V4 asked R1 to use the call light, but R1 replied that she didn't know where it was. Observed V4 got it for R1 and stated, The call light should be within her reach.On 6/17/26 at 11:00 AM, V6 (R1's nurse on duty on 6/5/26) stated, R1 had a fall at around 9:30 PM on 6/5/26. No one witnessed her fall. R1 is bed-bound but can roll left and right. She was trying to reach for something, and the CNA (V5) found her on the floor, with the remote also on the floor.On 6/16/26 at 10:05 AM, V8 (Nurse) stated, R1 is bed-bound, and always calls for help. On 6/5/26, R1 was trying to reach out for something from the table and fell with a right femur fracture.A review of the fall risk assessment dated [DATE] documented that R1 was at high risk for falls.A review of the care plan documented fall care plan interventions including: call light placed within easy reach at all times, personal items within reach such as water, TV remote control, pen, paper etc.A review of the reportable documented a fall with right distal femur fracture was reported to public health on 6/5/26.The hospital's Computerized Tomography (CT) of the right thigh/femur dated 6/6/26 resulted in an acute comminuted intra-articular fracture of the distal right femur.The facility provided hospital record Discharge summary dated [DATE] documented that R1 was admitted there for right distal femur fracture from a fall and underwent Open Reduction Internal Fixation (ORIF) of right distal femur fracture.On 6/16/26 at 11:45 AM, V2 (Director of Nursing) stated, R1 had a fall on 6/5/26 with a fracture of her right distal femur. No one witnessed the fall. I must relay what the staff told me to determine the root cause. I heard from staff that R1 was trying to reach out for something, and she fell. R1 should have her bedside table and her call light always within her reach.A review of the Fall Prevention Program provided revised on 11/21/17 purpose statement document: To assure the safety of all residents in the facility, when possible. The program will include measures that determine the individual needs of each resident by assessing fall risk and implementing appropriate interventions, including the use of necessary supervision and assistive devices. Fall Safety interventions may include, but are not limited to: the residents' personal possessions will be maintained within reach when possible. These items include tissues, water, drinking glass, and phone.2. R7 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE].On 6/19/26 at 9:35 AM, R7 stated, On Sunday, 6/14/26, I used the elevator from the second floor to the ground floor, and I was able to walk through the front door at 5:00 pm. I just walked out, and no one stopped me. I was trying to go home. There is no reason why I am here.On 6/19/26 at 11:00 AM, V15 (Police Officer) stated, We received a call from a motorist who observed R7 wandering around the car dealership. I met her at the dealer's shop. She was stumbling and swinging back and forth. I checked our system and found that R7 had an elopement from this facility (under previous management) in 2016. So, I brought her to the facility, and R7 confirmed that she belongs there. The facility was not even aware that R7 was missing until I brought her there.On 6/19/26 at 2:15 PM, V13 (R7's nurse on 6/14/26 PM Shift) stated, The CNA, during the round to remove the dinner tray at around 5:30 pm, noticed that R7's dinner tray was not touched. She called me, and we both looked for R7 throughout the unit. I called V12 (Nurse supervisor), and V12 called, code green. The police were already here with R7 around 6:00 pm, before we called them to report the elopement.On 6/20/26 at 10:30 AM, V17 (R7's assigned CNA on 6/14/26 PM shift) stated, I did head count at the start of my shift on 6/14/26, and R7 was on her bed. We passed dinner early that day, around 4:30 PM. R7 didn't eat her dinner, and after I removed her tray around 5:00 PM, I couldn't find her. I thought she might have gone to the nurses' station to grab something. I didn't know she was at risk of elopement. She was always in bed. Sometimes, she comes to the nurses' station to get something and will go back to her bed.On 6/19/26 at 2:45 pm, V14 (Receptionist on 6/14/26 PM shift) stated, I am new and have been here only six months. On Sundays, we have so many families visiting our residents. In that heavy traffic, I didn't notice R6 sneak out through the visitors. Sorry, it was my mistake.On 6/19/26 at 9:40 am, V2 (DON) stated that it's not only the receptionist's responsibility but also everyone's to monitor elopement risk, residents.A review of the facility provided elopement policy guidelines document: All personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises, or suspected of missing, to the charge nurse as soon as possible.

Based on observation, interview, and record review, the facility failed to comply with its Abuse and Retaliation Policy and Prevention Program by failing to protect a resident from staff abuse. This failure resulted in severe pain for 1 of 3 residents (R1) reviewed for abuse in a sample of 5.The findings include:R1 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the minimum data set (MDS) dated [DATE].On 6/16/26 at 9:45 AM, R1's door was closed, and a screaming sound was heard from R1's room. This surveyor knocked on the door and found that V7 (Certified Nursing Assistant /CNA) was providing care for R1. The surveyor stepped back and closed R1's door and remained in the hallway talking to another resident (R6) adjacent to R1's room.On 6/16/26 at 9:48 AM, the surveyor heard louder screaming from R1 and observed that R1 had turned to her left side with a right knee immobilizer and multiple pieces of linen on the floor. V7 responded that she is doing patient care. The surveyor stepped back, leaving the door closed. V3 (social service director) encountered this surveyor while exiting R1's room, handed over the requested documentation, and then heard another scream from R1. The surveyor requested that V3 check what was happening, as this surveyor had opened the door twice, and V7 wasn't happy to keep opening the door after each scream from R1.On 6/16/26 at 9:55 AM, V3 stated, V7 was providing care, and R1 was screaming because of the pain. V7 should have stopped care and reported the pain to the nurse.On 6/16/26 at 10:15 AM, R1 was observed in her bed along with R1's nurse (V4). R1 stated, I had a fall last week with a right knee fracture, and the CNA (V7) was very rough and hurtful. Observed V4 assessing R1 for pain, and R1 reported a pain level of 10 out of 10 with her right knee. V4 stated that R1 just woke up before patient care and wasn't this painful.On 6/16/26 at 11:50 AM, V2 (Director of Nursing) stated, When a resident screams and complains of pain during care, the staff should have stopped care and reported to the nurse. All the residents have the right to be free from abuse.On 6/17/26 at 1:00 PM, V1 (Administrator/Abuse Coordinator) stated, We suspended V7 and initiated an investigation. We sent the initial report to public health yesterday. All residents have the right to be free from abuse. V7 should not have proceeded with resident care when the resident was in pain.The facility presented Abuse and Retaliation Policy Prevention Program document: The facility is committed to protecting our residents from abuse, neglect, exploitation, retaliation, misappropriation of property, and mistreatment by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies.

Based on observation, interview, and record review, the facility failed to follow its Activities of Daily Living (ADL) care policy by failing to provide nail care to dependent residents. This applies to 1 of 3 residents reviewed (R3) for ADL care in a sample of 9.The findings include:R3 is a [AGE] year-old male admitted with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documented that R3 requires supervision or touching assistance for personal hygiene.On 6/16/26 at 10:32 AM, R3 was observed with long, dirty nails with brownish colored dirt accumulated underneath the nails. The left thumbnail was observed to be around 7 millimeters long, with dirt under the nails.On 6/16/26 at 10:40 AM, V4 (R3's Nurse) stated, The Certified Nursing Assistants (CNAs) are supposed to provide nail care.A review of the nurse practitioner's note dated 6/5/26 documented that R3's sores started with insect bites, with some appearing excoriated with central crusting/scabbing, one appears to have scabbed from repeated scratching/picking, and upon today's examination, the lesions are less red and inflamed.On 6/16/26 at 11:45 AM, V2 (Director of Nursing) stated, The CNAs are supposed to provide nail care. Having long, dirty nails can cause skin damage.The facility presented the ADL Care policy, reviewed on 6/15/26, document:Grooming: Maintaining personal hygiene, including planning the risk and gathering supplies, combing and/or styling hair, washing face and hands, shaving, applying makeup, nail care, and/or application of deodorant or powder.

Based on observations, interviews, and record review the facility failed to protect a resident's right to be free from physical abuse from another resident for 1 (R1) of four residents reviewed for abuse in a sample of four.Findings include:R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Paraplegia; Personal History of Other (Healed) Physical Injury and Trauma; Major Depressive Disorder; Adult Failure to Thrive; Nicotine Dependence, Cigarettes; Full Incontinence of Feces; Generalized Anxiety Disorder; Muscle Wasting and Atrophy; and Unspecified Lack of Coordination.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. R1's behavioral care plan dated 10/15/2025 reads in part, During the MDS mood state interview, (R1) answered affirmatively when asked if I feel lonely or isolated from those around me. This may be exacerbated by feelings I have of worry/uncertainty about my prognosis and my future. I have been observed avoiding social interaction. I may not take advantage of opportunities to engage with others (either in person or electronically).Absent is any documentation of R1's abuse care plan prior to 10/21/2025.R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris; Hypertensive Heart and Chronic Kidney Disease Without Heart Failure; Chronic Kidney Disease; Type 2 Diabetes Mellitus with Foot Ulcer; Schizoaffective Disorder, Bipolar Type; and Dementia in Other Diseases Classified Elsewhere.According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. R2's abuse care plan dated 10/14/2025 reads in part, (R2) DENIES having been exposed to abuse/neglect prior to or after admission and denies having been the perpetrator of mistreatment, abuse, neglect, and/exploitation. (R2) has been exposed to trauma: homelessness. (R2) does not present with unusual risk in these areas at this time. (R2) however does experience irritability, poor insight and judgement, history of falling, psychiatric history, and denial/evasiveness regard mental health.R2's several behavioral plans created during his stay at the facility show R2s maladaptive behavior due to his mental illness. R3 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side; Unspecified Focal Traumatic Brain Injury With Loss of Consciousness of Unspecified Duration; Aphasia; Acute Gastroenteropathy Due to Norwalk Agent; Depression; Generalized Anxiety Disorder; and Post-Traumatic Stress Disorder.According to R3's MDS (Minimum Data Set) assessment dated [DATE] under section C, R3 has BIMS (Brief Interview of Mental Status) score of 9 indicating moderately impaired cognition. R4 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Noninfective Gastroenteritis and Colitis; Opioid Abuse with Withdrawal; Essential (Primary) Hypertension; Unspecified Mood [Affective] Disorder; Nicotine Dependence; Depression; and anxiety disorder.According to R4's MDS (Minimum Data Set) assessment dated [DATE] under section C, R4 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderately impaired cognition. On 10/22/2025 at 11:00 AM Based on facility's record, R2 was discharged from the facility on 10/21/2025 and is not available for observation nor interview during this investigation.On 10/22/2025 at 11:05 AM Surveyor observed 3 mm laceration on R1's right upper lip and bruise on the right lower lip. R1 said, Yesterday (10/21/2025) around 8:30 AM, I was going for a smoke to the east side of the second-floor unit, where smoking room is located. There were several other residents chain smoking in the smoking room, so I said something about it. R2 heard me talk, didn't like what I said, came out of the smoking room, and hit me. It happened in the hallway, right in the front of the smoking room. It went from a verbal to physical altercation. R2 walked away and I went to the nursing station to let the nurse know that R2 hit me. The nurse gave me ice pack and some pain medication. I also called the police. The police came a few minutes later, took my statement and said they will ticket R2. I was also sent to the hospital. They irrigated my wound, gave me a shot, and sent me back to the facility. I don't know what they're doing with R2, they (facility staff) are not telling me. I'm subconsciously afraid, half of those people (residents) here, are mentally ill, you never know what they're going to do.On 10/22/2025 at 11:22 AM Surveyor observed smoking room on the east side of the second-floor unit. The smoking room monitored by staff via an outside monitor connected to the camera placed in the smoking room. V3 (Certified Nurse Assistant/Monitoring Staff) said, The smoking room is monitored most of the time. Different staff are assigned to monitor it. I know the smoking room is not consistently monitored but not exactly sure when it's not. On 10/22/2025 at 11:36 AM V4 (Licensed Practical Nurse) said, Yesterday (10/21/2025) between 8:25 AM and 8:30 AM, I heard shouting while I was preparing medications in the nursing station. I walked out of the nursing station and around the corner and saw R1 pointing at R2 and saying, He punched me. I attempted to ask R2 what happened, but he just kept walking. I then gave R1 ice pack and called for R1's assigned nurse. In the meantime, R1 called local police. I notified then V1 (Administrator/Abuse Prevention Coordinator), V2 (Director of Nursing), and a social worker. I'm not sure if I saw any staff present by the smoking room when I responded to the incident between R1 and R2, it was morning, so CNAs (Certified Nurse Assistant) were busy with a morning routine.On 10/22/2025 at 12:44 PM V7 (Staffing Coordinator) said, I make all schedules. The smoking room is monitored by different staff from different specialties. I make schedule daily that consists of extra staff. From Monday to Friday, there is one person per shift. V8 (Transportation Coordinator) is assigned to monitor the smoking-room Monday-Friday 6:00 AM - 5:00 PM. When V8 is busy with coordinating appointments, another staff member replaces her. V8 was monitoring yesterday (10/21/2025), at the time of the incident. After 5:00 PM, CNAs supervise the smoking room in two-hour intervals. On weekends there is regular staff who is assigned to monitor the smoking room, in addition to restorative aids and CNAs.On 10/22/2025 at 1:21 PM V8 (Transportation Coordinator) said, I was assigned to monitor smoking room yesterday (10/21/2025) between 6:00 AM to 5:00 PM. I monitor it for the most part unless I need a relief and that's when an available staff covers for me. I was there when an incident happened. I was helping in R3's room, right across the smoking room. I was responding to a call light when I heard commotion in the hallway, right by the smoking room. I came out immediately, asked what was going on, and noticed R1 yelling. I didn't see R2 hit R1. R2 wasn't saying anything. Other staff also responded to the commotion, so I went back to R3's room, I don't know what happened after that. I wasn't away from the monitoring desk for that long. Before I responded to the call light, R2 was lined up in the hallway to go into the smoking room. I don't remember seeing R1.On 10/23/2025 at 10:10 AM R3 utilizes electronic device to communicate due to significant aphasia. R3 typed, I didn't hear an altercation on the morning of 10/21/2025. The only time I use a call light is in the morning, afternoon, and at night when I have to have a bowel movement. V8 (Transportation Coordinator) did not respond to my call light on the morning of 10/21/2025, it was another staff.On 10/23/2025 at 10:15 AM R4 said, I was in the smoking room when the incident happened. R1 stormed into the room and was yelling There are people who want to smoke too! R2 got annoyed and got into a verbal altercation with R1. R1 and R2 left the smoking room and then I heard R1 yelling He hit me! There was no staff monitoring the smoking room when I was going in there. On 10/23/2025 at 11:17 AM V9 (Registered Nurse) said, The incident between R1 and R2 happened by the smoking room. I was administering medications, so I didn't witness it; however, I was told that R1 stormed into a smoking room, stepped out to the hallway, and got hit by R2 while in the front of the smoking room. Staff who was assigned to monitor the smoking room was responding to the call light during the incident, it happened very fast. I got called right after the incident and was told that R1, who was assigned to me that day (10/21/2025), needs medical attention. I gave R1 ice pack and pain medication, and he was sent to the hospital later that day, for further assessment. R1 called police too and the police came shortly after the incident and interviewed everyone. Immediately after the incident, 1:1 supervision was initiated to both residents to assure safety. R2 was later discharged from the facility, the discharged was initiated prior to the day of the incident and it just happened on the day of the incident.On 10/23/2025 at 12:40 PM V11 (Social Service Coordinator) said, I recently was assigned to R2 as a social worker. R2 was working with local contact agency in order to get transferred to lower level of care. R2's case worker was not being responsive, R2 felt like he should have been already transferred, so R2 came to me, and I found another long-term care facility that accepted R2. I submitted R2's referral packet on 10/16/2025, they reached back out to me, and accepted R2. R2 was discharged on 10/21/2025 coincidently to the incident.On 10/23/2025 at 1:01 PM V1 (Administrator/Abuse Prevention Coordinator) said, I was notified of an incident between R1 and R2 on the morning of 10/21/2025. I made sure first they're both safe, then I followed up with questions, ensured both residents got appropriate care, and are provided with 1:1 monitoring. I also made sure the police were notified. Shortly after, I sent an initial report. I then followed up with further interviews with residents and staff, and the investigation is continuing, and there is no final conclusion at this time. The abuse training for staff is done quarterly and as needed, for example, when there is a reportable incident. Most recent abuse training was done on 10/17/2025 due to another recent abuse incident. Per record review, progress note dated 10/21/2025 written by V9 (registered Nurse) reads in part, At around 0830, This writer was informed by staff that resident (R1) had a verbal altercation turned to physical and got hit on the right side of the face. Noted resident (R1) putting pressure on the affected area. Noted small skin tear on the upper and lower lip. Both residents (R1 & R2) were separated from each other. When asked what happened, per resident (R1), he was having a conversation with the other residents inside the smoking room. Conversation got heated and eventually turned to physical altercation. Right after the incident, resident (R1) who is alert and oriented x 3, called and reported to police what had happened. Both residents were immediately separated. Cold pack was applied on affected area. PRN Pain medicine given. Head to toe assessment done. Behavior monitoring initiated. At around 0835 police interviewed both residents separately. Per police interview, it was known that (R1) started the verbal altercation towards the other resident and ended up cursing the other resident that led the resident to hit (R1). Ordered to be sent to the ER for physical evaluation, resident (R1) refused going to ER for evaluation. Education was given and emphasized the importance of going for evaluation. (Medical Doctor) made aware and ordered to involuntary petition the resident to LGH.Per record review, police report dated 10/21/2025 reads in part, Upon arrival, I made contact with (R1 and R2). I observed (R1) to be bleeding from his lip. (R1) related that while in the smoking room he became frustrated with (R2) smoking too much and verbal argument ensued. (R2) then struck (R1) in the face with a closed fist. (R1) related that he does not wish to sign complaints and wants to document incident only.The facility Abuse Prevention and Reporting policy last revised on 10-24-2022 reads in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on observation, interview, and record review the facility failed to implement its policy for Abuse prevention program. This deficiency affects all four (R2, R3, R4 and R5) residents reviewed for Abuse prevention program. Findings include:On 10/8/25 at 1:30PM, V4 SSD (Social Service Director) said that as part of Abuse prevention program, Abuse/trauma assessment is completed upon resident admission, quarterly assessment, annually and as needed when there is allegation or incident of abuse. Abuse assessment score of above 2 indicates at risk for abuse and abuse prevention care plan should be initiated. Abuse prevention care plan is updated after investigation of allegation or incident of abuse or resident to resident altercation. On 10/9/25 at 9:30AM, V13 Care plan Coordinator said that Abuse prevention care plan is updated when there is an allegation or incident of abuse. V4 SSD is responsible for completing abuse assessment and updating abuse prevention care plan. 1.On 10/8/25 at 11:43AM, Observed R2 sitting on his bed. He is alert and responds coherently. He can verbalize his needs to staff. R2 is initially admitted on [DATE] with diagnosis listed in part but not limited to non-ST elevation myocardial infarction, Atherosclerosis, Ischemic cardiomyopathy, Anxiety disorder, Major depressive disorder. Abuse/Trauma assessment done on 9/27/22 with score of 0, not at risk for abuse but Abuse prevention care plan was initiated. On 8/29/25, physical resident to resident altercation investigation report was submitted to IDPH between R2 and R4. Abuse/trauma assessment was completed on 8/29/25 with score of 8 at risk for abuse but abuse prevention care plan was not updated. On 10/9/25 at 9:42AM, Reviewed R2's medical records with V4 SSD. Informed V4 of concern identified with R2 regarding implementation of abuse prevention program policy. Abuse prevention care plan was not updated after resident-to-resident physical altercation incident occurred on 8/29/25. V4 said that he should update the abuse prevention care plan after a resident-to-resident altercation report investigation. 2.On 10/8/25 at 11:23AM, Observed R3 sitting on his bed. He is alert and responds coherently. He can verbalize his needs to staff. R3 is initially admitted on [DATE] with diagnosis listed in part but not limited to Atherosclerotic heart disease, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, Presence of cardiac implants, Atrial fibrillation, Alcoholic liver cirrhosis, Bipolar disorder, Schizoaffective disorder, Abuse/Trauma assessment done on 6/25/24 indicated score of 4 at risk for Abuse/trauma related symptomatology. No Abuse prevention care plan was initiated. On 1/18/25, verbal and physical resident to resident altercation investigation report was submitted to IDPH between R3 and former resident in the facility. Abuse/Trauma assessment was done on 1/21/25 with score of 9 at risk for abuse but no abuse prevention care plan was initiated and updated. On 10/9/25 at 10:00AM, Reviewed R3 medical records with V4 SSD. Informed V4 of concern identified with R3 regarding implementation of abuse prevention program policy. No abuse prevention care plan was initiated when Abuse /Trauma assessment scored 4 and 9 indicated at risk for Abuse. No abuse prevention care plan was initiated and updated after resident-to-resident physical altercation incident occurred on 1/18/25. V4 said that he should initiate an abuse prevention care plan when abuse trauma assessment triggered score of 2 or more and he should update the abuse prevention care plan after an allegation report investigation of resident-to-resident altercation. 3.On 10/8/25 at 11:58AM, Observed R4 sitting at the hallway. He is alert but confused with flight of ideas. He responds incoherently. R4 is initially admitted on [DATE] with diagnosis listed in part but limited to Parkinson's disease, schizoaffective disorder bipolar type, Alcohol abuse intoxication, Age related cataract bilateral. Abuse/Trauma assessment done on 1/24/24 indicated score of 6 at risk for abuse/trauma related symptomatology. No Abuse prevention care plan was initiated. On 8/29/25, physical resident to resident altercation investigation report was submitted to IDPH between R4 and R2. Abuse/trauma assessment was completed on 8/29/25 with score of 9 at risk for abuse but no abuse prevention care plan was initiated and updated. On 10/9/25 at 10:12AM, Reviewed R4 medical records with V4 SSD. Informed V4 of concern identified with R4 regarding implementation of abuse prevention program policy. No abuse prevention care plan was initiated when Abuse /Trauma assessment scored 6 and 9 indicated at risk for Abuse. No abuse prevention care plan was initiated and updated after resident-to-resident physical altercation incident occurred on 8/25/25. V4 said that he should initiate an abuse prevention care plan when abuse trauma assessment triggered score of 2 or more and he should update the abuse prevention care plan after an allegation report investigation of resident-to-resident altercation. 4.On 10/9/25 at 11:30AM, Observed R5 lying in bed. She is alert and responds coherently. She can verbalize her needs to staff. R5 is initially admitted on [DATE] with diagnosis listed in part but not limited to Elevated white blood cell count, Acute kidney failure, Paroxysmal atrial fibrillation, Chronic obstructive pulmonary disease, ileostomy status, pressure ulcer sacral region stage 4 and left buttocks stage 3, Obesity. Abuse/Trauma assessment on 10/31/23 indicated score of 3 at risk for trauma related symptomatology. No Abuse prevention care plan was formulated. On 8/25/25, verbal/mental abuse investigation report was submitted to IDPH due to R5's allegation of verbal abuse. No abuse/trauma assessment was completed, and no abuse prevention care plan was initiated or updated. On 10/9/25 at 10:30AM, Reviewed R5's medical records with V4 SSD. Informed V4 of concern identified with R5 regarding implementation of abuse prevention program policy. No abuse prevention care plan was initiated when Abuse /Trauma assessment scored 3 indicated at risk for Abuse. No abuse/trauma assessment was done after verbal abuse allegation incident occurred on 8/25/25 and no abuse prevention care plan was initiated or updated. V4 said that he should initiate an abuse prevention care plan when abuse trauma assessment triggered score of 2 or more. He should complete an abuse/trauma assessment and update the abuse prevention care plan after an allegation report investigation of resident-to-resident altercation. On 10/9/25 at 1:30PM, Informed V1 Administrator, V2 ADON (Assistant Director of Nursing), V4 SSD and V13 Care Plan Coordinator of above concerns identified in implementation of abuse prevention policy.Facility's policy on Abuse Prevention and Reporting - Illinois revised 10/24/22 indicated: Guidelines: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Facility's policy on Abuse Prevention: Establishing a resident sensitive environment: Resident assessment: As part of the resident's life history on the admission assessment, comprehensive care plan and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.

Based on interviews and record reviews, the facility failed to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and failed to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision. As a result, R1 was allowed to eat independently, experienced a choking incident, and subsequently died in route to the hospital for emergency care. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 08/12/25 when R1 had a choking incident during mealtime while being watched by V6 (Certified Nurse, Assistant) and subsequently died during transport to the hospital. V1 (Administrator), V2 (Director of Nursing), V3 (Assistant Director of Nursing), V35 (Vice President of Operations) and V36 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on 09/02/25 at 11:15 AM. The survey team confirmed by observation, interviews and record reviews that the Immediate Jeopardy was removed on 09/02/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R1 is a [AGE] year-old, female, admitted in the facility on 07/18/25 with diagnoses of Acute Respiratory Failure with Hypoxia; Dysphagia, Oropharyngeal Phase; Chronic Obstructive Pulmonary Disease with Acute Exacerbation; and Mild Cognitive Impairment of Uncertain or Unknown Etiology. R1's MDS (Minimum Data Set) dated 07/28/25 recorded the following: Section (Sec) C - BIMS (Brief Interview for Mental Status) score is 14, which means little to no impairment in cognition.Sec. GG - Functional Abilities: A. Eating - 04, which means supervision or touching assistance. Helper provides verbal cues and/ or touching/steadying and/ or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Sec. I - Active Diagnoses: Additional Active Diagnosis - Dysphagia, Oropharyngeal PhaseSec. K - Swallowing/Nutritional Status: K0100 Swallowing Disorder - B. Holding food in mouth/cheeks or residual food in mouth after meals; D. Complaints of difficulty or pain with swallowing. R1's care plan documented:Requires set-up or clean-up assistance to substantial/maximal assistance in her functional mobility and ADLs such as bed mobility, transfer, toileting and eating, dressing, bathing and personal hygiene related to fatigue, generalized weakness and SOB (shortness of breath):Interventions:Resident (R1) usual performance: Eating - Supervision or touching assistance. POS (Physician Order Sheet) dated 07/20/25 documented R1 is on general diet, regular texture, thin consistency, no red meat. POS dated 07/21/25 recorded in part but not limited to the following: ST (Speech Therapy) evaluation and treatment 3-5x/week for 41 days, to address R1's dysphagia. Aspiration and reflux precautions. Progress notes dated 08/04/25 documented R1 was noted with difficulty swallowing after swallowing piece of burger. It also stated that R1 is already under ST (speech therapy) evaluation. ST (Speech Therapy) service date 07/21/25, re-evaluation 07/22/25 recorded in part but not limited to the following: Skilled ST to address dysphagia and to improve safety of oral intake provided. Proceed with m/s (mechanical soft) and thin liquids with strict aspiration precautions and ongoing assessment of swallowing function as medical necessary. On 08/25/25 at 3:25 PM, V7 (Speech Therapist) was asked regarding R1. V7 stated, She is alert. I reached out to V19 (Family Member) and based from his (V19) information, she (R1) has difficulty swallowing, therefore we prescribed liberalized diet with no red meat, and she (R1) is ok with turkey and chicken. I informed dietary regarding diet. I recommended to proceed with requested diet, no red meat. She refused video swallow test and he (V19) was informed. I recommended to eat slowly with small bites, small sips. She (R1) is on full aspiration precautions due to long history of dysphagia. Facility's incident report documented that on 08/12/25 while assigned CNA (Certified Nurse Assistant, CNA) was supervising R1 have dinner, she (R1) began to have difficulty breathing, signaling for help. CNA immediately performed abdominal thrusts and call staff for help. Assigned RN (Registered Nurse) and other nursing staff on the unit responded immediately. R1 was able to expel ingested food and was placed on supplemental oxygen with no loss of consciousness. R1 was able to verbalize she is okay. Paramedics arrived and took over. R1 was alert, responsive and breathing via nonrebreather mask with SpO2 (saturation of peripheral oxygen) level of 97% when picked up by paramedics. R1 was sent to the emergency room for further evaluation. R1's Ambulance Report dated 08/12/25, time stamped 5:13 PM, documented:Mental status - unresponsiveNarrative: Ambulance was dispatched to the above location for the choking. Upon arrival, patient (R1) was found unresponsive laying in bed. Facility staff reported the patient (R1) was eating and then started to choke on the food. Facility staff attempted to do the Heimlich maneuver and suction, but they were only able to get some pieces of food out. Crew noted a SpO2 of 60%. Patient (R1) had a NRBM (nonrebreather mask). Crew asked facility if the patient (R1) had a DNR (do not resuscitate) but one was not able to be answer or provide one right away. Patient (R1) was moved to cot and secured and taken to ambulance where vitals were obtained. Crew noted a SpO2 of 48%, BVM (bag valve mask) with supplemental oxygen was placed on patient; crew assisted with manual respirations. Reassessed SpO2 was 94% with BVM. 4 lead EKG (electrocardiogram) obtained and showed sinus [NAME]. IV (intravenous) attempted and established in the left AC (antecubital), with a 18 G (gauge) and saline lock. City fire department came to ambulance with a valid DNR. Hospital was contacted, no orders or questions. En route to hospital, crew noted patient did not have a radial or carotid pulse. No CPR (cardiopulmonary resuscitation) was initiated due to valid DNR. Hospital records dated 08/12/25 recorded: The pertinent facts of this case are [AGE] year-old female (R1) who presents with respiratory arrest. Patient (R1) brought by EMS (emergency medical service). Patient (R1) was reportedly eating at mealtime at long-term care facility when she began to have a choking episode. Staff attempted Heimlich maneuver without relief. EMS was contacted, on scene report that patient (R1) was continuing to have difficulty breathing and speaking, initial oxygenation was 97% then dropping. Patient (R1) with pulse and spontaneous movements at that time. During transport, patient (R1) became less responsive, sats dropped below 50% despite supplemental oxygen and bag valve mask. Patient (R1) lost her pulse at that time. Past Medical History: DysphagiaPatient Active Problem List: Dysphagia; Esophageal DysphagiaPE (Physical Examination): General - unresponsive; HEENT (Head/Eyes/Ears/Nose, and Throat) - pupils fixed/dilated, no corneal blink reflex; Cor - no palpable pulse Patient (R1) expired during transport to hospital after choking episode with respiratory arrest. On 08/25/25 at 3:05 PM, V6 (CNA) was asked on R1's incident on 08/12/25. V6 replied, She was in her room, sitting in the bed. I gave the dinner tray. I offered to feed her, but she refused, she said she can do it. She is able to do it. She cuts her foods. I was there. Her dinner was turkey, and some little bit of pasta. I was supervising her, then she stopped eating, her hand was in her throat. So, I did Heimlich and while I am doing it, I called then nurse who was in front of her room. When I saw she (R1) was holding her throat and choking, I positioned myself behind her, while she (R1) was sitting on the bed, the bedside table in front of her, I placed my hand below the breasts and started pushing it upwards. When nurse (V9, Registered Nurse, RN) came, she (V9) took over, she (V9) went to bed and sit behind her (R1) and did the same thing. Everybody came and we continue to do the Heimlich. While we are doing it, we called paramedics. The food couldn't come out despite Heimlich. There were tiny bit of foods coming out from the mouth. She was unable to respond verbally. We are still doing the Heimlich, we put oxygen, she was still not responding. Paramedics came, they took over. She was not responding but still breathing. The foods still did not come out. There was a small amount of saliva coming out from her mouth with small foods. When she was taken by the ambulance, she was breathing but not responding. On 08/26/25 at 12:21 PM, V9 was also asked regarding R1's choking episode on 08/12/25. V9 stated, She had the choking incident on 08/12/25 afternoon shift. Trays were passed, V6, her CNA gave her the tray and asked her (R1) to assist with cutting foods, but she (R1) refused. V6 was standing there while she was eating when she noticed that she (R1) was holding her (R1) neck and choking. At the time, I was at the nurses' station and went there right away. I started to do Heimlich, she (R1) was sitting at the edge of the bed. I placed my both hands under rib cage and did abdominal thrusts. I told V6 to call out everybody. I asked other staff to continue the Heimlich and I called emergency services. While others are doing the Heimlich or abdominal thrust, one of the staff, V14 (RN) said food came out and asked her (R1) if she feels better and she (R1) said yes. While we're doing Heimlich, we placed oxygen via nasal cannula to her (R1). Paramedics came. Nasal cannula was changed to nonrebreather mask. Her oxygen saturation was 60%, it was low. She was picked up by paramedics, she was alert, awake, breathing with nonrebreather mask. The cause of her choking was the food that she was eating. V6 tried to cut her food but she (R1) doesn't want any help. It was a hotdog in a bun. It was whole when it was served. She ate the hotdog in a bun. On 08/27/25 at 11:58 AM, V14 (RN) was asked regarding R1 and the incident on 08/12/25. V14 stated, I was working on the other side when I hear from the page about rapid response, and I went there. I observed R1 sitting at the edge of the bed, not breathing because a staff was doing the abdominal thrust. Her eyes were open but unable to talk. When it was my turn, I did the Heimlich maneuver. She (R1) was still sitting, I was behind her (R1), I wrapped my arms around her (R1) waist, below sternum, and made an upward thrust. Food has not come out yet. I continued, I saw the food coming out from around her mouth and started to see it coming out. I swiped it out with my fingers. It was chunky with a little bit of slush. She started breathing again and said she can breathe. Her oxygen saturation was 97%. Approximately 5-10 minutes EMS came. She is alert and can answer all my questions.On 08/28/25 at 4:21 PM, V22 (Ambulance Crew) was asked regarding R1's disposition on 08/12/25. V22 stated, We were dispatched on 08/12/25 around 5:17 PM to a call from facility for choking. We went there, walked in. When I saw the resident (R1), she was lying in bed and had shallow respirations, had a suction and a nonrebreather mask. She had a cannula but not connected to oxygen. She had a nonrebreather mask on but not connected to any oxygen. She was not responsive to verbal and painful stimuli, we called out her name, there was nothing. There was no eye opening. But she had a heart rate under 100 and SpO2 under 60s, that's what I have seen in their monitor. When we put her (R1) to our monitor, the SpO2 was 60%. There was no facility staff in the room when we get there. So, I went back out of the room and everybody, which I am sure were staff working in the facility, were just standing around. I asked what's going on and they pointed to the lady on the phone. She must be nurse and she told me that resident (R1) was eating, then choke, they did Heimlich, did suction, and she said, I quote they were able to get a little bit. When we put the resident (R1) on the monitor, we asked them if there is a DNR. No one can tell me anything. So, at that point, our main concern was the patient (R1) so we move her (R1) to our cot. On 09/02/25 at 10:37 AM, V33 (RN) was also asked regarding R1's incident on 08/12/25. V33 verbalized, I was at a different floor and heard the rapid response and I went to her room. I don't know the resident (R1). There were a lot of staff already in her room. She was with nasal cannula; connected to pulse oximeter. She was breathing abdominally with difficulty. I heard the nurse said she called 911. So, I went downstairs to hold the elevator for EMS. But they already went upstairs. When I went upstairs, she (R1) was already in the stretcher, and I asked the nurse to print the DNR (do not resuscitate) form and gave it to the police officer. Her (R1) eyes were open but not alert and oriented. I didn't really talk to her. V33 was asked regarding choking and on how to do the Heimlich maneuver. V33 stated, I will ask resident and if a resident cannot talk and holding throat, I will do the Heimlich. With resident on the floor, I will go on top of the resident and I'm going to do the abdominal thrust. Place heel of the palm of hands at the bottom of the sternum and push upwards. If resident is standing, I will be behind resident, wrapped around my arms, with both hands pushing upwards. If resident is sitting, I will be behind the resident. On 09/02/25 at 10:49 AM, V32 (CNA) was asked regarding R1's choking incident. V32 replied, I was in the hallway and heard a call from V6. I went into the room. Her (R1) eye were wide-open, hands-on throat. We started the abdominal thrust. She was sitting at the edge of the bed. I was behind her. I put my right hand underneath and left hand over it. Right where the end of the bone in the middle chest, moving upward and thrust. We did a finger sweep and a piece of bread and meat came out. The resident (R1) was sitting, responsive, we asked her, she was able to squeeze my finger when I asked her to. She (R1) was already alert. Paramedics came, she was alert when she left. I was in the room when paramedics came. I did not leave her (R1). I was there, V6 was there and all other staff, inside the room. My main concern at the time was the resident (R1) if she was okay.On 09/02/25 at 10:55 AM, V31 (CNA) also stated during interview, On 08/12/25, I heard the page. I was in 1 West. I went to 2 East, to R1's room. The staff were already doing abdominal thrust. When I went there, she (R1) was already breathing. I didn't do any Heimlich. She was responsive. Paramedics came, I went out of the room, but nurses and other staff were still there in the room. We did not leave the patient (R1). When paramedics came, she (R1) was alert, verbally responsive. I heard her (R1) say yes. I saw her oxygen saturation 97%. When I went there, she was breathing. I heard the nurse asked if she's okay, she said yes. Then I stepped out. I did not do the Heimlich. V31 was asked how to do Heimlich maneuver. V31 verbalized, Doing Heimlich, place both hands between breast under the center bone, and make an upward thrust. We do the Heimlich until food comes out and resident is breathing. Facility stated in their incident report that R1 was alert, talking and breathing when picked up by EMS. V9, V14, V31 and V32 all stated R1 was alert, oriented and verbally responsive when paramedics came and transported to hospital. However, ambulance report indicated R1 was found unresponsive by EMS.On 08/25/25 at 3:50 PM, V8 (Director of Food Services) was asked regarding R1's dinner on 08/12/25. V8 stated, On 08/12/25, menu was hotdog, and she was served with turkey hotdog. V19 did not want us to give him red meat. Per V19, no red meat and no pork per R1's preferences. She (R1) was served with foods, CNA offered to assist her, she refused, and she choked.A follow up interview with V6 was conducted on 08/26/25 at 3:25 PM regarding supervision while R1 eats. V6 verbalized, I served her dinner, I let her cut the foods because she refused. I was standing by the table supervising her, looking at her while she eats. I didn't say anything or tell her to eat slowly or small pieces and bites. I just stood there and watched her, then she started coughing and holding her throat.On 08/27/25 at 11:12 AM, V11 (CNA) was interviewed regarding R1. V11 stated, I have taken care of her in the past. She was admitted to our unit. She is alert, oriented to person and place; able to verbalize needs; supervision to limited assistance for ADLs (activities of daily living). With eating, she is on supervision. Supervision while eating means opening the milk, supervising if the patient is having hard time cutting foods. She eats by herself, more of supervising if she is eating the meal or if she wants the food. With R1, we don't need to tell her to eat slowly, or tell her to cut her foods in small pieces. Because she is on general diet. Not that I know of that she is on aspiration precautions. On 08/27/25 at 11:32 AM, V12 (RN) was asked regarding R1 supervision when eating. V12 verbalized, I took care of her when she was here in the facility. She is alert, oriented to person, place and time. She needs a lot of cuing, a lot of set-up, a lot of assistance. She has dysphagia. During eating, staff would observe her. She was on one-on-one supervision during eating. Staff is sitting next to her while eating, observe, cue her to eat slowly, small bites, chew and swallow. We would cut the foods for her. She was on a strict aspiration precaution, so we need to watch and cue her while eating.On 08/27/25 at 11:48AM, V13 (CNA) was also asked regarding R1. V13 mentioned, She is alert, oriented, demanding. She needs help in performing ADLs because she is unsteady. During eating, she was on supervision and cue her to eat. Bring the tray, open the milk, juice and let her to sit on the edge of the bed or chair - I watch while she eats. We cue her that she needs to eat, she needs energy. She does not have any dysphagia, and she can eat whatever she wants to eat, that's what V19 said. She (R1) does not have a problem with swallowing.In a follow up interview conducted on 08/27/25 at 2:34 PM, V7 was asked on what interventions should be done for R1 related to aspiration precautions. V7 stated, R1 is on full aspiration precautions. Staff has to remind her to eat slowly. With my clinical recommendations for R1, she needs to be sitting upright when eating; eat slowly; small sips and bite slowly; clear the mouth when done with food; chew food well, don't get distracted, don't talk; if there is a need that she eats big chunk of food, make sure she cuts her foods in small pieces. R1's care plan documented: Compromised nutritional status (07/21/25):Interventions:Determine food preferences.Weigh the resident monthly as ordered.Allow ample time to complete the meal. Offer between meals snacks and meal substitutions as appropriate. Offer the resident a bedtime snack. R1's difficulty swallowing was not addressed in any care plan. There were no other care plans presented by facility related to her (R1) swallowing problems. On 08/27/25 at 3:22 PM, V8 (Director of Food Services) was asked regarding R1's care plan related to swallowing difficulties. V8 replied, I initiated dietary care plan of R1, only for the menu choices. Other than that, I did not evaluate her for any swallowing difficulties. I am not aware that she has swallowing difficulties. I did not do her full dietary care plan, only the portion about food preferences. I do revise care plan only food preferences, likes and dislikes. If there is a significant change, I don't do revisions or updates. We follow speech therapist recommendation for consistency change, other than that no.On 08/28/25 at 2:08PM, V20 (Dietitian) was also asked regarding R1's care plan for swallowing difficulties. V20 stated, I was the one who did her admission assessment and one more follow-up after I spoke with V19. I saw her (R1) and assessed her to check up on her. I don't do swallowing test. V7 put in a concern about swallowing difficulties but she (R1) refused the video test. V19 wants to put her on a general diet. For R1, I don't believe I did a care plan. I am not aware if she has difficulty swallowing. I was not notified of anything about her swallowing difficulties. That is why we did the care plan for meal preferences.On 08/27/25 at 3:35 PM, V2 (Director of Nursing) was asked regarding R1. V2 verbalized, She has a history of dysphagia which is reversible. She is on supervision or touching assistance during eating. Staff visually supervised her, cuing like if she needs anything. She doesn't need to be prompted. She can eat on her own. For R1, she needs supervision when eating and she was supervised. R1 exhibited that she can do everything, and staff had supervised her. When she had the choke, we were on top of that, she was alert and talking when transported to the hospital.On 08/27/25 at 4:58 PM, V21 (Medical Director) was interviewed regarding resident with swallowing difficulties. V21 stated, For residents with dysphagia or difficulty swallowing, we have to follow whatever the speech therapy recommends. Go by what speech therapy suggest or recommends. Then talk to patient and family regarding recommendations and depending on what family wants. Nowadays, health of the patient is managed and directed by family. Look for specific instructions from speech therapy if resident is on aspiration precautions. Like for example, if it says small bites, they should be getting small bites. Follow the guidelines from ST and make sure staff follow instructions. And it should be care planned and needs to be in the interventions.On 08/28/25 at 4:21 PM, V22 (Ambulance Crew) also mentioned during interview, When we moved her (R1) over to our cot, we noticed a bruise underneath the sternum, under breasts area. That is not the proper placement of the hands when doing Heimlich maneuver. It would not be effective. If resident is already unresponsive, they have to do CPR. When we got there, she (R1) was still in sitting position, almost laying down. So, when they were doing the Heimlich, she was in a sitting position. Then it is not effective. It should be in a standing position. The following staff were interviewed regarding Heimlich maneuver:Interviews with V6, V9, V14, V31, V32 and V33 all stated with them positioned behind resident, placing both hands below the sternum or rib cage and make an upward thrust. 08/26/25 at 11:11 AM: V23 (Licensed Practical Nurse, LPN) verbalized, Go behind the resident with both hands on the lower sternum and in a scooping motion do the abdominal thrust. We do it while standing and we can do it while resident is sitting. We check the mouth if we're able to see if not suction it. If patient passes out, we call code blue. Continue abdominal thrust until food comes out.08/26/25 at 11:20AM: V17 (CNA) mentioned, Hand placed below the sternum; push up, resident can be sitting or standing up. 08/26/25 at 11:24AM: V24 (CNA) stated, We call nurse right away, do CPR and start chest compressions. 08/26/25 at 11:29 AM: V25 (CNA) stated, The resident needs to be in a sitting position. CNA behind the resident needs to be sitting as well. With locked hands, placed between breasts and pushed upwards and talk to resident to know if food went down or out. If not continue the thrust and get help. 08/27/25 at 11:12 AM: V11 stated, During choking, swipe if there is any obstruction, then perform the Heimlich, ask for help. With resident sitting, placed one hand making a fist and other hand on top of the fist hand below the sternum and make an upward push. Do the Heimlich until food comes out. 08/26/25 at 11:33 AM: V16 (RN) stated, When doing the Heimlich maneuver, if a resident can stand, we do it standing, if he can sit, we can do it sitting, but more on standing. Make a fist with one hand and placed below sternum and pull up. If he can't talk and nothing went out, we continue to do the Heimlich. 08/26/25 at 11:46AM: V27 (CNA) stated, Lift the bed, call for help. Sit the resident up.08/27/25 at 11:48AM: V13 stated, Do the Heimlich maneuver with resident sitting, go behind the back and make fist and place it under the rib cage and make a push upwards until the food come out. I have to call for help.08/26/25 at 12:00PM: V29 (CNA) stated, Position resident leaning forward, tap the upper back 3 to 5 times. Call nurse or use call light. 08/26/25 at 12:05PM: V28 (LPN) stated, Bring up the head and do the Heimlich maneuver. With fist hands placed below the sternum and move upward. Resident could be sitting or standing. In a follow-up interview conducted on 09/08/25 at 9:07AM, V21 was asked regarding staff training in dealing with emergency situations on a resident. V21 verbalized that there should be procedures and plans that should be followed in accordance with state and federal guidelines. V21 also added, These staff/nurses coming from other countries/places need to go to rigorous trainings and should follow procedures and plans for emergency situations. Facility's policy titled Comprehensive Care Plan dated 11-17-17 stated in part but not limited to the following:Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Facility's Emergency Care for Choking, undated stated in part but not limited to the following:Conscious Victim: If victim can breathe, cough or make sounds, do not interfere. If victim cannot breathe, cough or make sounds, ask if you can help. Give quick upward thrusts above the belly button and below the ribs until object if forced out, victim can breathe again, or victim becomes unconscious. Unconscious Victim: Send someone to call 911 and get the Automated External Defibrillator (AED). If you are alone, perform 5 sets of 30 compressions and 2 breaths before leaving to call 911. Follow these steps: 1. Give 30 compressions pushing down at least 2 inches on the center of the chest. Place one hand on top of the other. Push hard. 2. Open the airway and check the mouth for objects. Remove the obstructing object only if you see it. 3. With the airway open, attempt to give two breaths. If unsuccessful, return to compressions. Repeat steps 1,2 and 3 until victim starts breathing or until emergency medical help arrives. Facility's policy titled Cardiopulmonary Resuscitation - CPR dated 3-22-22 documented in part but not limited to the following:Guidelines:This facility will provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives.CPR for Choking Event: In the event that a resident is observed choking, Heimlich Maneuver will be initiated and will continue until the airway obstruction is cleared or emergency personnel arrive. If the airway is cleared and the resident has no pulse or respirations, CPR will be initiated regardless of DNR status. Facility's Adult and Child Choking First Aide Guide, undated, documented in part but not limited to the following:Emergency StepsEnsure scene safety, assess, get consent, and wear PPE (personal protective equipment) as needed.Recognize choking signs immediately.Call 911 if there's any doubt or the person can't breathe or respond.Provide care: 5 back blows: Stand or kneel behind; use heel of hand between shoulder blades. If still obstructed, 5 abdominal thrusts: Thrust inward/upward above the navel. Alternate sets until the person can cough, cry, speak or becomes unresponsive. If the person becomes unresponsive, lay them flat and begin CPR, starting with chest compressions. After compressions and before giving breaths: open mouth, look for visible obstruction. Remove object only if easily visible, do not sweep blindly. The Immediate Jeopardy that began on 08/12/25 was removed on 09/02/25 when the facility took the following actions to remove the immediacy.Corrective Actions Taken: R1 expired while in transit to (name of hospital) 8/12/25 after the Heimlich Maneuver was initiated by staff following choking incident, Heimlich maneuver was performed with positive results and food successfully expectorated, resident left facility with 911 EMS services with pulse, oxygen saturation 97%, but subsequently expired while in transit to hospital.This was verified during staff interviews and R1's record reviews on 08/25/25; 08/26/25 and 08/27/25. On 9/2/25 the Director of Nursing, MDS Coordinator, and Director of Therapy Services completed full facility audit of residents with a diagnosis of dysphagia, and those with aspiration precautions for which these residents have been identified and referred to speech therapy to ensure the proper level of care needed were identified. T This was verified on 09/04/25 with V2, V15 and V40 during interviews and record reviews. On 9/2/25 the identified residents at risk were reviewed by the Director of Nursing and MDS coordinator to ensure the appropriate individualized interventions are in place as indicated on the medical records profile banner as well as reflected in updated care plans.This was verified on 09/04/25 during interviews with V2 and V15; and during reviews of care plans of selected residents reviewed by facility - R7, R8 and R9 medical records were reviewed with no concerns noted. Based on facility staffing roster as of 9/2/25, all facility nurses and nursing assistants were educated by the Director of Nursing and/or Designee on signs and symptoms of aspiration including but not limited to coughing while eating, throat clearing while eating, difficulty swallowing while eating, pocketing of food, and who to report this to. This education will be ongoing. This was verified with V2 on 09/04/25; review of in-services dated 09/02/25 and interviews conducted with V9, V16, V17, V25, V42 (LPN) and V43 (CNA). Based on facility staffing roster as of 9/2/25, all facility nurses and nursing assistants were educated by the Director of Nursing and/or Designee on when to perform the Heimlich Maneuver in the event of a choking episode. This education will be ongoing.This was verified with V2 on 09/04/25; review of in-services dated 09/02/25 and interviews conducted with V9, V16, V17, V25, V42 (LPN) and V43 (CNA). Based on facility staffing roster as of 9/2/25, all certified nursing assistants educated by the Director of Nursing and/or Designee on identifying signs or symptoms that may indicate a resident needs assistance during meals to be reported to nursing staff for further assessment and interventions as needed. This education will be ongoing. This was verified with V2 on 09/04/25; review of in-services dated 09/02/25 and interviews conducted with V17, V25 and V43 (CNA). Based on facility staffing roster as of 9/2/25, all nurses educated by the Director of Nursing and/or Designee on reporting of signs and symptoms of aspiration or difficulty swallowing to MD to obtain orders for speech therapy screening and to down grade diet in the event of risk for aspiration while pending speech therapy evaluation. This education will be ongoing. This was verified with V2 on 09/04/25; review of in-services dated 09/02/25 and interviews conducted with V9, V16 and V42. On 9/2/25 stated education has been added by the Human Resources Director to the facility orientation packet for new hire direct care staff effective immediately. This education will be ongoing and verified by the Director of Nursing and/or Designee. This was verified on 09/04/25 with V41 (Human Resources Director) and per record review that information and guidelines are attached to the orientation packets of new staff. V2 also [NAME][TRUNCATED]

Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and by failing to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision and resulted in R1 experiencing a choking episode and subsequently died in route to the hospital for emergency care. Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision and resulted in R1 experiencing a choking episode and subsequently died in route to the hospital for emergency care. Findings include:R1 is a [AGE] year-old, female, admitted in the facility on 07/18/25 with diagnoses of Acute Respiratory Failure with Hypoxia; Dysphagia, Oropharyngeal Phase; Chronic Obstructive Pulmonary Disease with Acute Exacerbation; and Mild Cognitive Impairment of Uncertain or Unknown Etiology.R1's MDS (Minimum Data Set) dated 07/28/25 recorded the following:Section (Sec) C - BIMS (Brief Interview for Mental Status) score is 14, which means little to no impairment in cognition.Sec. GG - Functional Abilities: A. Eating - 04, which means supervision or touching assistance. Helper provides verbal cues and/ or touching/steadying and/ or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.Sec. I - Active Diagnoses: Additional Active Diagnosis - Dysphagia, Oropharyngeal PhaseSec. K - Swallowing/Nutritional Status: K0100 Swallowing Disorder - B. Holding food in mouth/cheeks or residual food in mouth after meals; D. Complaints of difficulty or pain with swallowing. R1's care plan documented:Requires set-up or clean-up assistance to substantial/maximal assistance in her functional mobility and ADLs such as bed mobility, transfer, toileting and eating, dressing, bathing and personal hygiene related to fatigue, generalized weakness and SOB (shortness of breath):Interventions:Resident (R1) usual performance: Eating - Supervision or touching assistance. POS (Physician Order Sheet) dated 07/20/25 documented R1 is on general diet, regular texture, thin consistency, no red meat. POS dated 07/21/25 recorded in part but not limited to the following: ST (Speech Therapy) evaluation and treatment 3-5x/week for 41 days, to address R1's dysphagia. Aspiration and reflux precautions. Progress notes dated 08/04/25 documented R1 was noted with difficulty swallowing after swallowing piece of burger. It also stated that R1 is already under ST (speech therapy) evaluation. ST (Speech Therapy) service date 07/21/25, re-evaluation 07/22/25 recorded in part but not limited to the following: Skilled ST to address dysphagia and to improve safety of oral intake provided. Proceed with m/s (mechanical soft) and thin liquids with strict aspiration precautions and ongoing assessment of swallowing function as medical necessary. On 08/25/25 at 3:25 PM, V7 (Speech Therapist) was asked regarding R1. V7 stated, She is alert. I reached out to V19 (Family Member) and based from his (V19) information, she (R1) has difficulty swallowing, therefore we prescribed liberalized diet with no red meat, and she (R1) is ok with turkey and chicken. I informed dietary regarding diet. I recommended to proceed with requested diet, no red meat. She refused video swallow test and he (V19) was informed. I recommended to eat slowly with small bites, small sips. She (R1) is on full aspiration precautions due to long history of dysphagia. Facility's incident report documented that on 08/12/25 while assigned CNA (Certified Nurse Assistant, CNA) was supervising R1 have dinner, she (R1) began to have difficulty breathing, signaling for help. CNA immediately performed abdominal thrusts and call staff for help. Assigned RN (Registered Nurse) and other nursing staff on the unit responded immediately. R1 was able to expel ingested food and was placed on supplemental oxygen with no loss of consciousness. R1 was able to verbalize she is okay. Paramedics arrived and took over. R1 was alert, responsive and breathing via nonrebreather mask with SpO2 (saturation of peripheral oxygen) level of 97% when picked up by paramedics. R1 was sent to the emergency room for further evaluation. R1's Ambulance Report dated 08/12/25, time stamped 5:13 PM, documented:Mental status - unresponsiveNarrative: Ambulance was dispatched to the above location for the choking. Upon arrival, patient (R1) was found unresponsive laying in bed. Facility staff reported the patient (R1) was eating and then started to choke on the food. Facility staff attempted to do the Heimlich maneuver and suction, but they were only able to get some pieces of food out. Crew noted a SpO2 of 60%. Patient (R1) had a NRBM (nonrebreather mask). Crew asked facility if the patient (R1) had a DNR (do not resuscitate) but one was not able to be answer or provide one right away. Patient (R1) was moved to cot and secured and taken to ambulance where vitals were obtained. Crew noted a SpO2 of 48%, BVM (bag valve mask) with supplemental oxygen was placed on patient; crew assisted with manual respirations. Reassessed SpO2 was 94% with BVM. 4 lead EKG (electrocardiogram) obtained and showed sinus [NAME]. IV (intravenous) attempted and established in the left AC (antecubital), with a 18 G (gauge) and saline lock. City fire department came to ambulance with a valid DNR. Hospital was contacted, no orders or questions. En route to hospital, crew noted patient did not have a radial or carotid pulse. No CPR (cardiopulmonary resuscitation) was initiated due to valid DNR. Hospital records dated 08/12/25 recorded: The pertinent facts of this case are [AGE] year-old female (R1) who presents with respiratory arrest. Patient (R1) brought by EMS (emergency medical service). Patient (R1) was reportedly eating at mealtime at long-term care facility when she began to have a choking episode. Staff attempted Heimlich maneuver without relief. EMS was contacted, on scene report that patient (R1) was continuing to have difficulty breathing and speaking, initial oxygenation was 97% then dropping. Patient (R1) with pulse and spontaneous movements at that time. During transport, patient (R1) became less responsive, sats dropped below 50% despite supplemental oxygen and bag valve mask. Patient (R1) lost her pulse at that time. Past Medical History: DysphagiaPatient Active Problem List: Dysphagia; Esophageal DysphagiaPE (Physical Examination): General - unresponsive; HEENT (Head/Eyes/Ears/Nose, and Throat) - pupils fixed/dilated, no corneal blink reflex; Cor - no palpable pulsePatient (R1) expired during transport to hospital after choking episode with respiratory arrest. On 08/25/25 at 3:05 PM, V6 (CNA) was asked on R1's incident on 08/12/25. V6 replied, She was in her room, sitting in the bed. I gave the dinner tray. I offered to feed her, but she refused, she said she can do it. She is able to do it. She cuts her foods. I was there. Her dinner was turkey, and some little bit of pasta. I was supervising her, then she stopped eating, her hand was in her throat. So, I did Heimlich and while I am doing it, I called then nurse who was in front of her room. When I saw she (R1) was holding her throat and choking, I positioned myself behind her, while she (R1) was sitting on the bed, the bedside table in front of her, I placed my hand below the breasts and started pushing it upwards. When nurse (V9, Registered Nurse, RN) came, she (V9) took over, she (V9) went to bed and sit behind her (R1) and did the same thing. Everybody came and we continue to do the Heimlich. While we are doing it, we called paramedics. The food couldn't come out despite Heimlich. There were tiny bit of foods coming out from the mouth. She was unable to respond verbally. We are still doing the Heimlich, we put oxygen, she was still not responding. Paramedics came, they took over. She was not responding but still breathing. The foods still did not come out. There was a small amount of saliva coming out from her mouth with small foods. When she was taken by the ambulance, she was breathing but not responding. On 08/26/25 at 12:21 PM, V9 was also asked regarding R1's choking episode on 08/12/25. V9 stated, She had the choking incident on 08/12/25 afternoon shift. Trays were passed, V6, her CNA gave her the tray and asked her (R1) to assist with cutting foods, but she (R1) refused. V6 was standing there while she was eating when she noticed that she (R1) was holding her (R1) neck and choking. At the time, I was at the nurses' station and went there right away. I started to do Heimlich, she (R1) was sitting at the edge of the bed. I placed my both hands under rib cage and did abdominal thrusts. I told V6 to call out everybody. I asked other staff to continue the Heimlich and I called emergency services. While others are doing the Heimlich or abdominal thrust, one of the staff, V14 (RN) said food came out and asked her (R1) if she feels better and she (R1) said yes. While we're doing Heimlich, we placed oxygen via nasal cannula to her (R1). Paramedics came. Nasal cannula was changed to nonrebreather mask. Her oxygen saturation was 60%, it was low. She was picked up by paramedics, she was alert, awake, breathing with nonrebreather mask. The cause of her choking was the food that she was eating. V6 tried to cut her food but she (R1) doesn't want any help. It was a hotdog in a bun. It was whole when it was served. She ate the hotdog in a bun. On 08/27/25 at 11:58 AM, V14 (RN) was asked regarding R1 and the incident on 08/12/25. V14 stated, I was working on the other side when I hear from the page about rapid response, and I went there. I observed R1 sitting at the edge of the bed, not breathing because a staff was doing the abdominal thrust. Her eyes were open but unable to talk. When it was my turn, I did the Heimlich maneuver. She (R1) was still sitting, I was behind her (R1), I wrapped my arms around her (R1) waist, below sternum, and made an upward thrust. Food has not come out yet. I continued, I saw the food coming out from around her mouth and started to see it coming out. I swiped it out with my fingers. It was chunky with a little bit of slush. She started breathing again and said she can breathe. Her oxygen saturation was 97%. Approximately 5-10 minutes EMS came. She is alert and can answer all my questions. On 08/28/25 at 4:21 PM, V22 (Ambulance Crew) was asked regarding R1's disposition on 08/12/25. V22 stated, We were dispatched on 08/12/25 around 5:17 PM to a call from facility for choking. We went there, walked in. When I saw the resident (R1), she was lying in bed and had shallow respirations, had a suction and a nonrebreather mask. She had a cannula but not connected to oxygen. She had a nonrebreather mask on but not connected to any oxygen. She was not responsive to verbal and painful stimuli, we called out her name, there was nothing. There was no eye opening. But she had a heart rate under 100 and SpO2 under 60s, that's what I have seen in their monitor. When we put her (R1) to our monitor, the SpO2 was 60%. There was no facility staff in the room when we get there. So, I went back out of the room and everybody, which I am sure were staff working in the facility, were just standing around. I asked what's going on and they pointed to the lady on the phone. She must be nurse and she told me that resident (R1) was eating, then choke, they did Heimlich, did suction, and she said, I quote they were able to get a little bit. When we put the resident (R1) on the monitor, we asked them if there is a DNR. No one can tell me anything. So, at that point, our main concern was the patient (R1) so we move her (R1) to our cot. On 09/02/25 at 10:37 AM, V33 (RN) was also asked regarding R1's incident on 08/12/25. V33 verbalized, I was at a different floor and heard the rapid response and I went to her room. I don't know the resident (R1). There were a lot of staff already in her room. She was with nasal cannula; connected to pulse oximeter. She was breathing abdominally with difficulty. I heard the nurse said she called 911. So, I went downstairs to hold the elevator for EMS. But they already went upstairs. When I went upstairs, she (R1) was already in the stretcher, and I asked the nurse to print the DNR (do not resuscitate) form and gave it to the police officer. Her (R1) eyes were open but not alert and oriented. I didn't really talk to her. V33 was asked regarding choking and on how to do the Heimlich maneuver. V33 stated, I will ask resident and if a resident cannot talk and holding throat, I will do the Heimlich. With resident on the floor, I will go on top of the resident and I'm going to do the abdominal thrust. Place heel of the palm of hands at the bottom of the sternum and push upwards. If resident is standing, I will be behind resident, wrapped around my arms, with both hands pushing upwards. If resident is sitting, I will be behind the resident. On 09/02/25 at 10:49 AM, V32 (CNA) was asked regarding R1's choking incident. V32 replied, I was in the hallway and heard a call from V6. I went into the room. Her (R1) eye were wide-open, hands-on throat. We started the abdominal thrust. She was sitting at the edge of the bed. I was behind her. I put my right hand underneath and left hand over it. Right where the end of the bone in the middle chest, moving upward and thrust. We did a finger sweep and a piece of bread and meat came out. The resident (R1) was sitting, responsive, we asked her, she was able to squeeze my finger when I asked her to. She (R1) was already alert. Paramedics came, she was alert when she left. I was in the room when paramedics came. I did not leave her (R1). I was there, V6 was there and all other staff, inside the room. My main concern at the time was the resident (R1) if she was okay. On 09/02/25 at 10:55 AM, V31 (CNA) also stated during interview, On 08/12/25, I heard the page. I was in 1 West. I went to 2 East, to R1's room. The staff were already doing abdominal thrust. When I went there, she (R1) was already breathing. I didn't do any Heimlich. She was responsive. Paramedics came, I went out of the room, but nurses and other staff were still there in the room. We did not leave the patient (R1). When paramedics came, she (R1) was alert, verbally responsive. I heard her (R1) say yes. I saw her oxygen saturation 97%. When I went there, she was breathing. I heard the nurse asked if she's okay, she said yes. Then I stepped out. I did not do the Heimlich. V31 was asked how to do Heimlich maneuver. V31 verbalized, Doing Heimlich, place both hands between breast under the center bone, and make an upward thrust. We do the Heimlich until food comes out and resident is breathing. Facility stated in their incident report that R1 was alert, talking and breathing when picked up by EMS. V9, V14, V31 and V32 all stated R1 was alert, oriented and verbally responsive when paramedics came and transported to hospital. However, ambulance report indicated R1 was found unresponsive by EMS. On 08/25/25 at 3:50 PM, V8 (Director of Food Services) was asked regarding R1's dinner on 08/12/25. V8 stated, On 08/12/25, menu was hotdog, and she was served with turkey hotdog. V19 did not want us to give him red meat. Per V19, no red meat and no pork per R1's preferences. She (R1) was served with foods, CNA offered to assist her, she refused, and she choked. A follow up interview with V6 was conducted on 08/26/25 at 3:25 PM regarding supervision while R1 eats. V6 verbalized, I served her dinner, I let her cut the foods because she refused. I was standing by the table supervising her, looking at her while she eats. I didn't say anything or tell her to eat slowly or small pieces and bites. I just stood there and watched her, then she started coughing and holding her throat. On 08/27/25 at 11:12 AM, V11 (CNA) was interviewed regarding R1. V11 stated, I have taken care of her in the past. She was admitted to our unit. She is alert, oriented to person and place; able to verbalize needs; supervision to limited assistance for ADLs (activities of daily living). With eating, she is on supervision. Supervision while eating means opening the milk, supervising if the patient is having hard time cutting foods. She eats by herself, more of supervising if she is eating the meal or if she wants the food. With R1, we don't need to tell her to eat slowly, or tell her to cut her foods in small pieces. Because she is on general diet. Not that I know of that she is on aspiration precautions. On 08/27/25 at 11:32 AM, V12 (RN) was asked regarding R1 supervision when eating. V12 verbalized, I took care of her when she was here in the facility. She is alert, oriented to person, place and time. She needs a lot of cuing, a lot of set-up, a lot of assistance. She has dysphagia. During eating, staff would observe her. She was on one-on-one supervision during eating. Staff is sitting next to her while eating, observe, cue her to eat slowly, small bites, chew and swallow. We would cut the foods for her. She was on a strict aspiration precaution, so we need to watch and cue her while eating. On 08/27/25 at 11:48AM, V13 (CNA) was also asked regarding R1. V13 mentioned, She is alert, oriented, demanding. She needs help in performing ADLs because she is unsteady. During eating, she was on supervision and cue her to eat. Bring the tray, open the milk, juice and let her to sit on the edge of the bed or chair - I watch while she eats. We cue her that she needs to eat, she needs energy. She does not have any dysphagia, and she can eat whatever she wants to eat, that's what V19 said. She (R1) does not have a problem with swallowing. In a follow up interview conducted on 08/27/25 at 2:34 PM, V7 was asked on what interventions should be done for R1 related to aspiration precautions. V7 stated, R1 is on full aspiration precautions. Staff has to remind her to eat slowly. With my clinical recommendations for R1, she needs to be sitting upright when eating; eat slowly; small sips and bite slowly; clear the mouth when done with food; chew food well, don't get distracted, don't talk; if there is a need that she eats big chunk of food, make sure she cuts her foods in small pieces. R1's care plan documented: Compromised nutritional status (07/21/25):Interventions:Determine food preferences.Weigh the resident monthly as ordered.Allow ample time to complete the meal.Offer between meals snacks and meal substitutions as appropriate.Offer the resident a bedtime snack. R1's difficulty swallowing was not addressed in any care plan. There were no other care plans presented by facility related to her (R1) swallowing problems. On 08/27/25 at 3:22 PM, V8 (Director of Food Services) was asked regarding R1's care plan related to swallowing difficulties. V8 replied, I initiated dietary care plan of R1, only for the menu choices. Other than that, I did not evaluate her for any swallowing difficulties. I am not aware that she has swallowing difficulties. I did not do her full dietary care plan, only the portion about food preferences. I do revise care plan only food preferences, likes and dislikes. If there is a significant change, I don't do revisions or updates. We follow speech therapist recommendation for consistency change, other than that no. On 08/28/25 at 2:08PM, V20 (Dietitian) was also asked regarding R1's care plan for swallowing difficulties. V20 stated, I was the one who did her admission assessment and one more follow-up after I spoke with V19. I saw her (R1) and assessed her to check up on her. I don't do swallowing test. V7 put in a concern about swallowing difficulties but she (R1) refused the video test. V19 wants to put her on a general diet. For R1, I don't believe I did a care plan. I am not aware if she has difficulty swallowing. I was not notified of anything about her swallowing difficulties. That is why we did was the care plan for meal preferences. On 08/27/25 at 3:35 PM, V2 (Director of Nursing) was asked regarding R1. V2 verbalized, She has a history of dysphagia which is reversible. She is on supervision or touching assistance during eating. Staff visually supervised her, cuing like if she needs anything. She doesn't need to be prompted. She can eat on her own. For R1, she needs supervision when eating and she was supervised. R1 exhibited that she can do everything, and staff had supervised her. When she had the choke, we were on top of that, she was alert and talking when transported to the hospital. On 08/27/25 at 4:58 PM, V21 (Medical Director) was interviewed regarding resident with swallowing difficulties. V21 stated, For residents with dysphagia or difficulty swallowing, we have to follow whatever the speech therapy recommends. Go by what speech therapy suggest or recommends. Then talk to patient and family regarding recommendations and depending on what family wants. Nowadays, health of the patient is managed and directed by family. Look for specific instructions from speech therapy if resident is on aspiration precautions. Like for example, if it says small bites, they should be getting small bites. Follow the guidelines from ST and make sure staff follow instructions. And it should be care planned and needs to be in the interventions. Facility's policy titled Comprehensive Care Plan dated 11-17-17 stated in part but not limited to the following:Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to manage a resident with an insulin overdose in accordance with the standards of care for 1 of 4 residents (R1) reviewed for quality of care in the sample of 4. This failure resulted in a delayed transfer to the hospital, R1's wife summoning EMS (emergency medical services) and R1 being admitted to the ICU (intensive care unit) with an insulin overdose and hypoglycemia. The findings include: On [DATE] at 1:02 PM, V4, Registered Nurse (RN), said he found R1 to be groggy and sleepy at the end of his (night) shift (on [DATE]). V4 said he checked R1's blood glucose (BG), all BG measurements in this citation are in milligrams/deciliter (mg/dl) and it was very low; in the 30s. V4 said he gave R1 glucagon (a medication used to treat severe low blood (sugar) glucose) which he got from the crash cart and R1 slowly regained his alertness. V4 said glucagon should start working 15 to 30 minutes after administration. V4 said he then gave R1 some juice. V4 said R1 admitted that he was giving himself insulin but could not say how much insulin or when he had injected it, but he had used Lispro (a fast-acting insulin) and a long-acting insulin. V4 said R1's BG increased from the 30s to the 50s. V4 said he is not sure when he gave R1 a dose of glucagon, thinks it was around 6:00 AM. V4 said he should have charted in on the MAR (medication administration record), but he is not sure if he did. V4 said drowsiness, weakness, and slurred speech are all symptoms of low blood sugar. V4 said he would monitor for symptoms of low blood sugar (hypoglycemia) and if there were still symptoms and the BG was not at a normal level, he thinks it would be best to send the patient to the hospital. On [DATE] at 11:55 AM, V3, Licensed Practical Nurse (LPN), said she does not remember R1, but in an emergency situation, one nurse will help another nurse manage a resident. After reviewing R1's medical record, V3 confirmed she had given R1 glucagon on [DATE] at 10:00 AM, and believes it is the only dose he received according to the documentation on the MAR. V3 said if a resident's BG is low, she gives them orange juice and they usually have glucagon ordered and she can give that too. If the resident is alert, she tries to get them to eat/drink. V3 said she would repeat the glucagon after 15 minutes if the BG continued to drop or if there was no improvement in their cognition. V3 said slurred speech is a symptom of hypoglycemia. V3 said she would feel like a resident was safe if their BG had increased greater than 100 or 125, the vital signs were OK, and the resident's cognition was back to their baseline. V3 said if R1 had been her patient, she would have insisted for the doctor to send him to the hospital because he ate, glucagon was given, and he was still not responding to the treatment interventions. On [DATE] at 12:30 PM, V6, RN, said night shift did not report having any problems with R1 to her during nurse-to-nurse report (on [DATE]). R1 said she checked R1's BG as ordered that morning. R1 was a very brittle diabetic and at one point they found insulin vials and pens at his bedside. V6 said R1's wife admitted to administering insulin to R1 while in the facility. V6 said R1's wife was screaming at her saying no one was taking care of her husband. V6 said the morning R1 went to the hospital ([DATE]), R1 was lethargic and had slurred speech. V6 said R1's BG was, a little bit low. V6 said she had no idea how much, when, or what type of insulin R1 or his wife administered to R1. V6 said she does not remember R1's BG level, but it was low enough that the other nurse working that day administered glucagon to R1. V6 said glucagon starts working in less than five minutes. V6 said she did not call R1's provider about R1's BG. V6 said she would be concerned about any BG less than 70. V6 said she would check the BG again less than five minutes after glucagon is given to see if it was increasing and if it was still low, she would send a resident to the hospital immediately. V6 said she would consider a resident stable if their mental status was at baseline, the BG was between 70 and 100, and their vital signs were stable. V6 said R1's wife called the ambulance and demanded he be sent to the hospital. On [DATE] at 1:47 PM, V2, Director of Nursing, said standards of care would consider a BG less than 70 as low. The doctor would need to be notified and nursing would follow their instructions. V2 said he would recheck a resident's BG in 10 to 15 minutes after administering glucagon and if it was still low, he would administer a second dose of glucagon. V2 said he would err on the side of a resident's BG going too high rather than too low and risk a permanent medical condition from hypoglycemia. V2 said nurses document their medications on the electronic MAR as well as the BG checks. V2 said if something is not documented, then it was not done. V2 said nurses can use nursing judgment and critical thinking to determine if a patient needs to go to the hospital, they do not require a physician's order. On [DATE] at 10:20 AM, V10, R1's physician, said he knows R1 very well and he did not have slurred speech at his baseline. V10 said slurred speech is a sign of hypoglycemia or stroke. V10 said R1 was using insulin without permission. V10 said if the BG was less than 60, they should try giving glucagon and if able, feed the patient, and monitor the BG closely, especially with R1 as he had kidney issues which alone can cause hypoglycemia. V10 said an unknown quantity, type and time of insulin was given, so he could not say when it would peak or how long it would last. V10 said if large amounts of insulin were administered, even glucagon could not bring up the BG effectively. V10 easily needed to be closely monitored for ,d+[DATE] hours after the insulin overdose. V10 said if a patient's care or safety was compromised, he would send them to the hospital. V10 said if R1's speech remained slurred, he would try to give the glucagon once and if he did not return to baseline, he would send him to hospital. V10 said he would expect a BG to go to the 200s after receiving glucagon. V10 said a BG of 37, 58, or even 60 is not ok. V10 said he would not consider a BG to be stable in the range of 37 to 60. V10 said if the facility called and told him R1's BG did not go up to a normal range and he still had slurred speech despite being given glucagon and having eaten, he would have told them to send him to the hospital. On [DATE] at 11:20 AM, V11, R1's Nurse Practitioner, said R1's speech was not slurred, nor was he lethargic or groggy at his baseline. V11 said R1 was an alert and oriented, brittle patient who was noncompliant and difficult to work with. V11 said she was informed after the incident that R1 had been given insulin, but no one knows what type, when, or how much insulin was given. V11 said she could not even estimate how long the insulin would last. V11 said she would have given glucagon, and if R1 was not responding, she would have sent him to the hospital. V11 said someone cannot survive with a BG of 37. V11 said a BG of 37 to 60 is not stable; it's not safe for a person. V11 said a normal range for a BG is 60 to 100. V11 said the BG should be checked and repeated if it's not above 60 within ,d+[DATE] minutes. V11 said if she had been informed that R1's speech became slurred and his BG never recovered to a normal range, she would have sent him to the hospital. Then V11 said, based on how R1 was as a patient, she would have sent him to the hospital anyway; he was noncompliant, not easy, and nothing good could have come out of this situation. V11 said she feels like patient safety is the most important thing. The nurses have a lot of patients on that floor that are very critical, and R1 could have probably died . V11 said the standards of care after an insulin overdose support that R1 should have been sent out to the hospital right away. R1's Admission Record dated [DATE] shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, left ankle and foot osteomyelitis, type 2 diabetes with foot ulcer, non-pressure chronic ulcer of other part of left foot, cellulitis of left lower limb, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, peripheral vascular disease, atherosclerosis of native arteries of extremities, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery, hyperlipidemia, gout, diabetic polyneuropathy, obstructive sleep apnea, gastroesophageal reflux disease, anemia, muscle wasting and atrophy, abnormal posture, hyperparathyroidism, vitamin D deficiency, depression, left eye cataract, urinary incontinence and long term use of anticoagulants. R1's Minimum Data Set, dated dated dated [DATE] shows R1's speech clarity is clear with distinct intelligible words. R1's MAR for [DATE] to [DATE] shows one dose of Glucagon Emergency Injection Kit 1 milligram (mg) was administered to R1 on [DATE] at 10:00 AM. R1's Weights and Vitals Summary dated [DATE] shows R1's BG was 37 at 7:01 AM on [DATE], 60 at 7:54 AM on [DATE], and 57 at 10:05 AM on [DATE]. R1's BG averaged 163.55 between [DATE] and [DATE]; it was never below 89 during that time span. R1's Progress Notes show his BG was 37 when it was checked at 7:04 AM on [DATE] and R1 was awake and alert with three insulin pens/needles at the bedside. R1 admitted to self-administering insulin. The same note shows a recheck BG was 54. R1's Progress Notes show on [DATE] at 7:05 AM, R1 was responsive and appeared to be responding to treatment. On [DATE] at 7:54 AM, R1's Progress Notes show his speech was slurred. On [DATE] at 8:30 AM, R1's progress notes show he was eating breakfast, but his speech remained slurred. On [DATE] at 9:03 AM, R1's Progress Notes show R1's wife was updated on R1's status. On [DATE] at 9:05 AM, R1's Progress Notes show he spoke to his wife on the phone with slurred speech. On [DATE] at 9:55 AM, R1's Progress Notes show R1's wife was at the bedside, R1 was staring ahead, blinking his eyes and not answering questions. On [DATE] at 9:59 AM, R1's Progress Notes show R1's wife called 911. On [DATE] at 10:15 AM, R1's Progress Notes show R1 was being transported via 911 to the hospital emergency room . R1's Care Plan initiated on [DATE] shows R1 has potential for fluctuating blood glucose levels related to type 2 diabetes and his BG levels will be maintained within the parameters set forth by his physician. Signs and symptoms of hypoglycemia include a BG less than 70 and BG monitoring will be provided as ordered and as needed. R1's hospital records dated [DATE] show the Emergency Physician documented that R1 presented to the hospital with an insulin overdose. EMS found a low blood sugar on arrival and started R1 on an intravenous dextrose solution infusion. R1's initial BG at the hospital was 107, but later dropped into the 50 range. The Triage Note shows R1 was found catatonic upon EMS arrival with an BG check reading low. R1 was admitted to the ICU with diagnoses including, but not limited to insulin overdose and hypoglycemia.

Based on interview and record review, the facility failed to follow manufacturer guidelines for the care of a Left Ventricular Assist Device (LVAD). This failure affected one resident (R1) who was emergently transferred to a local hospital for unresponsiveness and was diagnosed with complications involving a left ventricular assist device. Findings include: R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: acute and subacute endocarditis, ventricular tachycardia and the presence of heart assist device- HM3 implant on 10-26-2018 and status post ventricular tachycardia (VT) ablation on three different occasions on 8-2017. Minimum Data Set (MDS) reads under Brief Interview for Mental Status (BIMS) test results dated 12-24-2024 had a result of 15/15 cognitively intact. R1 needs partial to moderate assistance with toileting. The left ventricular assist device (LVAD), also known as a heart pump, is connected to the heart and helps pump blood from the left ventricle which is the primary pumping chamber in the heart. The LVAD then helps pump blood to the rest of your body. The LVAD is considered a form of life support, it may be a life-saving treatment. On 1-25-2025 at 11:39 am V13 (R1 Family Member), said, (R1) was at the facility for about 2 weeks, on 12-31-2024 at about 8:30 pm I called R1's room without any answer, I then called the nurse station and asked the nurse to please take the portable phone to R1's room. I am glad I called because R1 was unresponsive when the nurse (V17) went into R1's room. On 1-25-2025 at 1:05 pm V17 (Registered Nurse) said, R1 was alert and oriented, continent of bowel and bladder, able to verbalize her needs and wants, and knew how to manage the LVAD. On 12-31-20224 at 8:30 pm, R1's son called and requested for the portable phone to be taken to R1's room, I went to R1's room and R1 had a change in condition, R1 was breathing uneasy, R1 did not use oxygen but her saturation was in the 80's. R1 was not responding to verbal or external rub. I immediately called for help, I checked the LVAD, the machine was wet with urine, the machine was in between R1's legs and everything in the bag was wet, another nurse, V19, changed the battery then R1 opened her eyes but was having difficulty breathing, I put R1 on some oxygen, and she was not responding as her normal base line. 911 came and assessed the patient and took the patient to the hospital, R1 was breathing and responding at that time. On 1-25-2025 at 1:15 pm V19 (Licensed Practical Nurse) said, I was working on 12-31-2024, I remember that the nurse called for my help, R1 was not responding to verbal and tactile stimuli and she was breathing very slowly and she was slanted over to the front while in bed, I quickly replaced the battery and R1 started breathing and moving again, we did not know how long the machine was not working. No alarms were going off because the machine was totally off. 911 came to take the patient to the hospital. On 1-25-2025 at 1:27 pm V18 (Nurse Practitioner) I know R1, If the LVDA is not on the patient can become unresponsive, I was not aware that the machine got wet, this is the first time I heard that, I cannot confirm that the machine will turn off if it gets wet or not. On 1-25-2025 at 2:45PM V15 (Registered Nurse/ ADON) said R1, came with LVAD alert oriented X4, continent of bowel and bladder. R1 had experience caring for the assisted device at home. On 12-31-2024 I was informed by V16 (Nursing supervisor) that R1 was sent out via 911 to the hospital because the LVAD was malfunctioning. On 1-25-2025 at 2:20 pm V2 (Director of Nursing) said, we do not have any policy to care for patients with LVAD we have the manufacture recommendations that come from the hospital and the doctor's orders. The LVAD was not working because it was wet with urine, the LVAD needs to be dry at all times, R1 was able to change the batteries and manage the LVAD. V2 did not present any documentation on battery replacement. On 1-25-2025 at 4:15 pm V21 (Certified Nurse Assistant), said I worked on 12-31-2024, R1 was my patient, I gave her dinner tray to R1 at about 5:30 pm, and by 6:30 pm I gave R1 water and picked up her dinner tray. R1 was alert and oriented, continent of bowel and bladder, I assisted her to the bedside commode. R1's call light was within reach. At about 8:30 pm the charge nurse called me, I came to R1's room and saw that R1 was not looking well, the other nurses came and brought the emergency cart by the door, and they replaced the batteries in the cardiac bag that rests on R1's neck, they pulled out two batteries from the bag, as soon as they did that R1 started to take a deep breath and getting more alert, the paramedics came very shortly and took her to the hospital. On 1-25-2025 at 3:30 pm V1 (Administrator) presented Manufacture Guidelines titled: Heartmate 3 LVAD patient guide excellence in every moment. V1 said, on page 149: do not submerge the shower bag in water, the system controller must be kept dry at all times. On page 246 Submersion in water or liquid may cause the Left Ventricular Assist Device to stop. The reason for the LVAD was not functioning properly was because it was wet. On 1-26-2025 at 11:50 am V1 said, R1 was trained before coming here on how to monitor the LVAD, and how to change the batteries, R1 was admitted for wound management, not for LVAD management, R1 was able to manage the machine and the staff was assisting with the daily care to make sure the machine was working well and documented in the daily check form and also in the electronic medical record. We in service the nursing staff on care and management of the LVAD yearly and before R1 was admitted . On 1-26-2025 at 1:00 pm V20 (Cardiologist) said, I had a nurse practitioner that was following R1 weekly. I have worked with LVAD for over [AGE] years, I am not aware of any function built in to shut off the LVAD if is exposed to moisture, I had never seen that before. The patients that have the LVAD are patients that can care for the device independently, but I will expect the staff to help R1 to manage the care of the LVDA at all times including replacing batteries and making sure the device is working well. According to hospital #1 record dated 12-31-2024 R1 arrived at the emergency room at 9:33 pm, (R1) presented with unresponsiveness. Per long-term care report at 8:30 pm R1 was less responsive LVAD was not working, the battery was changed and the LVAD turned on. Per emergency medical services (EMS): R1 was found unresponsive, with no LVAD alarms. Battery changed on the LVAD and R1 slowly became more responsive. R1's admitting diagnosis to the emergency room was a complication involving the left ventricular assist device (LVAD). Per hospital #1 record on 12-31-2024 at 11:12 pm while R1 was in the emergency room the cardiology team ran a diagnostic (interrogation) of the LVAD with results as follows: at 6:50 pm low voltage, 9:40 pm pump completely off. R1 will be transferred to another local hospital #2 for a higher level of care and further management of the LVAD. According to manufacturer guidelines, low voltage is considered a Hazard Alarms occuring for conditions that are potentially life-threatening for the patient, the alarm will provide 15 minutes remaining of power. Hazard alarms require immediate attention. Hazard alarms flash and appear as black text on a red banner. On-screen messages for hazard alarms are accompanied by a continuous audio tone from the System Controller. 1. Daily Safety Check: Perform System Controller self test. When using a new power source, inspect System Controller power cable connectors for dirt, grease, or damage. When changing power sources, inspect connectors on battery clips for dirt, grease, or damage. When switching from the battery power to the Power Module or the Mobile Power Unit, inspect the connector pins and sockets for dirt, grease, or damage. Ensure that the Modular inline Connector is secure and the connector locking nut is in the locked position. Ensure no yellow indicator is seen under the inline locking nut. Perform a Power Module self test. Maintain the Power Module connection to the AC power source. If not properly monitored, the internal battery drains, causing potential damage. Manage the Driveline exit site in accordance with the instructions provided by the clinician. Inspect the Driveline exit site for signs of infection, including redness, tenderness, swelling, discharge, or a foul odor. Use sterile technique to touch or handle the exit site. 2. Weekly Safety Check, Clean the metal battery terminals and contacts inside the battery clips. Inspect the Power Module or Mobile Power Unit power cord, used to connect the Power Module to the AC electrical outlet, for damage or wear. Ensure that the cord is not kinked, split, cut, cracked, or frayed. Do not use the cord if it shows signs of damage. Obtain a replacement, if needed. Manage the Driveline exit site in accordance with the instructions provided by the clinician. Inspect the Power Module patient cable or Mobile Power Unit patient cable, used to connect the System Controller to the Power Module or the Mobile Power Unit, for damage or wear. Ensure that the cable is not kinked, split, cut, cracked, or frayed. Do not use the Power Module patient cable or the Mobile Power Unit patient cable if it shows signs of damage. Inspect the HeartMate Shower Bag for damage or wear. Replace any equipment component that appears damaged or worn.

Based on observation, interview, and record review, the facility failed to follow their medication storage policy by not ensuring an insulin vial was properly labeled and stored in accordance with accepted professional practice. This failure affected 6 residents with orders for Lispro (Human) insulin (R97, R105, R124, R146, R187, R193) of 6 residents reviewed for medication label and storage. Findings include: On [DATE] at 11:28 AM, reviewed medication storage and labeling task for 1 east med cart with V14 (Registered Nurse) and observed an opened and unlabeled vial of lispro insulin that was half filled. When asked which resident the insulin vial belonged to, V14 (RN) said he did not know. When asked if the insulin vial was currently being used and if the vial should be stored in the refrigerator when not in use, V14 (RN) said yes. V14 (Registered Nurse) then said the insulin vial should have been properly labeled with the resident's name, dated when opened with the date of expiration indicated to avoid staff administering expired insulin to a resident. Requested list of residents on unit 1 east who receive lispro insulin. V1 (Administrator) provided a list of dated [DATE] that showed the following residents: R97, R105, R124, R146, R187, and R193. Active physician orders reconciled with medication administration records for above listed residents that revealed an active order for lispro that is being administered daily as follows: 1. R97's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) five times a day for diabetes as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350 > give 8 units and notify physician. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R97. 2. R105's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals for per clinical parameters related to diabetes, inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 2 Units; 250 - 299 = 3 Units; 300 - 349 = 4 Units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R105 as of start date of [DATE]. 3. R124's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals and at bedtime, inject as per sliding scale: if 150 - 199 = 1 units; 200 - 249 = 2 units ; 250 - 299 = 3 units; 300 - 349 = 4 units more or = 350 milligram (mg)/deciliter (dl) 5 units call primary medical doctor (PMD) for blood sugar (bs) more than 400 and call PMD. Less than 60 mg/dl call PMD. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R124. 4. R146's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject 3 units subcutaneous (under the skin) every 6 hours for diabetes. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R146. 5. R187's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals and at bedtime for diabetes AND Inject 3 unit subcutaneously before meals and at bedtime related to diabetes, inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 2 Units; 250 - 299 = 3 Units; 300 - 349 = 4 Units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R187 as of start date of [DATE]. 6. R193's active physician orders showed order with start date of [DATE] for Insulin Lispro 100 unit/ml solution, inject subcutaneous (under the skin) one time a day with meal related to type 2 diabetes mellitus, inject as per sliding scale: if 150 - 199 = give 1 unit and notify physician; 200 - 249 = give 2 units; 250 - 299 = give 3 units; 300 - 349 = give 4 units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R193 as of start date of [DATE]. *Noted R193's discontinued order on [DATE] for Insulin Lispro 100 unit/ml solution with start date of [DATE] to inject subcutaneous (under the skin) before meals related to type 2 diabetes mellitus, inject as per sliding scale: if 0 - 69 = give 0 units and notify physician; 70 - 149 = give 0 units; 150 - 199 = give 1 unit; 200 - 249 = give 2 units; 250 - 299 = give 3 units; 300 - 349 = give 4 units; 350> give 5 units and notify physician. Medication administration records for last 60 days (,d+[DATE] through [DATE]) showed daily administrations of lispro insulin for R193 as of start date of [DATE]* On [DATE] at 11:55 AM, V2 (Director of Nursing) said all insulin vials should be dated upon opening and should include residents name and expiration date. Medication storage policy last revised [DATE] reads in part: to ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. Once any medication or biological package in opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to United States Pharmacopeia guidelines for temperature ranges. Vials and Ampules of Injectable Medications policy effective [DATE] reads in part: vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. The date opened and the initials of the first person to use the vial are recorded on the multidose vials. Medication in multidose vials may be used until the manufacturer's expiration date/for the length of time allowed by the state law/according to facility policy/ for thirty days. USP <797> guidelines recommend discarding multidose vials at 28 days after opened. Reviewed lispro manufacturer instructions for use after vials have been opened that indicated to store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 28 days and throw away all opened vials after 28 days of use, even if there is insulin left in the vial.

Based on observations, interviews, and record review, the facility failed to administer medications as ordered for 1 (R93) of 5 residents reviewed during medication administration in the sample of 48. There were 27 opportunities with two errors resulting in a 7.41% error rate. Findings include: On 08/12/24 at 09:22 AM Surveyor observed V11 (Licensed Practical Nurse) administering medications on the second floor unit. Surveyor observed V11 (LPN) administering medications to R93. On 08/12/2024 at 01:56 PM Surveyor noticed, while completing medication reconciliation, that V11 (LPN) documented in R93's MAR (Medication Administrator Record) two medications as given whereas surveyor did not observe those medications being given during medication administration task. On 08/12/24 at 02:13 PM Surveyor interviewed V11 (LPN). Surveyor asked if V11 (LPN) gave all medications to R93, V11 (LPN) said, R93 refused two. Surveyor asked if V11 (LPN) followed up with R93 and offered it again, V11 (LPN) said, I will do it right now. Surveyor established that V11 (LPN) signed out both medications as given, V11 (LPN) said, I'm sorry, let me see if R93 wants them now. Surveyor asked what should have been done this morning, upon R93's refusal, V11 (LPN) said, I should have documented it as refused when R93 refused to take two of the medications this morning. On 08/13/24 at 10:17 AM Surveyor interviewed V2 (Director of Nursing) who stated: If a resident refuses a medication, nurse should re-offer the medication in a few minutes and try to find out why the resident doesn't want to take it. The nurse should document the refusal and notify all involved parties, such as doctor and resident representative. Surveyor clarified why is it inappropriate to document that medication was given when, in fact, it was not, V2 (DON) said: The documentation is inaccurate if a nurse signs off medication as it was given but, in fact, it was not given. R93's physician order dated 11/27/2022 reads in part, Tiotropium Bromide Monohydrate Capsule 18 MCG 1 capsule inhale orally one time a day for COPD Rinse mouth with water and spit after administration due at 9:00 AM R93's physician order dated 11/27/2022 reads in part, Wixela Inhub Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone- Salmeterol) 1 puff inhale orally every 12 hours related to Unspecified Asthma. Rinse mouth with H2O and spit back in cup after use due at 9:00 AM and 9:00 PM R93's MAR (Medication Administration Record) for August 2024 shows both, Tiotropium Bromide Monohydrate Capsule and Wixela Inhub Aerosol Powder documented as given on 08/12/2024 at 9:00 AM by V11 (LPN). The policy provided by the facility MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/2024 reads in part, Refusals of Medications: 5) Medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be documentation of prescriber notification of such. Documentation (including electronic): 1) At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.

Based on interview and record review, the facility failed to ensure that a resident's hospital bed was in good working order and in condition to be used safely. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall from bed that resulted in R3 sustaining a right arm (humeral) fracture. The surveyor confirmed by observation, interview, and record review that the deficient practice was corrected on 4/17/24, prior to the start of this survey, and was therefore Past Noncompliance. Findings include: R3 is an [AGE] year-old female with medical diagnoses that include (but not limited to): Disruption of external operation (surgical) wound, unspecified fracture of the lower end of right radius, vascular disorder of intestine, presence of cardiac pacemaker, difficulty in walking, abnormal posture, weakness, and history of fall. R3 was admitted to the facility on [DATE] and discharged after transfer to hospital on 04/18/24. R3's Care Plan includes the following: - Requires set up to dependent assist of 1-2 staff w/her functional mobility, transfer, toileting, eating, dressing & personal hygiene related to impaired mobility secondary to dx of fracture of lower end of right radius, wound dehiscence (abdomen), morbid obesity. She is ambulatory w/walker and partial to dependent assist related to weakness on both lower extremities. Date Initiated: 3/18/24, Revision on: 3/20/24; Interventions include: Resident usual performance: Dressing - lower body dressing - substantial/max assist; putting on/taking off footwear - dependent; Resident usual performance: Bed Mobility - sit to stand - partial/mod assist .Date Initiated: 3/18/24, Revision on: 3/20/24. - At risk for falls Deconditioning. Initiated: 3/18/24, Revision on: 3/20/24; Interventions include .Keep furniture in locked position. Initiated: 3/18/24. Facility provided facility reported incident documenting that R3's normal baseline - alert/oriented x4, she is able to ambulate and transfer with 2 person assist. On the afternoon of 4/18/24, resident c/o right arm pain to assigned nurse. PRN medication was administered with little relief. MD and POA were notified. MD ordered resident to be sent to local hospital for further orthopedic evaluation. Per hospital update received on 4/19/2024, x-ray result of the right elbow showed a traverse fracture of the right humerus .(R3) had a fall on 4/4/24 and was sent to local hospital for evaluation. X-ray of the right elbow was done on 4/5/24, however the transverse fracture was not seen in the prior elbow study. This was documented several times in the hospital records. Resident came back same day 4/5/24 . Facility provided documentation of Post Fall Huddle for R3 for fall dated: 4/4/24 which documents: Event: Resident was sitting in bed putting on her shoes with CNA assisting. Per resident, the bed moved making her fall from bed; Root Cause: Rubber part of wheel was worn causing less brake traction . Hospital record for date of service 4/5/24 HPI documents: [AGE] year-old female accidentally fell on to her right shoulder apparently the bed was not locked, and she fell .Chief Complaint includes: Patient reports she was putting on her shoes at the edge of the bed, the bed was a lot [sic], the bed slid out from underneath her, patient landed on her right side on her right shoulder and her right elbow. A lidocaine patch is in place without significant improvement in symptoms . Hospital record for date of service 4/19/24 documents: X-ray Humerus (RT): Impression: Transverse fracture through medial lateral epicondyle of the distal humerus as described above. This is not seen on the prior elbow study dated 4/5/24 .Ortho/Heme: Right distal humerus fracture and acute on chronic blood loss anemia due to hemi arthrosis of right shoulder. These findings are acute based on x-ray on this admission but may have been suffered from mechanical fall ~ 2 weeks ago. Imaging at that time was negative . On 6/10/24 at 3:03PM V25 (CNA) confirmed that they witnessed the fall in question that R3 sustained on 4/4/24. V25 said, I was helping (R3) get her shoes on. She was sitting on the edge of the bed. When I bent down to get her shoes, I think she tried to stand up. I don't know if it was her body weight or that her legs twisted, but somehow when she leaned on the bed it slid. When the bed slid, she fell on the floor. I think she landed on her right side because that was the side that she was complaining about after she fell . I immediately pulled the call light for staff to come assist. She tried to get up from the floor, but I told her not to get up because we should wait for the nurse to come and assess her first. The two or three nurses who were working, all came in the room and then I'm not exactly sure what happened. She was complaining that her right shoulder was hurting. The bed was locked but I don't know how it slid over. On 06/07/24 at 1:50PM V1 (Director of Nursing) said, the CNA was helping (R3) get dressed and she fell because the wheel of the bed was damaged. It popped off and it caused her to fall off the bed. Then it happened with another resident, and we knew we had to do a full facility sweep. The beds are old and so we checked all of the beds in the facility and identified any that were old and needed to be replaced. The cost is over $400 per wheel so we had to get approval from corporate because I told them I could not have any more injuries because of this problem. We recently finished replacing all the damaged beds. On 6/8/24 at 10:52AM, V1 added that R3 complained of post fall pain, I think 3/10 and right arm pain the next day. We ordered a STAT x-ray, but the company was taking too long so we sent her to the hospital for the x-ray. She already had a fracture when she got here but when we sent her out to the hospital the x-ray came back inconclusive. V1 then provided documentation of 4/5/24 x-ray being inconclusive and provided documentation of when R3 was sent to hospital second time for further testing of right arm/shoulder pain. 06/08/24 at 10:11AM V7 (Director of Environmental Services) said, it was reported to me that one of the beds was damaged, I think it was in April. The brakes were not holding. When we checked the bed, two of it's wheels were worn. The rubber on the wheels was very thin and worn. I removed the bed and put a different bed on the room, ordered new wheels, and replaced them. After that, I did an audit on the entire building and checked every single bed. We found a few more like that, we removed them from the units, and we replaced the actual wheel. There was a second one on 5/5/24 room [ROOM NUMBER]-B that we found during the audit. The original one reported to me was (R3's room) on 4/4/24 (V7 showed surveyor tracking app on his phone with date). The order requests are put in the app and then we go and follow up. The one in May was the same issue and that one was replaced as well. I ordered a bunch of wheels to have them on hand and we replaced them to avoid this problem from happening. Facility provided log of Quarterly Preventative Maintenance on Hospital Bed, dated 4/5/24 which documents yes for the question Are the wheels of the bed in good working condition for rooms 103A, 104C, 105A, 113C, and 115A. Comments section on the same log then documents that on 4/17/24 wheels were replaced on beds for the above listed rooms. Facility provided a copy of their Maintenance Policy (undated), which reads: Purpose: To ensure that the building (interior and exterior), grounds, and equipment are maintained in a safe and operable manner. Responsibility: Maintenance Director, Administrator Policy: It is the policy of the facility to provide a safe, accessible, effective, and efficient environment of care that is consistent with its mission, services and law and regulations. Guidelines: 1. The department shall be supervised and managed by a qualified Maintenance Director. 2. Sufficient staff are oriented to, educate about the environment of care, and possess knowledge and skills to perform duties consistent with management plans . 4. The department shall maintain all equipment and supplies in a safe and operating condition. Maintenance supplies shall be provided and inventoried in sufficient quantity to assure equipment and systems are maintained in good working order . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included in-service training for staff on reporting/checking/identifying damaged equipment, audit of all beds in the facility, replacement of damaged wheels on resident hospital beds, QAPI bed maintenance review, and ongoing weekly QA audits of damaged hospital beds. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on interviews and record reviews, the facility failed to follow its own policy by not providing the services of an onsite beautician, this failure affected four (R4, R5, R6, and R7) of four residents reviewed for resident rights. Findings include: On 6-8-2024 at 1:30 PM V20 (R4's family member) said, R4 cannot be scheduled to see a barber at the facility because they do not provide the services of a barber or a beautician, for a very long time, I can send money for R4 to be scheduled with the barber because R4 likes to have a short hair. On 6-8-2024 at 10:50 am R4 said, my hair is long now, I am waiting for my family to take me out to get it groomed because not everyone can take care of my hair (referring to the curly hair), we do not have a barber here in the facility for a long time. R5 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: asthma, chronic pulmonary disease, and diabetes. MDS- BIMS: 15/15 dated 5-3-2024. On 6-8-2024 at 11:20 am, R5 said, we have not had any beautician for several years, it would be nice to have one because my hair is long and needs to be cut and styled. R6 is a [AGE] year-old female originally admitted on [DATE] with medical diagnosis that include and are not limited to: chronic obstructive disease, schizoaffective disorder, and anxiety disorder. MDS- BIMS: 15/15 dated: 4-29-2024. On 6-8-2024 at 11:30 am R6 said, we have not had any beauticians for several years, we had one before, and is nice because they can cut and fix the hair nicer. R7 is a [AGE] year-old female originally admitted on [DATE] with medical diagnosis that include and are not limited to: schizoaffective disorder, bipolar disorder and hypertension. MDS- BIMS: 14/15 dated: 4-19-2024. On 6-8-2024 at 12:20pm R7 said, I need to go out with my family to have my hair cut and color, they do not have any beautician here to give us the services. On 6-8-2024 at 9:20am V6 (Director of Social Services) said, we do not have a barber for some time. On 6-8-2024 at 11:40am V16 (Certified Nurse Aide) said, we do not have a beautician, if the family or the patient asks the nursing staff to cut the hair of any of the residents, we can do it, I am not licensed beautician, but I had done it for a very long time and I do a very good job. On 6-8-2024 at 11:45am V8 (Life Enrichment Director/Activity Director) said, we have a beauty salon, but I have not seen any beautician since I started working here more that 11 months ago. On 6-10-2024 10am V19 (Administrator) said, we do not have a beautician now, we should have one available if the resident wants the services on site. On 6-10-2024 at 12:40pm V21 (Social Worker) said, we do not have a beautician for almost a year, we have a beauty shop but not a beautician. 6-10-2024 at 1:30pm V19 (Administrator) provided a written statement that reads: the last time we had a beautician was on May 11th, 2023. V1 (Director of Nursing) provided a policy titled: On-site Health care services dated: 9-2015, reads: to make available on-site health care services, it is the policy of the facility to assist residents in arranging health services on site services available: Beautician/Barber services.

Based on interview and record review, the facility failed to ensure that residents are personally seen by their physician for an initial comprehensive visit upon admission and at least once every 60 days while in the facility. This failure applied to four of four (R1, R4, R5, R6) residents reviewed for physician services. Findings include: R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: Myopathy, Hemiplegia and Hemiparesis following cerebral infarction. R1's primary care physician is V24 (Medical Director). R4 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: cerebral palsy, schizo-affective disorder, diabetes, and hypertension. R4's primary care physician is V26 (Medical Doctor). R5 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: asthma, chronic pulmonary disease, and diabetes. R5's primary care physician is V27 (Medical Doctor). R6 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: chronic obstructive disease, schizo-affective disorder, and anxiety disorder. R6's primary care physician is V27 (Medical Doctor). During the course of this investigation, while reviewing resident records for change of condition, it was noted that there was no documentation of physician progress notes for the period reviewed (over the past six months) for R1, R4, R5, and R6. Interview with V1 (Director of Nursing) on 6/8/24 at 2:30PM, V1 stated that he was not sure how often the physicians are required to see the residents. Facility was asked to provide the last two physician notes for R1, R4, R5, and R6 and the following were/were not provided: R1 - no physician progress notes provided R4 - no physician progress notes provided R5 - most recent physician notes provided were for 9/30/20 and 9/10/20 R6 - most recent physician notes provided were for 3/30/2019 and 3/22/2019 On 6/10/24 at 2:08PM, V19 (Administrator) confirmed that the above dates were the most recent progress notes for R1, R4, R5, and R6. On 6/8/24 at 1:17PM V24 (Medical Director) was interviewed and stated, (regarding R1), I didn't see him when he first came in because I was out of the country, but I did see him when he came back (from the hospital in April) . I document in (progress notes) but I don't know how this got missed with this patient. There is generally good documentation of my visits. I cannot give you a good explanation of why there is no note. I come in every week while I am in town. I see all the new patients and I talk to them and see them, and I see families. They know I come in on Thursdays. I am at least there 42 weeks and if I can't come in on Thursday then I change my day. I don't see long term patients very often. I just make sure that I see them every 6 months, but I tell (V1 - Director of Nursing) to let me know if I need to see anyone. (Nurse Practitioner) will see them every month and then they are seen by all sort of people - rehab, ID, cardiology. I tend to see them every 6 months or every year. I see the dialysis and ventilator patients until I see that they are stable. I do stay involved with the people who are sicker where I am able to provide a lot more help rather than the stable people who don't need to be seen as often. You can see my notes - this is an anomaly. Facility provided a copy of their Physician Services Policy (Effective Date: 11/15/23), which reads: Policy: It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. Policy Specifications: To ensure that each resident receives proper medical care and to define the requirements and responsibilities for positions admitting and caring for residents. Responsibility: Attending Physicians, Medical Director, and Administrator Standards: 1. Physicians providing medical services in this facility will be approved by the Credentials Committee and abide by the Medical Practice and By-Laws Policies, Physician Services Policy and all other policies indicated. 2. Physicians who have facility privileges will have files maintained and periodically audited which contain the following current records: a. License b. DEA number c. Certificate of insurance d. Verification of professional standing from the Health Professional Bureau and State Medical Board e. Clinical performance evaluations f. Credentials and hospital privileges 3. A physician's admission order approving or recommending that the individual be admitted to the facility shall be required for all residents. 4. Upon admission, each resident shall designate an attending physician and physician will verify willingness to attend the resident at the facility. 5. The Administrator and/or Medical Director shall ensure that all attending physicians are provided with current copies of the following policies: a. Physician Services Policy b. Resident Rights and Responsibilities c. Advance Directives Policy d. Nurse Practitioner/Physician Assistant Services e. Medical Practice Policy f. Medical Staff By-Laws g. Physician Notification Policy 6. The attending physician shall be responsible for informing the resident or his/her legal representatives, of his/her medical diagnosis, treatment and prognosis in terms and language the resident can reasonably expect to understand, and the resident shall be permitted to participate in the planning of their total care and medical treatment to the extent his/her condition permits. 7. At the time of admission, the physician must provide immediate care, i.e., medications, treatments, and diet. 8. At the time of admission or within forty-eight (48) hours thereafter, the physician will provide resident information which includes: a. Relevant past medical history b. Current medical findings c. Prognosis and Rehabilitation Potential d. Diagnosis e. Regimen of Medical Care f. Report of Physical Examination performed not earlier than five (5) days prior to admission and updated to include new medical information if the resident's condition has changed since the examination was performed. g. Statement that resident is free of tuberculosis in a communicable state h. Results of a chest x-ray performed within the last six months and Mantoux test within three (3) months of admission i. Recommendation for level of care j. Mobility status k. Orders regarding permission to leave premises on LOA l. Allergies 9. The above listed requirements may be considered met if a medical referral (transfer record) accompanies the resident at the time of admission providing all required information and the physician documents in the medical record that referral reports are accurate and acceptable. 10. In the event the transfer institution does not provide the report of physical examination, the attending physician will provide sufficient written admitting medical information for the provision of care during the forty-eight (48) hour period. If a medical history and physical examination is performed with and five (5) days admission in the report is recorded in the medical record, the report will be accepted. 11. Each resident will have medical plan of care for twenty-four (24) hours a day. In the event of the attending physician's absence or in case of emergency, the physician will provide the name, telephone number or answering service number of the alternate physician. In the event it is determined that a physician is unable to fill his/her obligations of providing continuity of care, the resident and/or their legal representative will be requested to obtain alternate physician services. 12. Arrangements are made for the medical care of the resident twenty-four (24) hours a day. In the event of the attending physician's absence or in case of emergency, the physician will provide the name, telephone number or answering service number of the alternate physician. In the event it is determined that a physician is unable to fill his/her obligations of providing continuity of care, the resident and/or their legal representative will be requested to obtain alternate physician services. 13. The attending physician is responsible for performing, on an annual basis, a physical examination of each resident under his/her care. Examination will include resident vital signs and physical findings, current diagnosis, and statement that the resident is free of tuberculosis in infectious stage. 14. Blood transfusions or chemo/radiation will only be administered in the facility if: a. Contracts for both services are current and signed by authorized individuals b. There is evidence of staff education prior to service being provided 15. Written orders for all medications and treatments, in sufficient detail for the provision of care, shall be prescribed by the physician upon admission and updated throughout the resident's stay. All orders and treatment shall be reviewed and personally signed and dated by the physician. The physician shall assure that current diagnoses are available to support care and treatment. 16. Telephone orders shall be signed on the physician's next visit. Admission verbal orders shall be countersigned within forty-eight (48) hours of admission. Signed orders received by fax machine do not require re-signing. 17. Signature stamps are not acceptable for physician orders and standing orders may not be used. 18. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care, i.e., comprehensive assessments, care plans, medication and treatments and approving such by signing and dating the current order recap. 19. The physician's visit will be considered timely if it occurs no later than ten (10) days after the required date. 20. The attending physician shall certify upon admission and at each visit every 30/60 days thereafter what level of care the resident requires and document the for a change in the progress notes. 21. A physician may delegate tasks to a physician assistant, nurse practitioner or clinical nurse specialist who is under the supervision of the physician and acts within the scope of practice as defined by the state law and are authorized by Medicare Regulations. The delegating physician shall be responsible for specifically delineating assigned duties, in writing, and methods of supervision that meet appropriate statutes. (See Nurse Practitioner Policy) 22. In the event a physician and alternate physician cannot be contacted or refuse to respond to a licensed nurse, and the situation requires immediate action, the Director of Nursing or on-call designee shall be notified for direction. The Medical Director shall also be contacted when medical intervention is required. 23. Unsuccessful attempts to contact physician and his/her refusal shall be documented in the nursing progress notes by the licensed nurse making the attempts to notify the physician. 24. The physician shall be notified when an emergency arises due to medical necessity, and no do not resuscitate order is written. Licensed nurses shall initiate basic life support, call 911 and immediately transport the resident to the nearest hospital. 25. The facility shall notify the attending physician of any accident, injury or significant change in the resident's condition that threatens the health, safety, or welfare of the resident, including but not limited to abnormal laboratory values, significant change in vital signs, symptoms of infection, changes in skin conditions such pressure ulcers, weight fluctuations of 5% or more within a one-month period or 10% within six months. 26. Specific criteria shall be developed and implemented regarding physician notification upon change of resident condition. (See Nursing Procedure Manual) 27. Medical consults shall be obtained with concurrence of the attending physician notification and approval unless in conflict with the resident's wishes. Results and/or recommendations of all consults shall be conveyed to the attending physician in writing and consulting reports retained in the medical record. Consultant physician order shall be reported to the attending physician for approval. 28. Physician shall certify and decertify the need for Medicare skilled services in accordance with CMS requirements. Physicians may sign an initial certification and one more re-certification at the same time.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for serving food under sanitary conditions by not properly wearing hair restraints, not practicing hand hygiene when necessary, not ensuring sanitizer solution was replaced when needed, not ensuring kitchen appliances were properly cleaned and stored, not ensuring the ice machine was thoroughly clean when in use, and not recording final cook temperatures. This failure has the potential to affect all 210 residents in the facility. Findings include: 09/11/2023 at 10:23 AM - 10:40 AM, Observed a large ice machine filled with ice to have heavy rust like buildup inside of the machine at the hinge of the door. Observed V4 (Director of Dining Services) was able to wipe away the buildup with his finger. V4 stated the ice machine is cleaned weekly. V4 stated the buildup in the ice machine could possibly be rust. V4 stated the ice machine should be free of any buildup. Observed the meat slicer to have stuck on and loose food particles once the plastic bag cover was removed by V4. Observed V4 firmly rub the area of the meat slicer with the stuck-on food particles and state the particles don't come off. V4 stated the meat slicer should be cleaned after each use and he will have it recleaned. Observed V5 (Dietary Aide) and V6 (Dietary Aide) with hair exposed from the sides and back of their hairnets while working in the food prep area. Observed the sanitizer bucket in the food prep area with no sanitizer solution in it when tested . V4 stated the sanitizer solution in the bucket had not been changed. V5 stated the sanitizer solution in the bucket needed to be changed. 09/12/2023 at 10:05 AM - 11:30 AM, Observed V5 (Dietary Aide), V6 (Dietary Aide), and V7 (Cook) with hair exposed from the sides and back of their hairnets while working in the food prep area. Observed V7 pick up an oven mitten from the floor with gloved hands, place on the oven mitten over his glove, pick up a large pan of melted butter from the stove and transfer it to the food prep table then remove the oven mittens and gloves. Observed V8 (Dietary Aide) with hair exposed from the sides and back of her hair while rolling silverware. Observed V7 temp the chicken fried steaks before removing them from the oven then have them placed in a separate container and moved to the steam table without recording the final cook temp. Observed V5 place the cooked mixed vegetables that were held on the stove and purees held in the heated oven/hot box for several minutes on the steam table. Observed V7 temp the foods on the steam table while V5 documented the temperatures on the temp log in the section for held food temperatures. Observed the food temperature log dated 09/12/2023 did not include the final cooking temperatures of the prepared food. Observed V6 remove four slices of bread from a package of bread and pack them into small bags with her bare hands. Observed V6 then seal the package of bread and set aside for later use. V6 stated she was packing the bread to be sent out with residents who will be leaving for an appointment. V4 stated he did observe V5, V6, and V8's hair was exposed from underneath their hairnet. V4 stated the hair of staff working in the kitchen should be fully covered by their hairnet. 09/12/2023 at 10:30 AM V4 (Director of Dining Services) stated he observed V6 (Dietary Aide) had handled bread with her bare hands in the kitchen on 09/12/2023 and she knows this is not appropriate. V4 stated no food being prepared for service should be touched with bare hands. V4 stated gloves should be changed and hands washed after handling contaminated items such as when V7 (Cook) picked up the oven mitten off the floor with his gloved hands. V4 stated he was never instructed that the temperatures of foods when removed from the oven needed to be documented. V4 stated the facility was only advised that the final temperatures of foods when held on the steam table needed to be documented. V4 acknowledged that the food temperature logs include a section for documentation of food temperatures when removed from the oven and stated he was never instructed that he must complete that section of the log. The facility's Hair Restraints Policy reviewed 09/13/2023 states:Hair restraints shall be worn by all Dining Services staff when in food production areas. Hair restraints shall be used to prevent hair from contacting exposed food. The facility's Food Preparation Policy reviewed 09/13/2023 states: Food is prepared using safe food handling methods which protect the food from contamination, prevent food-borne illness and preserve nutritive value of the food. Avoid bare hand contact with any food. The facility's Proper Hand Washing and Glove Use Policy reviewed 09/13/2023 states: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Gloves are changed any time hand washing would be required. This includes if gloves become contaminated by touching a non-food contact surface. The facility's Food Temperature Policy reviewed 09/13/2023 states: Food and Nutrition Services employees will practice safe food handling to prevent food borne illness. It is the policy of the dietary department to take and record final cook temperature. Food will be removed from the oven and placed directly in the steam table. Temperature will immediately be taken and recorded as the final cook temperature. The correct temperature will be recorded in a temperature log. The facility's Sanitizer Policy/Procedure reviewed 09/13/2023 states: Buckets should be changed every 2-4 hours or more as needed to keep the water clean and the sanitizer effective in use. The facility's Cleaning Instructions for Slicer reviewed 09/13/2023 states: Slicer will be cleaned and sanitized after each use. The facility's Cleaning Instructions for Ice Machine and Equipment reviewed 09/13/2023 states: Ice machine and equipment will be kept clean and sanitized. Wash inside.

Based on observation, interview, and record reviews the facility failed to follow their policy and procedure for catheter use by not ensuring a urology evaluation for urinary catheter removal was scheduled for a resident with a history of urinary tract infections. This failure applies to one of two residents (R199) reviewed for catheter and urinary tract infection. Findings include: R199 is a [AGE] year-old male with a diagnoses history of Urinary Tract Infection, Hypertensive Chronic Kidney Disease, and Stage 4 Chronic Kidney Disease who was admitted to the facility on [DATE]. On 09/11/23 at 11:33 AM Observed R199 lying in his bed with a urinary catheter attached. V23 (Family Member) reported that the facility was supposed to have faxed a request for a urology appointment for R199 with the VA (Veterans Administration) however the VA had not received it. V23 stated he and R199 are still waiting for the urologist to confirm receiving the request. V23 stated R199 wishes to have his catheter removed due to limited mobility. V23 stated R199 was admitted to the facility with a catheter that he has had since June. R199's Nurse Practitioner Progress note dated 8/16/2023 documents R199 was at previous facility in June 2023, approximately one month for kidney issue/condition which was treated at Nxxxxxxxxxxx Memorial Hospital. Urinary catheter was inserted at this time. R199 was independent for ambulation and activities of daily living until hospitalization at Nxxxxxxxxxxx. Per V23 (Family Member) R199 has had multiple urinary tract infections since foley catheter inserted, tried for removal at previous facility. Will refer to outpatient urology for further evaluation/treatment. R199's Nurse Practitioner Progress note dated 8/22/2023 documents R199 is a [AGE] year-old male being seen today per facility's request for urinary tract infection. R199 was hospitalized from 8/9-8/15 due to agitation and was diagnosed with urinary tract infection. TODAY R199 states he wants the urinary catheter out. R199's physician order sheet reviewed 09/12/2023 did not include an order for a urology evaluation. On 09/13/2023 at 2:35 PM V3 (Assistant Director of Nursing) stated she followed up with V15 (Scheduler/Transportation Coordinator) on whether R199 was scheduled for a urology consult and there was no appointment scheduled for him. V3 stated today V15 scheduled a urology appointment on October 02, 2023 for R199. V3 stated she is not sure why a urology appointment was not already scheduled for R199. V3 stated if the nurse practitioner noted in R199's medical records on 08/16/2023 that he should be referred to the urologist for evaluation, at that time the nurse practitioner should have placed an order for the appointment and coordinated with the nurse to schedule a urology evaluation for him. V3 stated she did not find an order for a urology appointment in R199's physician order sheet at this time. V3 stated it was important to have R199's urology evaluation scheduled as soon as it was recommended by the nurse practitioner because if it is possible for R199's catheter to be removed it will reduce the risk of him developing an infection. V3 stated whenever a catheter is in place it increases the risk of infection.

Based on observation, interview, and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to: 1) ensure a COVID-19 positive resident is not cohorted together in one room; 2) follow appropriate protective personal equipment (PPE) guidelines in the observation rooms for COVID-19 residents on contact and droplet precautions; and 3) failed to ensure that residents and their representatives are informed of the latest incidence of COVID-19 infections in the facility. This failure has a greater potential to affect R4 given his congregate nature, age, and underlying medical conditions. Findings include: 1. R1 is an [AGE] year old male with the following medical history: Seizure, Brain lesion, Malignant neoplasm metastatic to brain, Metastatic squamous cell carcinoma, Open wound of scalp with complication, subsequent encounter, Tonic clonic seizures, Anemia of chronic disease, Chronic indwelling Foley catheter, Subacute osteomyelitis, other site, Bacteremia due to Enterococcus, Acute respiratory failure with hypoxia, Deep vein thrombosis (DVT) of lower extremity, unspecified chronicity, unspecified laterality, unspecified vein. R1 is non-verbal and is not interviewable. R1 was sent to the hospital on 4/3/2023 because of witnessed seizure episode and returned to the facility on [DATE]. On 4/21/2023 at 11:30 AM, with V4 (Registered Nurse/RN), the door to R1's room was observed to be wide open, with a sign by the door stating, Contact and Droplet Precautions. Personal Protective Equipment was available outside R1's room. R1 was observed in bed, appears clean and orderly. No intravenous access observed. When asked if he has any concerns regarding his care while in the facility, R1 did not respond. It was also observed that R4 is in the same room as R1. When asked if R4 is also positive for COVID-19, V4 stated that R4 is not positive for COVID-19. R1's Physician Order Sheet with an order date of 4/17/2023 documents the following orders: Isolation Precaution Contact and Droplet - due to COVID + result. On 4/21/2023 at 11:55 AM, V4 (RN) stated, I am the regular nurse for R1 and R4. I don't think R4 knows that his roommate, R1 is positive for COVID-19. I didn't tell him that R1 is COVID positive. I think he should be transferred to a different room because the roommate is positive. Only R1 is positive for COVID. Because they are in the same room, R4 might get COVID from R1. When asked why he is in the same room as R1 when R1 has COVID-19 infection, V4 did not respond. On 4/21/2023 at 12:00 PM, interviewed R4 with V4 (RN). R4 had no mask on. R4 stated that facility has been testing him for COVID-19. R4 stated nobody informed him that his roommate tested positive for COVID-19, that nobody talked to him about being transferred to a different room and that he will not object to being transferred if needed because roommate tested positive for COVID. R4 stated nobody informed him about consequences of staying in the same room with somebody who has the COVID-19 infection. On 4/21/2023 at 3:00 PM, when asked if V1 talked to him about transferring to a different room on 4/17/2022, V4 stated, She came here to tell me she did, but I don't remember it. Nobody educated me regarding COVID-19. I go to dialysis; I cannot get sick from COVID. I don't think the dialysis center knows that I am with somebody who is positive for COVID. R4 is a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Anemia, unspecified, Atherosclerotic heart disease of native coronary artery without angina pectoris, Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, End stage renal disease, Orthostatic hypotension, Thrombocytopenia, unspecified, Chronic combined systolic and diastolic heart failure, Non-rheumatic aortic stenosis, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, Candidiasis, unspecified, Other symptoms and signs involving the musculoskeletal system, Mixed hyperlipidemia, Obstructive sleep apnea, Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation, Personal history of COVID-19, Major depressive disorder, single episode, unspecified, and Essential hypertension. R4's Minimum Data Set with Assessment Reference Date of 3/29/2023 under Section C: Brief Interview for Mental Status documents a score of 15 which affirms that R1 has no cognitive impairments. On 4/21/23 at 1:30 PM, V1 (Administrator) stated R4 will be tested again today, and we will convince him to transfer to a different room. Later on, V1 stated that R4 was tested , and the result was negative and that R4 agreed to be transferred and will be moved to a different room as soon as possible. On 4/21/2023 at 1:37 PM, V3 (Infection Preventionist) stated, We tested R1 for COVID-19 upon readmission on 4/10/2023 and the result was negative. Then R1 was tested again on 4/13/2023 and 4/15/23 and it was both negative also. On 4/17/23, R1 was coughing, so R1 got tested again and the result was positive. On 4/17/23, it was a rapid test and results were received the same day. It is our policy for readmits to be tested upon readmission, on the 3rd day and 5th day. Since 4/10/2023 until today, R1 has been in the same room with R4, who does not have the COVID infection. We did not move R4 to another room. We are monitoring him for symptoms. We tested R4 right after we tested R1 which was on 4/17/23 and 4/19/23 and both results were negative. We still did not transfer R4 to a different room knowing R1 is positive because R4 is already exposed, we didn't move him. When asked why R4 was not transferred to a different room since roommate R1, tested positive on 4/17/23, V3 stated that because R4 is very much set in his ways and will not allow them to transfer R4 to a different room. V3 stated that V3 did not document that she talked to R4 regarding transferring to a different room, and there is no documentation of educating R4 regarding dangers and consequences of being in the same room as R1 who tested positive on 4/17/2023. When asked what the dangers of cohorting 2 patients are when R1 is positive for COVID and the other one, R4 is not positive for COVID-19, V4 stated, There is a danger that the R4 can contract COVID-19 infection from R1 resident since they are in the same room. On 4/21/2023 at 12:50 PM, V1 (Administrator) stated, I talked to R4, and he said he didn't want a room change, but he didn't want to be changed. As far as documentation, there is nothing documented that I talked to him regarding being transferred to a different room. R4 is alert and oriented, but he tends to forget. I know that if it's not documented, it didn't happen, unfortunately we didn't document that we provided education to R4. Normally if we found out we talk to them multiple times. When asked how many times she spoke with R4 regarding room change, V1 stated she talked to him once. When asked if she documented somewhere in R4's medical records her conversation regarding education about COVID and need for room transfer, V1 stated, I didn't document it. On 4/21/2023 at 3:00 PM, V1 (Administrator) presents a Concern and Grievance Log that affirms that somebody from Social Services Department spoke to R4 regarding need for room change and that R4 refused. V4 (RN) also stated that R4 was tested , and his result came back negative for COVID-19 and that they convinced R4 to move to a different room and will be moved right away. Review of medical records affirm that R1 and R4 both have orders for Isolation Contact Precaution due to Colonized Candida auris, both were admitted with those infections. Only R1 tested positive for COVID-19. R4 tested negative on 4/17/23, 4/19/23 and 4/21/23. R4 was finally transferred to a different room on 4/21/2023. Facility presented a policy with original effective date of 3/05/20 titled Infection Control- Interim COVID-19 Policy under Management and Care of Residents with Suspected or Confirmed COVID-19 Infection which documents: If cohorting, only residents with the same respiratory pathogen should be housed in the same room. 2. On 4/21/2023 at 12:00 NN, while outside room of R1, while surveyor was putting on Personal Protective Equipment/PPE with V4 (RN), V5 (family member) entered room of R1 and R4 without donning PPE. V4 was with surveyor outside the room of R1. V4 did not stop and instruct wife of R1 to don PPE. V4 stated, she had already told earlier V5 to wear gown and gloves. When asked, why V4 did not stop V5 from entering room without wearing proper PPE, V4 did not respond.When asked if somebody told her about the use of PPE, V5 responded, No. I wasn't told. I don't know about that. V5 also stated that she is not aware of facility incidence of COVID-19 infections because nobody has informed V5 about the number of staff and residents who tested positive for COVID-19. Facility presented a policy with original effective date of 3/05/20 titled Infection Control- Interim COVID-19 Policy under Visitation of Residents in Transmission Based Precautions and During Outbreak which documents: For the safety of the visitor, in general, in-person visitation should be discouraged while the resident is in transmission-based precautions and during outbreak. However, the facility must still allow the visitations to occur while ensuring that the visitors are informed of the risks and measures to reduce risk of transmission as follows: Counsel residents and their visitor(s) about the risks of an in-person visit. Encourage use of alternative mechanisms for resident and visitor interactions such as video call applications on cellphones or tablets, when appropriate. Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched and use of PPE according to current facility policy. 3. On 4/21/2023 at 9:00 am, during entrance to the facility, a sign is posted in the front entrance door which states: Last Known Positive Resident COVID-19 Case: 3/28/2023. On 4/21/2023 at 2:18 PM in the presence of V1 (Administrator), V3 (Infection Preventionist) further stated, R1 was symptomatic on 4/17/23 that's why R1 was tested and readmitted . R1's result was positive on 4/17/2023. I did unit-based testing for staff and residents. Only residents in 1 East were tested , nobody tested positive. The residents and family members can look at the facility website to look for information regarding COVID-19 status updated. The residents are informed of COVID-19 updates via the postings in the entrance, elevator, day room, nurses' station, entrance, and exit doors. Surveyor informed her that the posting states that the last in-house positive case was on 3/28/23 but R1 tested positive on 4/17/2023. V3 stated, Up to this day, 4/21/2023, I have not confirmed if R1 is an in house COVID positive, that's why the posting did not get updated. When asked if R1 and R2 were provided education, V3 stated, When R1 tested positive, I educated him and the wife regarding the COVID-19 positive result. For R4, I wasn't able to educate R4 regarding COVID-19, its consequences of being in the same room with the resident who is positive. I asked help. V1 talked to R4. V1 (Administrator) provided the website where family members are updated regarding presence of COVID-19 in the facility: https://elevatecare.com/covid-19/. The website as of 4/21/23 lists Zero (0) under Current Positive In-House COVID Residents and Zero (0) under Current resident PUI. V1 stated that V3 already submitted the facility report to the corporate office who is in charge of updating the website. As of 4/21/23, there is one resident (R1) who is positive for COVID-19 infection Facility presented a policy with original effective date of 3/05/20 titled Infection Control- Interim COVID-19 Policy under Communication to Residents, Representatives and Families which documents: Inform residents, their representatives and families of those residing in the facilities by 5 pm the next calendar day following the occurrence of: - either a single confirmed infection of COVID-19, or - three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.

Based on observation, interview and record review the facility failed to ensure ongoing assessment and documentation of skin impairment. The facility failed to notify physician and obtain treatment order for change of skin condition. The facility failed to follow physician order for wound care. The facility provided treatment without physician order. The facility failed to update the wound/skin care plan for changes in skin condition. This deficiency affects 3 (R1, R3, R4) of 3 residents reviewed for skin/wound care management. Findings include: 1. On 4/4/23 at 10:28am, R1 said that she was admitted last year in June and developed a wound on her left thigh. She said that the nursing staff are applying cream to her thigh, but it's still sore. R1 said that she is allergic to zinc oxide cream. On 4/4/23 at 10:32am, surveyor observed R1 with V10 (Certified Nursing Assistant/CNA). R1's disposable adult brief was soiled with urine. No wound dressing was observed. R1 has moisture associated skin disorder (MASD), which was observed as increased dark pigmentation on colored skin on inner thighs and perineal and sacral area. V10 said that he changed R1 after breakfast around 8am. V10 said that he applied Vit A and D ointment after he provided incontinence care early this morning to her inner thigh and buttocks. V10 said that he also applied Zinc oxide cream. On 4/4/23 at 10:46am, V9 (Wound Care Nurse/WCN) and V11 (Wound Tech/CNA) came to R1's room. V9 said that R1 has on and off MASD. She has Vit A and D ointment and Zinc oxide ointment treatment for MASD. R1 refused zinc oxide cream. V10 (CNA) provided incontinence care to R1. R1 said that she is allergic to zinc oxide cream. She prefers that powder medication that that CNA applies that is in a small container. V9 said that medication is nystatin power. V9 said that R1's MASD is healed. Surveyor observed pinkish and white tissue from the MASD on inner thigh and sacral area. V9 applied Vit A and D ointment to inner thigh and sacral area then applied abdominal (ABD) pad in between inner thigh and sacral area. R1 complained of pain when V9 applied cream to her inner thigh and sacral area. On 4/4/23 at 11:00am, surveyor informed both V9 (WCN) and V10 (CNA) that R1 does not have ABD dressing in between inner thigh and sacral area. V9 said that she left ABD pad at bedside for the nurses to apply when dressing gets soiled. V10 said that he did not see ABD pad at bedside, but he informed the nurse that the dressing was soiled when he changed her early this morning. R1 was readmitted on [DATE] with diagnoses listed in part but not limited to acquired absence of left leg above the knee amputation, peripheral vascular disease, abnormal posture, congestive heart failure, colonized contact isolation. Most recent Braden scale/skin assessment dated [DATE] indicated at risk for skin impairment. No documentation of active skin impairment. Physician Order Sheet indicated Apply A &D ointment to right leg/foot daily and as needed for protection. Sacrum/buttocks/perineum: cleanse with peri wash cleanser or cleaning wipes apply moisture barrier cream (Zinc oxide cream) every shift and as needed. Wound treatment: coccyx/bilateral buttocks: cleanse with normal saline and apply Triad cream daily and as needed. Wound treatment left medial thigh: cleanse with peri wash cleanser or cleaning wipes apply moisture barrier cream (Zinc oxide cream) cover with ABD pad every shift and as needed. Wound treatment: Left medial thigh: cleanse with peri wash cleanser or cleaning wipes apply moisture barrier cream (Zinc oxide cream) cover with ABD pad every shift and as needed for wound. On 4/5/23 at 12:46pm, Review of R1's medical records was completed with V9 (WCN). Surveyor informed V9 that R1 does not have treatment order to apply Vit A &D to left inner thigh, perineum and sacral area, which she applied yesterday during wound care observation. R1 has order of Vit A & D to right leg/foot only. R1 has been refusing the zinc oxide cream ordered for left medial thigh, perineum and sacral area MASD because she said she has allergy on this medication, but she did not call the physician to have the treatment order changed. R1's physician treatment order and care plan has not been updated based on most recent wound assessment done on 2/9/23 indicated no active wounds. 2. On 4/4/23 at 1:48pm, surveyor observed R3 sitting in wheelchair in her room. R3 has O2 via nasal cannula (NC). She is alert and oriented x 3, able to verbalize needs to staff. V18 (CNA) and V19 (Resident Assistant) transferred R3 from wheelchair to bed. R3's disposable brief was soiled with urine and her pants were wet from urine. V18 said that R3 was changed around 11am. V18 said that R3 has Vit A and D ointment and Zinc oxide cream for her perineal and sacral rashes. V18 provided incontinence care to R3. Surveyor observed R3 with redness on abdominal folds, bilateral groin, peri area, inner thigh and sacral area. V9 said that R3 has fungal irritation redness on right posterior thigh (approximately 4cm x 6cm) and left posterior thigh (approximately 2cm x 3cm). V18 applied zinc oxide to all affected areas. V9 said that she mixed the Vit A and D ointment into the zinc oxide container and left it at bedside. R3 was admitted on [DATE] with diagnoses listed in part but not limited to acute and chronic respiratory failure with hypoxia and hypercapnia, congestive heart failure, chronic obstructive pulmonary disease, Type 2 diabetes mellitus, chronic kidney disease, najor depression. Physician Order Sheet indicated: Apply moisture barrier cream (Zinc oxide cream) to buttocks/peri area/groin every shift and as needed for wound/protection. Nystatin powder apply to buttocks/skin folds topically two times a day and as needed for rashes. Apply nystatin cream to abdominal folds/groin topically every day and evening shift and as needed for wound/rash. Most recent Braden scale/skin assessment dated [DATE] indicated R1 is at moderate risk for skin impairment. Most recent wound assessment done on 3/31/23 indicated MASD closed, intact skin. On 4/5/23 at 12:46pm, surveyor reviewed R3's medical records with V9 (WCN). Surveyor informed V9 that there is no order for Vit A & D ointment that she mixed with Zinc Oxide cream container and applied to redness on abdominal folds, groins, peri area, inner thigh, sacral area, fungal irritation redness on bilateral posterior thigh. Nystatin power and cream was not applied as ordered during wound care. Surveyor informed V9 of duplication order of nystatin cream and powder on the same site. No treatment order for the fungal irritation redness on bilateral posterior thigh. R3's last wound documentation dated 3/31/23 indicated that her MASD is closed with intact skin. Wound/Skin care plan is not updated. No documentation of observation of redness and fungal irritation as indicated above. V9 said that she just came from vacation on 4/3/23. V9 observed R3's redness on abdominal folds, groin area, peri area, inner thigh, sacral area, fungal irritation on bilateral posterior thigh on 4/3/23 but she did not document the observation in wound report. She was not aware that V24 (Wound Care Nurse) closed/healed the MASD last 3/31/23. She did not read the wound report prior to performing wound care. V9 said that she should update the wound report, call the physician and family for changes in skin condition and update the care plan. 3. On 4/4/23 at 2:06 pm, Surveyor observed R4 lying in bed. He was alert and oriented x 3, speaks Spanish fluently but able to express himself in English language. V20 (CNA) and V21 (CNA) assisted R4 to side lying position and opened the disposable brief. R4's brief was observed as dry. Surveyor observed redness on scrotal, groin area and sacral area. Sacrum dressing was intact. V20 wiped with wet wash cloth the scrotal and groin area, obtained fecal matter. V20 obtained fecal matter when cleansing sacral/rectal area. V9 (WCN) took opened and used container of zinc oxide cream from the treatment cart and placed it in R4's drawer. She mixed Vit A and D ointment and zinc oxide cream in plastic medicine cup and applied to R4's scrotum, groin area and sacral area. Right surgical hip incision was observed healed, no dressing. R4 was admitted on [DATE] with diagnoses listed in part but not limited to wedge compression fracture of T5-T6 vertebrae, displaced fracture of fifth metatarsal bone right foot, fracture of part of the neck right femur, history of falling, hypotension, dizziness and giddiness, major depressive disorder, chronic embolism and thrombosis, severe protein calorie malnutrition, diabetes mellitus with ketoacidosis, acute kidney failure, infection and inflammatory reaction due to internal right hip prosthesis. Physician Order Sheet indicated: Apply A &D ointment to Bilateral Lower Extremities (BLE)/feet daily and as needed. Perineum/buttocks: cleanse with soap and water pat to dry apply moisture barrier cream every shift and as needed for MASD/protection. Wound treatment: right thigh and right hip - cleanse with Normal Saline (NS) apply dry dressing daily and as needed for wound. Wound treatment: Sacrum - cleanse with NS apply Medi honey and alginate cover with bordered gauze daily and as needed for wound. Braden scale/skin assessment dated [DATE] indicated R4 is at moderate risk for skin impairment. Most recent wound assessment done on 4/3/23 indicated: Surgical incision on right thigh and right trochanter hip, skin intact. Sacrum unstageable pressure ulcer and MASD on buttocks and perineal area - denuded, 100% non-granulating tissue. On 4/5/23 at 12:46pm, Surveyor reviewed R4's medical records with V9 (WCN). Surveyor informed V9 that there is no order of zinc oxide cream for R4 that she applied. No right hip/thigh dressing was observed during wound care on 4/4/23. Most recent wound assessment done on 4/3/23 indicated surgical incision on right hip and thigh is healed, skin intact. Wound treatment and care plan are not updated. Facility Pressure Injury and Skin Condition Assessment policy documents: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. 3. A wound assessment will be initiated and documented in the resident chart when pressure and or other ulcers are identified by licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 5. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. 17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. 18. Physician ordered treatments shall be initiated by the staff on the electronic treatment administration record after each administration. Other nursing measures not involving medication shall be documented in weekly.

Based on observation, interview and record review the facility failed to follow its policy in promoting resident's ability to maintain or regain the highest degree of independence and failed to assess and evaluate resident following physical therapy referral to Restorative Nursing. The facility also failed to evaluate and update care plan. This deficiency affects one (R1) of three residents reviewed for Restorative Program. Findings include: R1 was admitted on [DATE] with diagnoses listed in part but not limited to acquired absence of left leg above the knee amputation, peripheral vascular disease, abnormal posture, congestive heart failure, colonized contact isolation. Minimum Data Set (MDS) quarterly assessment dated [DATE] Section G Functional status indicated: Bed mobility and dressing needs extensive assistance with 1 person assist. Functional limitation in Range of Motion (ROM): Impairment to lower extremity on 1 side. Mobility devices: none use. Most recent Restorative assessment done on 1/9/23 indicated that she is on ROM and Dressing program. Care plan indicated she is on Restorative program for Active Assisted Range of Motion (AAROM)/Active Range of Motion (AROM) to all extremities and Dressing. She was discharged from skilled Physical Therapy (PT) on 2/17/23 with referral to Restorative nursing. Care plan was not updated with therapy recommendation upon discharge. Restorative program log indicated that she is on bed mobility and ROM program. On 4/4/23 at 10:28am, Surveyor observed R1 lying in bed. She was alert and oriented x3, able to verbalize needs to staff. Her left leg prosthesis was at bedside. She has left above the knee amputation. R1 said that she like to use her prosthesis on her left leg. She said that neither the therapist nor nursing has not put her leg prosthesis on in the last 2 months because of her wound on her left thigh stump but it was healed recently. She was discharged from PT because her insurance will not cover her therapy, and she has to pay privately. On 4/4/23 at 11:06am, V7 (Therapy Director) said that R1 has Medicaid insurance and was allowed to receive 6 visits per therapy discipline. R1 was discharged last [DATE]. V7 said that R1 has not used her left leg prosthesis due to her non-compliant with the stump shrinker/stocking. R1 refused to use it due to the wound on the bottom of her left AKA (above the kneed amputation). V7 said that R2 was referred to Restorative program after discharged to therapy. On 4/5/23 at 12:08pm, surveyor review R1's therapy records with V7 (Therapy Director). R1's PT evaluation and plan of treatment dated 2/6/23 to 3/18/23 indicated: Referral for PT services for L (left) prosthetic management. Moderate complexities. Weakness of trunk and BLE (Bilateral Lower Extremities) musculatures, decreased sitting balance, difficulty with bed mobility and remained at total assist with transfers. R1's discharge summary therapy notes dated 2/17/23 indicated: Date of service from 2/6/23 to 2/17/23. Patient reached maximum potential with skilled services. Recommend continuing with facility restorative program upon discharge from skilled PT services. Restorative ROM program. AAROM on RLE and L hip muscle group x 10 reps x 2 sets in all planes. R1's therapy to nursing recommendations dated 2/17/23 indicated: Restorative recommendation: AROM- AAROM RLE (Right Lower Extremity) and AROM L hip, Bed mobility, L hip shrinker (stump shrinker) donning daily with skin inspection every shift. Provide upright sitting on Geri chair/wheelchair as tolerated. V7 said that that R1 has PT eval on 2/6/23. PT services were provided on 2/8, 2/9, 2/10, 2/14 and 2/15. R1 was discharged from therapy on 2/17/23. V7 said that they don't have documentation on that R1 is noncompliance with application of left thigh stump shrinker/stocking. R1 care plan did not indicate that she is noncompliant with application of left thigh stump shrinker/stocking for the left prosthesis to be applied. On 4/4/23 at 2:30pm, V22 (Restorative Nurse) said that they don't do a restorative assessment when therapy department referred resident for restorative program. They just follow their recommendation. They only do restorative assessment upon admission, quarterly, annually and when there is significant change of condition. Surveyor reviewed R1's medical record with V22. R1 was readmitted on [DATE]. Most recent quarterly assessment dated [DATE] indicated that R1 is on dressing program and ROM to all extremities. Therapy referred R1 for restorative program on 2/17/23 for AROM (AAROM RLE and AROM L hip), bed mobility and L hip shrinker/stump shrinker - donning daily with skin inspection. Promote upright sitting on Geri chair/wheelchair as tolerated. No Restorative assessment/evaluation was done. V22 said that V18 (Restorative Nurse) changed the restorative program per therapy recommendation on 3/21/23 without evaluation or documentation. Care plan was also not updated. There was no documentation in care plan which documented R1's noncompliance with application of left thigh stump shrinker/stocking. They only adapted AROM and bed mobility but not the L hip shrinker/stump stocking application. V22 said they should do an assessment/evaluation when therapy referred resident to restorative program and update the care plan. On 4/5/23 at 3:30pm surveyor informed V1 (Administrator) and V4 (Infection Coordinator) of above concern. Facility Restorative Nursing Program documents: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Guidelines: Appropriateness for a restorative program will be determined by the interdisciplinary team as needed and or may be determined as a continuation of care following a course of physical, occupational and or speech therapy. Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Each resident's progress will be evaluated periodically by the licensed nurse. The restorative nurse will review the restorative program at least quarterly or as needed for appropriateness of that individual plan and will document a note on the appropriate form. This form includes the program goals, interventions, patient tolerance and any recommended changes to the plan.

Based on interview and record review, the facility failed to ensure continuity of care and services for a resident who required weekly electroconvulsive therapy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Facility Abuse prevention and reporting policy reviewed 1/27/19 Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has had multiple hospitalization s since admission to the facility. Census includes hospitalization s on 6/27 - 6/30/22, 7/20 - 7/21/22, 7/25 - 8/5, and was most recently transferred on 8/25/22. At the time of the survey, R1 was still hospitalized and reviewed as a closed record. Facility admission packet for R1 includes documentation that R1 entered the facility with a pressure ulcer wound on the sacrum and is being treated with Medi-honey. The nursing report form documents, started 5/3 - ECT/need to cont/set-up therapy. Plan - neuro ECT .[MEDICATION(S)] 1mg Q (every) 6 (hours) duration TBD .Stable on ECT decrease to 3x week (5/23, 5/25, 5/27) then 2x week (5/31 & 6/2) then weekly .slow taper ECT to minimize risk of autonomic dysfunction. Nurse Progress Note dated 8/25/2022 13:00 reads: Note Text: The resident was safely transferred from bed to stretcher by two person assist with stable vital signs BP- 117/60, T-98, PR- 113, RR- 22, O2 Saturation 95%. [MEDICATION(S)] Tablet 1 MG given and was suctioned for secretions. Picked up by ambulance for Neuro Appt 8/25/22 at 1:30 PM. Nurse Progress Note dated 8/25/2022 15:47 reads: Note Text: (Ambulance Representative) called this writer and informed that the office of appointment (Neurology Dept. in hospital) held the resident for observation and said to this writer to call the office # for further details. NP notified. Family made aware. Surveyor noted the following documentation from hospital records (requested by surveyor): Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Formulation: (R1) is a 30 y.o. single, domiciled AA male with anti-NMDA R encephalitis c/o seizures and catatonia presenting from clinic on 8/25/22 with worsened mental status. LTACH (facility) stopped [MEDICATION(S)] and ECT for unclear reasons. Primary restarted [MEDICATION(S)] 1mg Q4H. Psych consulted for treatment recommendations, specifically on whether restarting ECT would be appropriate. (R1) is experiencing a relapse in malignant catatonia (a life-threatening form of acute brain dysfunction that has several motoric manifestations) s/t anti-NMDA Receptor [CONDITION(S)], likely triggered by discontinuation of scheduled [MEDICATION(S)] and potential ECT outpatient in the context of his [CONDITION(S)] disease. Give pt's limited response to [MEDICATION(S)] alone, hx of malignant catatonia is a medical emergency. Further recommend continuing scheduled [MEDICATION(S)] 1mg q4hrs for catatonia with max daily dosing of 15mg/day given impaired kidney functioning. We will reach out to ECT to get pt scheduled tomorrow as able. Will discuss these recommendations with pt's family, mother. Plan: -Recommend emergency daily ECT given catatonia, not responding to restarting scheduled [MEDICATION(S)] . Barriers to Discharge .Per discussion in IDR, psychiatry consulted for recommendations as medical team states pt's presentation may require ECT. Team states that pt admitted from SNF and was found to have scabies, with concerns for possible neglect on the part of the SNF .SW discussed with Neuro Critical Care Team (including physician and bedside nurse). SW informed that pt has scabies, a stage four pressure injury, and medical team was made aware that pt has not been receiving recommend [MEDICATION(S)] dose or ECT. SW informed that lack of recommended [MEDICATION(S)] and ECT likely contributed to this admission and severity of pt's current condition . R1 had orders to receive ECT (electroconvulsive therapy) weekly as confirmed from facility medical record since admission. Nursing progress notes document the following ECT appointment related information: 6/9/22 - R1 left for ECT appointment but it was not done because he was not NPO; this appointment was rescheduled for 6/10/22 6/10/22 - R1 left for ECT approximately 6:22am and returned at approximately 1pm 6/16/22 - R1 left for ECT approximately 6am and returned at approximately 1pm 6/23/22 - R1 left for ECT approximately 5:30am and returned at approximately 11:29am 6/30/22 - R1 was scheduled for ECT but did not attend due to hospitalization 7/7/22 - R1 left for ECT approximately 5:30am 7/14/22 - R1 left for ECT approximately 5am 7/25/22 - R1 was hospitalized thru 8/5/22 After re-admission from hospital stay, on 8/9/22 14:26 Admission Note, written by V5 (Internist), under A&P includes to continue weekly ECT. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with V2 (RN/Infection Preventionist) on 9/3/22 at 2:05pm regarding ECT appointments for R1. V2 said that R1 goes to ECT once a week in the city. He is transported via ambulance, and it can take hours with the traffic, etc. For example, he can leave here at like 7/8am or can return as late as 1/2pm. At times we have worried that he is being admitted because it's been 5 or 6 hours before he returns. He had orders for ECT upon admission but then it was paused for some time because the doctor wanted him to stop going for a while - in that time he wanted him to have a neurology consult because there was a change in his cognition. We tried to find a closer place to get the ECT because the transportation alone was rough for him because it was so far. He did go to the neurology consult and that is when they made the decision to admit him. Facility was asked to provide confirmation that physician made decision to pause R1's ECT per interview with V2 and it was not provided during the course of this survey. Facility provided documentation that R1 went out on an appointment on 8/12/22 - email confirmation from receptionist, however, lists RE: multiple [CONDITION(S)]. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No information was provided during the course of the survey to show that resident continued to receive weekly ECT any time after re-admission on 8/5/22.

Based on interviews and record reviews, the facility failed to follow fall prevention interventions to include having the bed in the lowest position while in the bed to prevent or reduce the risk of falling. This deficient practice affects one resident (R4) of three residents reviewed for fall prevention protocols. R4 rolled off the bed, and the bed was not in the lowest position. R4 sustained fractures of the medial aspect of left superior and inferior rami (pelvic) and possible fracture of the right superior pubic ramus (bones at the end of the trunk-between the spine and the legs). Findings Include: Reviewed facility reported incident to SA (State Agency) dated 5/15/22 and with description of occurrence that CNA reported that during routine morning rounds, CNA heard a loud thud coming from R4's room. CNA observed R4 on a landing mat, left side lying position and with complaint of left hip pain. Final report summary reads in part: R4 had an unwitnessed mechanical fall sustaining a fracture of the medial aspect of left superior and inferior rami and possible fracture of the right superior pubis ramus (pelvic fractures). Interviewed CNA and assigned nurse. R4 repositioned self to bed towards the left side of the bed with low airloss mattress causing imbalance. Resident during the time scooted to the left side of the bed and slid off the edge causing a thud that the CNA heard. On 7/1/22 at 12:55pm, V6 (CNA) stated that V6 was assigned that day with R4. V6 stated that the last time V6 saw R4 was after V6 assisted R4 with breakfast, V6 fed R4 in bed. V6 reported that V6 left R4 in bed with head of bed slightly elevated. V6 did not position R4's bed in lowest position. V6 reported that the bed level was at the height above V6's knee and below V6's hip. V6 stated that it was V6's forgetfulness part that V6 did not lower the bed to the lowest position. V6 reported that V6 left R4's room to assist other residents in the unit with eating. V6 stated that he returned approximately 830am to 9am to provide R4's morning care. V6 stated that V6 went straight to R4's bathroom to put water in the basin. V6 reported that upon entering the room of R4, V6 observed R4's bed not in lowest position, R4 on his left side with wedge on R4's back. V6 reported that R4's positioned in bed was close to the edge on the left side of the bed. V6 stated that V6 did not reposition R4 at that moment because V6 was about to provide the morning care. V6 decided to go and get the water first, and that was when V6 heard a loud thud. V6 checked on R4, R4 was on the floor in left side lying position with complaints of pain. V6 reported this to the nurse on duty. On 7/5/22 at 12:45pm, V12 (RN) stated I entered the room. In the room were V6, the roommate and R4. I observed R4 on the floor on the landing mat on the left side of the bed. R4 was on a left side lying position, kind of leaning almost. R4's legs both extended and able to move lower extremities per baseline but with pain. We assisted R4 back to bed using a mechanical lift. Pain medication was given prior to transferring back to bed. This fall incident happened approximately 830 or 900am. I observed the bed was in lowest position. V6 reported to me that V6 was about to give hygiene care to R4 and V6 pulled the wedge out, V6 then went to the bathroom to get water and left R4 in bed, no other staff present at that time. V6 heard a thud, V6 went and checked on R4, V6 then noted that R4 was on the floor on landing mat. On 7/6/22 at 11: 35am, V2 (Director of Nursing) stated Nurse reported that R4 was observed on the landing mat in a side lying position, on left side. X-ray was ordered and R4 had superior and inferior ramus fracture. I reported this incident to the state the same day when the fractures were discovered. In my investigation, what stood out during my investigation was that staff reported that earlier in the day, R4 was more alert than usual, saying I want to go home. CNAs reported that they observed R4 at times reaching over and try to get out of bed and they redirected R4 when needed. I interviewed V6. V6 reported to me that V6 was about to do routine care to R4, was about to wash R4's face. V6 removed the wedge off R4's back to off load and V6 then proceeded to go to the bathroom to run the warm water, and according to V6 that was when R4 tried to get out of bed. V6 assumed R4 tried to get out of bed, because there is no other explanation why R4 rolled out of bed. Bed not in lowest position but in mid position, not in the highest position either. Bed does not need to be in the lowest position because R4 was not high fall risk because R4 had not fallen for over a year. R4 is dependent in bed mobility. R4 had [CONDITION(S)] with right sided weakness. Low airloss mattress was in used. Alternating pressure of the low airloss mattress, and by R4 reaching over, it could have displaced R4's weight and caused the mattress to displaced her in bed and that night have caused R4 to rolled off the bed. In general, if a resident needs repositioning, my expectation is for my staff to provide the repositioning and/or ask for assistance if the task requires two person assist with bed mobility. It is for resident's safety and comfort also. R4's records reviewed. Fall Risk assessment dated [DATE] (pre-incident) shows that R4 is at risk for falls. Another Fall Risk Assessment was also completed post fall incident dated 5/15/22 and shows R4 is at risk for falls. R4's Care plan reviewed. Fall intervention with a created date of 11/18/21 reads: Provide two-person physical assistance in areas of mobility and transfer. Another fall intervention with a created date of 5/10/21 reads: Provide R4 with wedge to help with repositioning and to help prevent R4 from rolling out of bed. These two interventions were created before the unwitnessed fall on 5/15/22. MDS (Minimum Date Set), Section G dated 4/15/22 (Assessment pre-fall of 5/15/22) shows that in bed mobility, R4 was total dependent and requires a two-person assist. X-ray result dated 5/15/22 reads: Impression likely acute bilateral superior and inferior pubic rami fractures. Fall Prevention Program, with a revision date of 11/21/17 reads in part: To Assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: use and implementation of professional standards of practice, communication with direct staff members, interventions are changed with each fall, as appropriate, preventative measure. In addition to use of Standard Fall Precautions, the following interventions maybe implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in safe position. The frequency of safety monitoring will be determined by the resident's risk factor and plan of care.

Based on interview and record review, the facility failed to protect a resident from abuse and neglect by leaving a resident, dependent on staff for care, lying on a bed pan for an undetermined amount of time. This failure resulted in an alteration in skin integrity and scarring of skin tissue. This failure affected 1 of 3 residents (R1) reviewed for abuse and neglect. Findings include: R1 is a [AGE] year old alert and oriented resident admitted to the facility with [DIAGNOSES REDACTED]. Skin condition form dated 10/12/19 written by V8 (Wound nurse) shows, Abrasion r/t (related to) fall. Lower back to gluteal folds-circular shape skin alteration, Trauma related to bedpan. [DATE]20 at 11:30 am interview with V8 (Wound Nurse) stated, I remember her. (R1) is a [MEDICAL TREATMENT] patient and compromised and high risk for skin breakdown. Surveyor asked what he meant by compromised, V8 stated, (R1) is very compromised as she came in with a wound. I worked in the morning and it was reported to me and I went and checked. It's(skin alteration) from the bed pan and a circular formation from the bed pan. There was a partial loss of skin and because her skin was compromised, her skin was swollen and she had that mark on the dermis (surface) of the skin. I did not take a picture of it that day. I talked to the husband who told me (R1) called for a bed pan, she's very alert. Surveyor asked if R1 used the call light, V8 stated, Yes but the nurse and staff needs to follow up too, and once you do something you have to follow up. When I came back to work, R1 was sent back to the hospital so I couldn't see her wound again. Nursing notes written by V10 (LPN-Licensed Practical Nurse) on 10/14/2019 at 12:24 pm states, Per nurse to check resident regarding the sacrum and right knee. The knee has been noted, but there was serous drainage, notice there is [MEDICAL CONDITION] of both legs and right hand. Husband was present when doing the wounds. There are notes on the wounds. There is outlining around the buttocks area of the bedpan. 2/10/20 at 10:40 am interview with R1, It was in the middle of the night and I needed to go to the bathroom so I asked my nurse (certified nurses aide) for help and she put the bed pan under me while I was in bed. Surveyor asked when this happened, R1 stated, I think it was close to the start of the shift so maybe around 12 or 12:30 (a.m.). I think I fell asleep because it was already light out when I woke up and I was still on the bedpan and nobody bothered even checking on me. I remember waking up cold because I didn't have a blanket over me so they should've seen that. Surveyor asked if she used the call light to call anyone, R1 stated, I did use the call light and I was crying out for someone to help and no one even came by and I must have fallen back to sleep because of the pain on my butt and I was tired of waiting, but it wasn't till the morning when a different nurse finally came to take the bed pan away. I told my husband all this and I have this huge permanent mark on my butt and they didn't even care. I don't like it there so my husband looked for another place for me. 2/10/20 at 12:20 pm interview with V4 (Assistant Director of Nurses) states, There was an incident one weekend where the resident had a skin alteration due to a bed pan that was left behind towards from night shift to morning shift. Surveyor asked V4 to clarify about the skin, V4 stated, A skin alteration because of the bedpan. The c.n.a put her (R1) on the bedpan during her shift and in the morning c.n.a found it under the resident. The nursing supervisor did an investigation but I can't recall what happened. The c.n.a the following day did not show up and was termed. The skin alteration left a mark on the resident's skin. It was an abrasion. V8 (wound nurse) did the assessment and treated the skin alteration. Surveyor asked if incident was reported to public health, V4 stated, I do not know if this was reported. I am not sure if this is reportable. Surveyor asked if she considered this incident a form of abuse, V4 stated, This would be considered an abuse. I don't know where R1 is now. We sent her (R1) out to the hospital but for a different medical issue. V8 told me the c.n.a forgot to take out the bed pan and caused a mark on her buttocks. I felt that it was an unfortunate incident. We should have investigated it more because it left a mark on the back of the resident. 2/10/20 at 12:30 pm interview with V2 (Director of Nursing) states, We didn't do any investigation because the c.n.a (V13) forgot the bed pan but R1 should have used her call light. She is alert and oriented and didn't call anyone. Surveyor asked V2 whether nursing had a responsibility to check in on R1, V2 stated, Yes you're right, someone should have checked in on her. Surveyor asked about the absence of any investigation, V2 stated, We only report injuries of unknown origin so we didn't do one. Surveyor asked if he saw R1's injuries to her buttocks, V2 stated, No, I was informed of them by the wound care nurse. Surveyor asked if he knew how long R1 was laying on top of the bed pan, V2 stated, I don't think it was long. Surveyor asked V2 how this timeframe was determined since there was no investigation conducted, V2 stated, Yes you're right, I don't really know how long she was on that bed pan. 2/11/2020 at 10:36 AM interview with V7 (Human Resources Director) states, I do the hiring of all staff. I don't do the interviewing but the background checks and putting them through the system. They are interviewed by the nurse managers including the director of nurses. Once interviewed and determined for hire I start to do background checks which include IDPH and sex offender websites. I reach out to references and if ok, they are offered the position. Once all background checks are accomplished, they can start as soon as the employee is ready. V13(c.n.a.) personnel file was provided to surveyor. V13's personnel file showed differing names and date of birth not matching the actual person hired. Surveyor showed V7 (human resource director) this discrepancy and V7 stated, This has never happened before. I do see her date of birth and names don't match. I just assumed she used her nickname. Surveyor asked V7 about the date of birth on the application and date of birth on the background checks, V7 stated, Yes, they are different dates of birth. Asked if all of V13's training materials would be included in the file, V7 stated, Yes, they are all in one file. Review of V13's personnel record show no abuse prohibition training. Surveyor asked about the training, I think they are trained by the nursing department when they go on the floors. 2/11/2020 at 11:00 AM, V4 (nurse supervisor) was asked if her cna's were given abuse prohibition training prior to working the floors, V4 stated, No they don't do that anymore. They do annual competencies but not any training before going on the floors to work. V1 (administrator) present in the room stated, The newly hired cna goes around with someone but we don't test them about abuse. 2/11/20 at 1:30 PM V13 (cna-certified nurses aide) stated, Yes I worked there but I didn't like it because they didn't pay enough. Surveyor asked if she remembered R1, V13 stated, I don't remember her. Asked about abuse prohibition training she received from the facility V13 stated, I didn't get any abuse training. I was put on the floor right away when I got hired. I remember getting a bunch of papers and I signed it but I didn't get a test or anything. I worked right away and that was it. 2/11/20 at 3:35 pm interview with V14 (Weekend supervisor), stated, The incident was reported to me when I did my rounds on the weekend in the beginning of the shift. I was the weekend supervisor and I was told there was a bed pan and the nurse did an assessment. I looked at it (wound) and there was discoloration. It was somewhat red and there was redness in sacral area. There is injury to the site and it looked like a bed pan. The part of the skin that was indented was red. I asked the morning c.n.a what happened but she didn't know how long she was on the bed pan because I couldn't talk to the previous c.n.a. She could have been on it long but I can't answer that. Surveyor asked if she knew the c.n.a that took care of R1, V14 stated, No, she (V13) wasn't here long. [DATE] at 2:50 PM V12 (Physician) stated, I saw markings on her (R1) behind. The husband and nursing staff informed me that it came from her previous nursing home where she was left on the bed pan by staff. Surveyor asked if the injury was permanent, V12 stated, If this happened last October than yes there is still markings of that injury. There is scarring but in time perhaps it will fade but there's definite scarring if that's what you're asking because you can still see the outline of the bed pan she was left on to this day. Policy and procedures dated 1/16/19 titled Abuse Prevention Program and Reporting states in part but not limited to, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: a. Concern Identification and follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's grievance procedures. At least annually, an interdepartmental team will both tour the facility assessing the safety of the facility environment, and review both accident reports and concern identification reports to identify any physical features that should be modified for greater resident and staff safety and protection. As part of the resident social history evaluation and MDS assessments, staff will identify residents within increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems. The facility will not knowingly employ any individual convicted of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property listed on the Illinois Health Care Registry. This facility will not knowingly hire any staff with a disciplinary action in effect against their license by a state licensing body that results from a finding of abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Prior to a new employee starting a work schedule, this facility will: Initiate a reference check from previous employers, in accordance with facility policy; Obtain a copy of the state license of any individual being hired for a position requiring a professional license; Check the Illinois Health Care Worker Registry on any individual being hired for prior reports of abuse, neglect, or misappropriation of resident property, previous fingerprint check results, and the sex offender Website links on the Registry; and Initiate an Illinois State Police live scan fingerprint check for any unlicensed individual being hired without a previous fingerprint check.