Every finding on record at Elevate Care Waukegan

Based on observation, interview, and record review, the facility failed to ensure linens and personal clothing were laundered and available to residents in a timely manner. This applies to 4 of 4 residents (R2-R5) reviewed for homelike environment in the sample of 5. The findings include: On 7/22/26 at 9:33 AM, two linen carts on the 2nd floor did not have washcloths, towels, or quilted under pads. There was no linen supply in the supply closet on the 2nd floor. At 9:57 AM, the linen carts located on the 3rd floor also did not have linens available including wash cloths, towels, quilted under pads and flats sheets. At 10:12 AM, the soiled laundry room located in the basement had a heaping mound of soiled laundry. The linen supply room located in the basement was bare. There were no bath towels, washcloths, flat sheets, and under pads available. A handful of pillowcases, a couple dozen gowns and several bath blankets were available. V9 (Laundry Aide) and V10 (Housekeeping) were folding clean linens in the laundry room. The laundry room was equipped with three washing machines and three dryers. V8 (Certified Nursing Assistant/CNA) came to laundry room looking for clean clothing for R4 and R5. R4 and R5's laundry was not clean. On 7/22/26 at 9:35 AM, V4 (CNA) said linens are not always clean or available for the residents. She said it's mostly washcloths and towels they run out of. We've reported to the supervisor about the linen shortage, but nothing has changed. On 7/22/26 at 9:43 AM, R2 was in his room sitting in his wheelchair. He was wearing a shirt with visible spots of debris. R2 said the facility runs out of linens. He takes his laundry downstairs. They don't have enough people to wash clothing. He's been waiting a week for his clothing to be laundered. When they are staffed, it comes back quicker; there is only one person doing laundry. Sometimes they have other staff in a different department to help. R2 said he is running out of clean clothes to wear. On 7/22/26 at 9:52 AM, V5 (CNA) said there is a lack of linens including under pads, washcloths and towels. She said she went downstairs to laundry room two times this morning for linens. There was only one person doing laundry and sometimes there is no staff doing laundry. She grabs what linens are clean and makes several trips to laundry room to get linens. V5 said it's taking a long time for residents' clothing to be laundered. It used to take a couple days for the residents' clothes to laundered now it takes a couple of weeks. On 7/22/26 at 9:52 AM, V6 (CNA) said there is a shortage of linens including washcloths and under pads. V6 said laundry used to bring up the linen carts to floor. The CNAs go downstairs at the start of their shift and fill up their own linen cart. It's a race to get downstairs to get linens. On 7/22/26 at 10:08 AM, V7 (CNA) was changing linen in a resident's room. V7 said he is using a bath blanket and a fitted sheet because there were no clean flat sheets or under pads when he went to laundry to get linens this morning. V7 said laundry used to bring up the linens to each floor; now they have to go downstairs and get their linens. We improvise using what we have. On 7/22/26 at 10:16 AM, V9 (Laundry Aide) said there are supposed to be two laundry staff for 1st and 2nd shift and no staff on night shift. V9 said she is sorting, washing, and folding. I need more help. Two staff are not scheduled for day shift. One of the washing machines was not working; it had been repaired a couple of times but it's not working properly. The machine can only wash a small size load. V9 has notified her supervisor to purchase more linens. Some of the staff throw linens away and they don't have enough linens. They know about the linen shortage, and they say they are going to order more. The staff are using pillowcases instead of washcloths to clean residents due to linen shortage. V9 said during the day shift she can only wash ten personal laundry loads because the other two washing machines are used for linens. On 7/22/26 at 10:27 AM, V8 (CNA) said she is looking for R4 and R5's personal laundry. R4 is out of clean clothes to wear. V8 said residents are waiting too long for their clothes to be laundered, several residents complained about their laundry not being done. On 7/22/26 at 10:23 AM, V3 (Maintenance/Housekeeping Director) said, We have linens, I don't know where all the linens are. I can't tell you what happened. The linen supply closet should be stocked with a couple of dozen of each item. V3 said one of the laundry aides went on leave and they have been trying to fill the gap with other staff from different departments. He said some of the staff and residents are hoarding the linens, throwing them away and not sending down the linens to be laundered. V3 said on 7/18/26, the laundry aide called off and there were no laundry staff on day shift. It was a mess. V3 said they used to have the linens sent out to be laundered and only laundered residents' personal clothing at the facility. That has changed and they do all the laundry in-house. V3 said there has been resident complaints about the turnaround time of personal laundry being returned; it should be laundered within a week. V3 said he has communicated the staffing concerns and linen supply with V1 (Administrator) and are waiting for corporate approval. On 7/22/26 at 11:05 AM, R3 was not in his room, his laundry bag could not be located in his room. V4 (CNA) said R3 has complained about his laundry not being returned. On 7/22/26 at 12:48 AM, V1 (Administrator) confirmed some staffing issues related to housekeeping and said they are trying to fill the staffing holes with assistance from other departments. Some of the staff and residents hoard the linens. R3's Concern Form, dated 7/13/26, shows a concern regarding his laundry not being returned. I send my clothes to get washed two weeks ago. They're not back yet, by now they probably have mold on the pile.The pile is getting bigger down there.On 7/22/26 at 1:50 PM, V1 said she is aware of R3's concern. Some of his clothing was returned but he is still waiting for the rest of his clothes to be laundered. The Resident Council Minutes, dated July 15, 2026, shows concerns regarding Laundry. Residents said their clothes have been in the laundry for two weeks.Administration has meet with [V3] regarding the shortage of staff.Residents voiced concerns of reporting concerns with no resolution. The Resident Council Minutes dated June 16, 2026, shows laundry concerns. Residents are waiting for their clothes to be laundered. The facility did not have a policy regarding linen supply or resident laundered services.

Based on observation, interview, and record review, the facility left R1 eating alone in the bedroom with a small plastic spoon to eat providing no supervision, cuing, or touch assist for 1 of 13 residents (R1) reviewed for Activities of Daily Living in the sample of 13.The findings include:R1's Minimum Data Set (MDS) shows supervision for eating. R1 may need cueing during the meals. R1's MDS, dated [DATE], shows, Eating: 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. On 04/22/2026 at 12:46PM, R1 was sitting at the overbed table alone in the room, in a wheelchair with the noon meal. R1 was using a small, child sized, plastic spoon. R1 gripped the tiny handle of the plastic spoon with a loose fist. When R1 scooped the food with the spoon, the spoon flexed towards gravity and the food fell off the spoon. R1 did not notice the food falling off the spoon. R1 attempted to take the bite off the spoon. This continued with every other bite, two bites in a row, up to five bites in a row; the food would fall off, R1 expressed frustration. R1 ate 50% of the noon meal. On 04/22/2026 at 12:46PM, R1 stated, I am losing my vision. It is getting hard for me to see. I do not like using the plastic (flatware), what can you do? This is what they give me. I am not able to straighten my fingers out. On 04/22/2026 at 1253PM, V5, LPN-Licensed Practical Nurse, said, We do not have any metal spoons. We only use plastic ones. I do not know why they use plastic. On 04/21/2026 at 1:15PM, V6, Dietary Manager, said, The kitchen will use plastic when there is not enough metal flatware. Resident Council Minutes, dated 02/18/26, documents, Dietary: two residents complained about receiving plastic ware.

Based on interview and record review, the facility failed to monitor R1's anticoagulant blood levels, resulting in R1 being hospitalized for 1 of 13 residents (R1) reviewed for medication in the sample of 13.The findings include:R1's Medical Record on 04/21/2026 shows thrombosis of the right upper extremity. R1's Physician's Orders, dated 03/02/2026 shows draw INR (International Normalized Ratio) blood test. R1's Progress Note, dated 03/20/2026 at 3:51PM, shows patient was admitted (to the hospital with a) diagnosis of supratherapeutic INR-International Normalized Ratio blood test. R1's Medical Record on 04/21/2026 shows no results for R1's 03/02/2026 INR blood test order. R1's prior INR result was dated 1/16/26 with an INR 1.2 On 04/21/2026 at 2:18PM, V2, DON-Director of Nursing, said, We had an issue with our lab. (R1's) INR was ordered on 03/02/2026. The blood was drawn on 03/03/2026 but the PT-Prothrombin Time (blood clot formation time) and the INR blood test were not completed. The laboratory orders were placed correctly but the anticoagulation testing was not performed. More INR tests were scheduled for (R1) on 03/13/26,03/14/26, 03/16/26, 03/17/26, and 03/18/26. No INR results were obtained for those order dates. (R1) was discharged from the facility and admitted to the hospital on [DATE]. R1's hospital discharge instructions, dated [DATE], shows on 03/19/2026, Hospital Laboratory results: PT 96.6 normal value 12.3-15.1 seconds, INR 12.0 normal value is 0.8-1.2. On 04/22/2026 at 10:11AM, V10, Medical Doctor, said, Supratherapeutic INR means too much coumadin. INR levels are used to regulate (R1's) anti-clotting medication. (R1's) therapeutic INR range should be 2-3. A level of 12 can be critical if the patient is bleeding. The elevation could be due to (R1's) diet. I ordered (R1's) INR test frequently at the facility; I never got any of the laboratory results. The facility did not provide a policy at the time of the survey.

Based on observation, interview, and record review, the facility failed to ensure plastic insulated plate bases were air dried prior to stacking and storing. This has the potential to affect all residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid Services Form 671, dated 3/9/26, shows there are 172 residents residing in the facility. Facility provided Diet Type Report, dated 3/9/26, shows there are 16 residents with orders of NPO (nothing by mouth) and they do not receive food from the kitchen. On 3/9/26 at 9:47 AM, three employees were at the dish machine doing dishes. V23 (Dietary Aide) was on the outfeed side of the dish machine and removing clean and sanitized trays, allowing stuff to sit for a minute or two, then placing them onto carts to air dry. V23 removed plastic insulated plate bases from the dish rack, while still wet, stacked them, and placed them in a cart located underneath the outfeed table. On 3/9/26 during the lunch service from 11:37 AM until 12:38 PM, wet insulated plate bases were being pulled from the storage cart and placed onto trays for service. On 3/9/26 at 1:00 PM, V17 (Food Service Director) said all dishes should be air dried before stacking and storing. Facility Mechanical Ware Washing (Dish Machine) policy, no date, states 13. It is especially important to air dry the dishes before stacking. Leave dishes, trays, and other items in the racks before stacking them.

Based on observation, interview, and record review, the facility failed to ensure residents' rooms were clean, and failed to provide residents with linen for bathing for 5 of 34 residents (R11, R41, R66, R124, R151) reviewed for clean, comfortable homelike in the sample of 34. The findings include: On 03/09/2026 at 10:27 AM, R11 was in bed in her room. There was orange liquid splashed on the wall and on the nightstand next to her bed. R11 showed this surveyor her bed sheet that had multiple areas of orange substance. R11 stated, That's from my meds they gave me this morning; it made a mess. They need to change my sheets. On 03/09/2026 at 10:40 AM, R151 was in bed sleeping. R151's tube feeding was connected and running. There was dried brown tube feeding on the floor next to R151's bed. On 03/10/2026 at 9:43 AM, R151 was in bed sleeping. The dried brown tube feeding was still on the floor next to R151's bed.On 03/10/2026 at 9:52 AM, R11's wall and nightstand were still splattered with orange substance. R11 said they did change her sheets, but they didn't clean the mess over there and pointed to the wall area. R11 said she did not get her bed bath and hair wash last night because they did not have any washcloths or towels. On 03/10/2026 at 10:20 AM, during the group meeting, R41 and R66 both said they did not get showers or baths due to running out of towels and washcloths. R41 said running out of linen has been an ongoing problem for the past 6 months since the facility started doing all laundry in-house. R66 said the garbage in her room was not changed from Friday to Monday of this week. R124 said floor in his room is not mopped. On 03/10/2026 at 10:15 AM, V21 (Environmental Director) said, Last night, the third shift laundry aide came in sick, and I had to send her home so there was no one to do laundry, and that's why there were no towels or washcloths. Sometimes staffing is the issue, or that staff don't know how to get into the locked area where we keep extra linen. Housekeepers are supposed to mop resident rooms daily and if they see spills those should be cleaned up and not left. Garbage in resident rooms is removed daily and as needed by housekeeping or nursing staff.On 03/11/2026 at 11:05 AM, R66 said last month there were no towels so she didn't get shower. R66 said her boyfriend bought her own towel so now that's not a problem for her anymore. On 03/11/2026 at 11:11 AM, R41 said everyday there is an issue with lack of towels or washcloths. R41 said she likes to have a bed bath daily due to health issues so she had to buy her own towels and washcloths so she could have her daily baths.The facility's Resident Council Minutes for August 2025, September 2025, and February 2026 shows concerns with lack of linen.The facility's Housekeeping Services Policy shows, It is the policy of the facility to maintain a clean, odor free, comfortable, and orderly environment in all health care and public areas, which meet the sanitation needs of the facility and residents right for a safe, clean, comfortable homelike environment. Each resident shall have bed and bath linens that are clean and in good condition.

Based on observation, interview, and record review, the facility failed to ensure residents that require extensive assistance received showers and personal hygiene care. This applies to 4 of 34 residents (R170, R160, R3, R11 ) reviewed for activities of daily living in the sample of 34. The findings include: 1.R170's face sheet shows he was admitted to the facility on [DATE], with diagnoses including history of falling, heart disease, atrial fibrillation, anxiety, depression, and unspecified fracture of occiput. On 03/09/2026 at 10:20 AM, R170 was in his room lying in bed. R1 said he was supposed to get a shower on Monday (3/2/26). The aide came to my room and said he would be back, but never came back. The staff told him he cannot shower alone because he's a fall risk. R170's hair was unkept and greasy. R170's facial beard was overgrown and thick. He said he does not keep his beard outgrown and has not shaved since admission. On 03/10/2026 at 9:12 AM, R170 was in his room. R170's hair still unkept and his beard outgrown. He said he was not offered a shower yesterday. On 03/10/2026 at1:09 PM, V26 (Certified Nursing Assistant-CNA) said R170 is a new resident, he is a fall risk, and cannot shower independently. V26 said residents should receive two to three showers a week. Showers are documented in electronic medical records. The 4th floor shower schedule provided on 3/11/26 shows R170's shower days are Monday, Wednesday, and Friday evening. The facility did not provide documentation of R170's shower report. 2. R160's face sheet shows he has diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type 2 diabetes, peripheral vascular disease, venous insufficiency, and COPD (Chronic Obstructive Pulmonary Disease).On 03/09/2026 at 10:23 AM, R160 was lying in bed. R160's hair was unkept, disheveled, and greasy. He said he has not had his hair washed in a while. On 03/10/2026 at 10:22 AM, R160 was lying in bed. His hair remained unkept and disheveled. The 4th floor shower schedule provided on 3/11/26 shows R160's shower days are Monday, Wednesday, and Friday on day shift. On 3/10/2026 at 1:09 PM, V26 said R160 is alert and oriented, he is dependent on staff for all cares. He receives bed baths and staff should be washing his hair. V26 said, Yeah his hair is bad, it needs to be washed.3.On 03/09/2026 at 10:10 AM, R3 was lying in bed. R3 has overgrown facial hair on her chin, her hair unkept and not brushed. On 03/10/2026 at 9:25 AM, R3 was lying in bed. R3's overgrown facial hair presents on her chin, her hair unkept and disOn 03/10/2026 at 1:09 PM, V26 (CNA) said R3 is dependent on staff for all cares. R3 gets bed baths, and they shave R3's facial hair when it gets long. V26 confirmed her facial hair needs to be shaved. The 4th floor shower schedule provided on 3/11/26 shows R3's room is not listed on the shower schedule. 4. R11 was in bed watching TV. R11's hair appeared greasy and stringy. R11 ran her fingers through her hair and said she was supposed to get bed bath and a hair wash that night. R11 said her hair really needs to be washed. On 03/10/2026 at 9:52 AM, R11 was in bed. R11's hair still appeared greasy and stringy. R11 said she did not get bed bath last night or her hair washed because they did not have washcloths or towels. R11 said it happens often that they don't have towels or washcloths. R11 said she did get her sheets changed but she really wanted a bed bath and her hair washed. On 03/10/2026 at 9:57 AM, V22 (Laundry Aid) said there were no staff working last night in laundry and that was why there were no towels or washcloths. The facility was unable to provide shower documentation for R11 for 3/9/26.On 3/11/26 at 11:19 AM, V29 (Registered Nurse) said R11 is alert and oriented and needs assistance of two staff for showers.The facility's Shower and Tub Bath Policy revised 2018, states, To ensure resident's cleanliness to maintain proper hygiene and dignity.

Based on observation, interview, and record review, the facility failed to ensure puree green beans and puree beef stew were served at an appetizing temperature. This affects 4 of 4 residents (R30, R31, R37, R164) reviewed for puree diets in the sample of 34. The findings include: 1. R164's Speech Therapy notes, dated 3/7/26, state R164's recommended food and liquid consistency is pureed foods with slightly thick drinks. On 3/10/26 at 1:44 PM, V16 (Registered Dietitian) said R164 was admitted to the facility on a regular diet then requested to be downgraded to mechanical soft. Then R164 said she wanted to try puree as R164 was still experiencing swallowing difficulties on mechanical soft foods. V16 and V17 (Food Service Director) said a downgraded diet slip was provided to the kitchen over the weekend and R164 was downgraded to puree on 3/7/26. On 3/10/26 at 9:40 AM, R164 said the puree food R164 has been receiving has been cold. On 3/10/26 at 12:23 PM, R164 said R164's lunch came approximately 15 minutes ago and R164 sent it back because it was cold. R164 confirmed it was puree food. 2. Facility provided diet order report, dated 3/9/26, shows R30, R31, and R37 are on pureed diets. On 3/9/26 at 12:38 PM, test trays of the regular meal and the puree meal were plated like normal and sent up to the second floor. At 12:56 PM, all trays for the floor were served and V17 (Food Service Director) took the temperature of the foods. The puree green beans and puree beef stew were both at 98 degrees Fahrenheit. V17 said V17 would prefer the foods to be over 100 degrees Fahrenheit. This surveyor tested the puree green beans and puree beef stew, and neither were hot and were lukewarm.

Based on observation, interview, and record review, the facility failed to follow a resident's care plan interventions for communication for 1 of 34 residents (R44) reviewed for accommodation of needs in the sample of 34. The findings include: On 03/09/2026 at 10:15AM, R44 was lying in bed. R44 made several attempts to communicate by moving his mouth and left arm. R44 became frustrated when not understood. R44 then waved a hand in a never mind gesture and looked away. No communication binder was found in R44's room. On 03/09/2026 at 10:15 AM, V9, Certified Nursing Assistant (CNA, said, (R44) did have a communication board. (R44) was moved to a different bed. I do not know where (R44's) communication binder is at.R44's current Care Plan on 03/09/2026 with intervention revised 01/06/2026 shows R44 presents with an alteration in the ability to communicate related to: Impaired cognitive abilities, Impaired speech. Patient communicates via pointing, nodding, and using his communication binder.

Based on interview and record review, the facility failed to ensure a resident with an Advanced Directive of Do Not Resuscitate (DNR) had a physician order for DNR for 1 of 34 residents (R4) reviewed for Advanced Directives in the sample of 34. The findings include:R4's Physician's Order Sheet, printed on [DATE], shows an order, dated [DATE], for Full Code. R4's IDPH (Illinois Department of Public Health)-Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], shows R4 wishes to be a DNR.On [DATE] at 1:16 PM, V14 (Licensed Practical Nurse) said if a resident was found pulseless, she would check the order in the system to see if she needed to attempt resuscitation and if it says Full Code she would start CPR. On [DATE] at 1:23 PM, V2 (Director of Nursing) said once a POLST form is completed by the resident or resident representative, the order for DNR is put into the system, if that is what they elect. V2 said the POLST form and order should always match the resident's wishes. V2 said a resident's code status is always discussed at care plan meetings as well. The facility's Advanced Directives Policy shows, If a resident or health care representative indicates an Advanced Directive(s) regarding CPR or DNR/Scope of Treatment (POLST form), the appropriate forms will be completed to indicate their wishes. A written physician's orders shall be specific and address each Advanced Directive(s). Advanced Directive(s) shall be included in the resident's care plan and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present.

Based on observation, interview, and record review, the facility failed to initiate a resident reported grievance in a timely manner for 1 of 34 residents (R11) reviewed for grievances in the sample of 34.The findings include:On 03/09/2026 at 10:27 AM, R11 was in bed in her room on the third floor. R11 said since she moved to this room from the second floor, she is missing a gray comforter and a green bath towel. R11 said her Guardian Angel (a staff member assigned to round on her) spoke with her this morning and R11 had told her about the missing items. On 03/09/2026 1:18 PM, V1 (Administrator) said there were no grievances reported for March 2026.On 03/10/2026 at 9:52 AM, R11 was in bed in her room said she had not heard anything on her missing items, and no one had been in to talk to her about them after she told her Guardian Angel. R11 said she forgot to tell her Guardian Angel about missing her slippers and her wallet and was going to tell her when she came back to round on her. On 03/11/2026 at 11:15 AM, R11 said her Guardian Angel came in on Monday, and she told her about missing items, and then she also rounded yesterday as well. R11 said yesterday her Guardian Angel wrote down a list and said she would turn it into the Administrator. On 3/11/2026 at 1:12 PM, V12 (Social Services Director) said when a resident has a grievance the information is taken down and a grievance form is filled out and sent down to the Administrator. V12 said the grievance is then forwarded to the manager of the appropriate department to handle the issue. V12 said she would expect the staff receiving the resident grievance to submit the grievance the same day.The facility could not provide a Concern/Compliment form for R11 until the morning of 3/11/2026. This form was dated 3/10/2026The facility's Grievances Policy, dated 11/28/12, shows, To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished.

Based on interview and record review, the facility failed to document medical symptoms and ensure non-pharmacological interventions were implemented prior to starting a resident on Seroquel (anti-psychotic medication) for 1 of 5 residents (R17) reviewed for chemical restraints in the sample of 34.The findings include:R17's Physician's Order shows a phone order, dated 12/24/25, for Seroquel 50 milligrams (mg) -1 tablet twice a day for anxiety was received.R17's Psychiatric Provider Note, dated 10/14/25, shows, Patient seen in room, after breakfast, with hospice staff present. He is alert, able to answer some questions appropriately. He denies depression, anxiety, he has been sleeping well at night, occasional daytime drowsiness. Staff have reported no concerns, no overt s/s (signs/symptoms) of sadness, loneliness noted, no changes in appetite. Patient does not exhibit symptoms of SI (suicidal ideation)/HI (homicidal ideation), patient has been negative for hallucinatory behaviors. Staff have reported patient has been cooperative, compliant with care, medications, no agitation or outburst reported.R17's Nurse Practitioner Note, dated 12/25/25, shows, Vascular dementia, depression/anxiety, insomnia-Per hospice CNA (Certified Nursing Assistant), patient has been trying to get out of bed more on his own, will reinstate his Seroquel at a lower dose of 50 mg BID (twice a day).in-house psychiatry following.R17's electronic medical record (EMR) does not have any behavior notes documented from 10/14/25 to 12/24/25. R17's EMR shows he was last seen by the psychiatrist on 10/14/25. R17's EMR does not document why an order for Seroquel was initiated on 12/24/25.On 3/11/26 at 2:01 PM, V2 (Director of Nursing-DON) said behavior monitoring should be documented in the resident's electronic medical record. V2 said that prior to initiating a new psychotropic medication, there should be documentation in the resident's record regarding behaviors they are having and what non-pharmacological interventions were attempted. V2 (DON) said it is not appropriate to start a resident on a psychotropic medication just because they are trying to get out of bed. V2 said he reviewed R17's medical record and did not see any behaviors documented prior to the 12/24/25 Seroquel order.The facility's Psychotropic Medication-Gradual Dosage Reduction Policy shows, Purpose-To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin and an allegation of abuse for 2 of 34 residents (R31, R133) reviewed for abuse in the sample of 34. The findings include: 1.On 03/09/2026 at 11:47 AM, R31 was lying in bed with a left frontal hematoma and abrasion to the head. R31 did not respond to verbal stimulation due to his impaired cognition.On 03/09/2026 at 11:55AM, V4 (Certified Nursing Assistant-CNA) stated, I am not sure how (R31) was injured. I am a float CNA. I do not work with (R31) often. On 03/10/2026 at 9:39 AM, V1 (Administrator) stated, I did not know about (R31's) injury until yesterday (03/09/2026) when you asked. I have not talked to the staff yet. On 03/10/2026 at 9:42 AM, V6 (CNA) stated, (R31) had bruising to the head when I started my shift on Thursday (03/05/2026).On 03/10/2026 at 9:55 AM, V8 (Registered Nurse-RN) stated, I saw (R31's) bruise on Sunday (03/08/2026). I did not report the wound; the wound was not new; it was in the healing stage. I do not remember seeing the wound on Saturday (03/07/2026). I did not receive any information during nurse-to-nurse report about (R31's) injury. On 03/10/2026, R31's latest New Skin Condition assessment, dated 12/25/2025, shows, no injury. R31's Wound Rounds record on 03/10/2026 shows no active wounds. R31's Nurse Practitioner Assessment, dated 03/04/2026 at 8:22AM, shows Head: Normocephalic. R31's MDS-Minimum Data Set, dated [DATE], shows: 00-severe cognitive impairment. (R31) requires substantial/maximal assistance, helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort when (R31) is rolling left or right in bed, sit to lying, lying to sitting. The helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity of standing, transferring from the bed to the chair, or transferring from the chair to the bed.On 03/09/2026 at 12:15PM, 03/10/2026 at 9:39 AM, and 03/11/2026 at 10:00AM, V1 (Administrator) was asked to provide R31's initial hematoma and abrasion investigation to this surveyor.On 03/11/2026 at survey exit, V1 (Administrator) did not provide any documents related to R31's Injury.2. On 03/09/2026 at 12:32 PM, V31 (R133's sister) was sitting at the bedside of R133. V31 said her mom had an issue on Friday (3/6/26) with one of the CNAs that was helping R133. V31 said R133 needed to be changed and when she went and got the CNA, the CNA acted mad since she had just changed R133 and he had a bowel movement again. V31 said the CNA was rude and abrupt with her mom, and then when the CNA was rolling R133 to the side, the CNA grabbed R133 harshly and pushed him so fast that his leg went over the bed. V31 said another family member, who was with her mom, ran up and grabbed R133's leg. V31 said her mom was so upset because of the incident, she was crying in the hallway. V31 said V30 (Human Resources) came out and asked her what was wrong and talked to her mom about what happened. V31 said V30 took her mom's statement but she hasn't heard anything about it since. On 3/09/2026 at 2:06 PM, V30 Human Resources Director said R133's mom was in the hallway and was upset. V30 said R133's mom reported to her the CNA was rough to R133 and rude to her. V30 said she got V1, Administrator, and they both started an investigation and interviewed the CNA (V32) involved. V30 said she thought it was abuse at first and that is why she got V1. V30 said she was not sure what V1 did after that with the investigation. On 03/10/2026 at 1:43 PM, V1 said, An allegation that staff is rough and rude would be reported to me or a nurse supervisor as an allegation of abuse to be investigated per policy. When asked again, V1 said she had no abuse investigations pending for March 2026. When asked about the concerns family reported to V30 about V32 being rough and rude to R133, V1 said yes, the situation had been reported to her. V1 said she talked to R133's mom and V31 and took statements. V1 said she did a soft file file on the incident. V1 said she spoke to V32 (CNA) and R133's nurse that day but she didn't do other staff or resident interviews. V1 said she was not looking at the incident as abuse so didn't do an abuse investigation and report it. V1 said based on the interviews and investigation that she did, it was a customer service issue. V1 said she sent V32 home, but not because she was following abuse policy just because there was only 5 or so minutes left of V32's shift. V1 said she told R133's mom that R32 would not be assigned to R133 again.On 03/11/2026 at 10:45 AM, V1 provided her soft file for R133. The soft file contained statements from R133's mother, V31, V32 (CNA), and other staff. The file also contained resident interviews about care from staff (components of an abuse investigation) and a grievance form. V1, when asked about the grievance form and why she didn't provide this when asked two days prior if there were any abuse or grievances for March, said she forgot it was in this file. The facility's Abuse and Retaliation Policy Prevention Program, dated 1/2026, shows, Any allegation of abuse, retaliation, or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any Incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to refer a resident for a Preadmission Screening and Resident Review (PASARR) Level II evaluation after a new diagnosis of psychosis for 1 of 5 residents (R17) reviewed for PASARR in the sample of 34. The findings include:R17's Face Sheet shows he admitted to the facility on [DATE], with diagnoses of generalized anxiety disorder and major depression. R17's Face Sheet shows he received the diagnosis of Psychosis not due to substance or known physiological condition on 1/30/24 during his stay. R17's PASARR Level 1 Screening, dated 10/3/22, shows he does not have any serious mental illness diagnoses and a Level 2 screen is not indicated. On 3/11/2026 at 11:15 AM, V28 (Social Service Coordinator) said corporate does PASARR screening for residents prior to admission. V28 said she is not sure who checks them for accuracy. V28 said if a resident receives a new severe mental illness diagnosis, corporate will refer them for a PASARR level II evaluation. V28 said she is not sure how corporate is notified of any new diagnoses. V28 said corporate did contact her in February and told her to do a PASARR for R17 but she was having issues with the system. V28 said a new diagnosis of psychosis would require a PASARR Level II evaluation.The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy shows, The facility will refer all level II residents and all residents with newly evident or possible serious mental illness disorder, intellectual disability, or related condition for a level II review upon significant change in status assessment to the state PASSAR representative.

Based on observation, interview, and record review, the facility failed to ensure a resident with dysphagia was supervised during meals. This applies to 1 of 34 residents (R141) reviewed for safety in the sample of 34. The findings include: R141's face sheet shows he has diagnoses including dysphagia, hemiplegia and hemiparesis following non traumatic subarachnoid hemorrhage affecting right dominant side, type 2 diabetes, and carpal tunnel syndrome left upper limb. R141's Physician Order Sheets, dated March 2026, shows orders for mechanical soft diet and nectar thick liquids. On 03/09/2026 at 12:17 PM, R141 was eating in his room during the noon meal. R141 was sitting in his wheelchair with his meal tray on his bedside table. He was served beef stew and green beans. R141 was drinking water (not thickened) and coughing after water and bites of food. On 03/10/2026 at 1:00 PM, V27 (Certified Nursing Assistant) said, (R141) is on the list to be supervised and assisted during meals for safety. (R141) is on mechanical altered diet and nectar thickened liquids, he should not be eating in his room unsupervised.R141's current care plan does not include his dysphagia diagnosis or interventions implemented.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter was secured to prevent pain and/or injury for 1 of 5 residents (R1) reviewed for urinary catheters in the sample of 34.The findings include:On 03/09/2026 at 10:19 AM, R1's urinary drainage bag tubing was hanging off the bed. The drainage tubing was being fully supported by the indwelling urinary catheter inside of R1's bladder. R1 did not have an external securing device for the indwelling urinary catheter. On 03/09/2026 at 10:22 AM, V9 (Certified Nursing Assistant) said, (R1's) catheter securing device may have fallen off.On 03/10/2026 2:29 PM, V10 (Licensed Practical Nurse) said, We use catheter securing devices. It prevents yanking on the catheter that may cause the catheter to come out of the urinary urethra causing damage or pain to a resident.The facility's Urinary Catheter Care policy, revised 02/14/2019, shows, indwelling catheters may be secured to prevent trauma and tension.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements for a resident at risk for weight loss. This applies to 1 of 6 residents (R141) reviewed for weight loss in the sample of 34. The findings include: R141's face sheet shows he has diagnoses including dysphagia, hemiplegia and hemiparesis following non traumatic subarachnoid hemorrhage affecting right dominant side, type 2 diabetes, and carpal tunnel syndrome left upper limb. On 03/09/2026 at 12:17 PM, R141 was eating in his room during the noon meal. R141 appeared thin and underweight. R141 was served beef stew and green beans. There was no frozen nutritional supplement provided with his meal. On 03/10/2026 at 1:00 PM, V27 (Certified Nursing Assistant-CNA) said the frozen nutritional treats should come on the resident's meal tray from the kitchen. R141's dietary note, dated 1/10/26, documents he is underweight at 103 lb (pounds) continue supplements frozen nutritional treat and nutritional shake twice a day. R141's current care plan shows he is at risk for compromised nutritional status with interventions to provide dietary supplements.

Based on observation, interview, and record review, the facility failed to obtain weights for a resident with a gastrostomy tube for 1 of 7 residents (R191) reviewed for gastrostomy tubes in the sample of 34.The findings include: On 03/09/2026 at 10:06 AM, R191 was in bed sleeping. R191's gastrostomy tube was connected to the feeding pump. Osmolite 1.2 was running at a rate of 70 cubic centimeters (cc)/hour.On 03/10/2026 at 1:19 PM, V2 (Director of Nursing) said resident weights are checked on admission, weekly x 4 weeks to get the residents baseline weight, and then monthly. V2 said for residents on gastrostomy tube feedings, the Dietician needs weights to make sure the tube feeding is meeting the caloric needs of residents.R191's Weights and Vital Summary, dated 3/10/26, shows the only weight obtained for R191 was done on 3/10/26.R191's Physician Orders (POS) for March 2026 shows R191 was admitted on [DATE]. This same POS shows orders Weigh upon admission & weekly x 4 and weigh monthly and record. This POS shows R191 is NPO (nothing by mouth) for diet and Enteral feed order every shift Osmolite 1.2 at 70 milliliters (ml)/hr.The facility's Enteral Nutrition- Tube Feeding Policy dated 2020 shows, Monitoring of the individual's actual intake and tolerance of tube feeding is important to ensure that nutritional goals are met and maintained. Monitoring of the individual with tube feedings is and interdisciplinary team effort an includes-Enteral feed is being delivered as ordered by physician and weight.

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen was administered according to physician orders for 1 of 9 residents (R162) reviewed for oxygen in the sample of 34.The findings include:On 03/09/2026 at 9:59 AM, R162 was sleeping in bed wearing a nasal cannula. R162's oxygen concentrator was set at 5 Liters (L).On 03/10/2026 at 9:38 AM, R162 was in bed watching TV with a nasal cannula on. R162's oxygen concentrator was set at 5 Liters.On 03/10/2026 at 1:19 PM, V2 (Director of Nursing) said the nurse should follow the oxygen order in Physician Orders when setting the level of oxygen being administered. Residents can have respiratory issues if oxygen is set too high.R162's Physician Orders dated 6/18/2025 shows, On 3L/min of oxygen via nasal cannula.The facility's Oxygen Therapy Policy, dated 12/1/2024, shows, It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care. Set-up and administration of oxygen: Attach the nasal cannula/mask to the oxygen source and turn the flow meter to the ordered flow rate.

Based on interview and record review, the facility failed to discontinue an antibiotic as ordered for 1 of 34 residents (R57) reviewed for unnecessary medication in the sample of 34.The findings include:R57's Face Sheet shows that he admitted to the facility on [DATE], with diagnoses of: acquired absence of right great toe, right toes, left great toe and osteomyelitis.R57's Hospital Discharge Medications, dated 2/8/26, shows an order for cephalexin 500 milligrams (mg)-1 capsule 4 times a day for 7 days.R57's February and March Medication Administration Record shows that he received cephalexin 500mg-1 capsule four times a day from 2/8/26 to 3/11/26. R57's Infectious Disease Nurse Practitioner Note, dated 2/23/26, shows, Patient is on cephalexin 500 mg po (by mouth) four times a day, no end date: however, according to hospital records it was supposed to be only for 7 days. Will verify with nursing staff if someone extended. At present, the patient is clinically stable: afebrile, vital signs stable, no signs or symptoms of systemic infection. There is a potential medication management risk related to cephalexin duration, as hospital records indicate a 7-day course; clarification is needed to determine whether therapy was appropriately extended.On 3/11/2026 at 9:18 AM, V13 (Infection Preventionist) said when a resident admits with antibiotic orders, the nurse should be put the medication in the system with the appropriate stop date. V13 said she did not notice R57 had a duration on his discharge papers. V13 said R57 should have stopped the cephalexin after 7 days. V13 said no one had spoken to her in the past regarding R57's antibiotic. The facility's Antibiotic/Antimicrobial Stewardship Program Policy shows, This program help ensure that our residents get the right antibiotics a the right time for the right duration.The facility will work towards implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility with the cooperation of the physician. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of antibiotic when the clinical picture is clearer and more information is available.

Based on observation, interview, and record review, the facility failed to administer medications as ordered for 2 of 3 residents (R4, R71) reviewed for medication administration in the sample of 34. This failure resulted in 6 errors out of 30 opportunities resulting in a 20% medication error rate.The findings include:1.R4's March 2026 Medication Administration Record (MAR), documents, Metoprolol Succinate Extended Release 50 milligrams; give 1 tablet by mouth once a day, hold medication if resident's heart rate (pulse) is less than 60 beats per minute.On 3/9/26 at 10:02 AM, V15 (Registered Nurse-RN) administered 50 milligrams of Metoprolol to R4. V15 did not assess R4's pulse prior to administering the medication. V15 stated the last time she assessed R4's pulse was around 8 am on 3/9/26. On 3/9/26 at 12:40 PM, V2 (Director of Nursing-DON) stated as per the physician's order, R4's pulse should be checked immediately prior to administering her Metoprolol medication. 2. R71's March 2026 Medication Administration Record (MAR) showed the following medication orders for R71:Duloxetine 60 milligrams (mg); give 1 capsule two times a day at 9 AM and 6 PM.Metoprolol Tartrate 25 mg; give 1/2 tablet every 12 hours at 9 AM and 9 PM.Mucinex Extended Release 12 Hour 600 mg; give 1 tablet two times a day at 9 AM and 6 PM.Buprenorphine 2 mg; give 1 tablet three times a day at 9 AM, 2PM and 9 PM.Topamax 50 mg; give 1 tablet three times a day at 9 AM, 2 PM and 6 PM. On 3/9/26 at 10:30 AM, V14 (Licensed Practical Nurse) administered doses of Duloxetine, Metoprolol, Mucinex, Buprenorphine, and Topamax to R71. On 3/9/26 at 12:40 PM, V2 (DON) stated medications should be administered as per physician order. V2 stated medication administration is considered late if a medication is administered later than one hour after its scheduled time. The facility's Medication Administration policy, dated 10/25/14, showed the Five Rights of medication administration are to be followed when administering medications which include the right resident, right drug, right dose, right route, and right time. The policy showed, Medications are administered in accordance with written orders of the prescriber. Medications are administered within 60 minutes of scheduled time.

Based on observation, interview, and record review, the facility failed to ensure a light fixture was in safe operating order. This failure resulted in the light fixture falling from the ceiling, landing on the resident while in bed, and R1 sustaining a second degree burn. This applies to 1 of 3 residents (R1) reviewed for safe physical environment in the sample of 3.The findings include:R1' s electronic face sheet documents R1 has diagnoses that include peripheral vascular diseases, left leg amputee, and hypertension.R1's facility assessment, dated 10/3/25, show R1 has no cognitive impairment.R1's Emergency Department (ED note), dated 10/6/25, documents, Patient presented from facility burned to right upper arm. EMS stated light fixture caught on fire and plastic pieces came down on patients' right arm second degree burn noted. Patient alert and denied shortness of breath said he was in his room when the light fixture above had a clot fire and melted plastic pieces dripped down his arm, patient complaining of pain in his right upper arm-skin: warm to touch, 14x 7 centimeter (cm) with blanching erythema as well as epidermal desquamation, the distal palmar surface of the left middle finger has mild blanching erythema. Diagnoses: second degree burns with deep and superficial partial thickness burn-right upper arm as well as superficial partial thickness burn of the palmar aspect of his distal left middle finger due to melted plastic without evidence of infection, tetanus updated in the ER patient was given pain med-improvement of pain. R1 was discharged with topical antibiotic ointment applied three times a day-TID. On 11/18/25 at 10 AM, R1 was alert and pleasant lying in bed. A dressing was noted to his right upper arm. R1 stated, That time when I got burned, I was eating my cereal for breakfast, all of a sudden the light fixture on the ceiling above me exploded, the plastic covering fell on me, it was so hot it burned me it hurt so bad (pointing to his right upper arm), my blankets, my hospital gown were on fire, I was yelling for help! R1's left middle finger redness had subsided. V2 (Director of Nursing) removed R1's dressing. R1's right upper arm was still reddened with several small open areas with clear drainage noted. V2 said R1's right upper arm that was burned was being treated with antibiotic ointments covered with dry dressing.On 11/19/25 at 9:30 AM, V4 (Registered Nurse-RN) said she was R1's Nurse last 10/6/25. V4 (RN) said she was outside R1's room passing morning meds when she heard R1 yelling for help. V4 said she went to R1, there was fire in the ceiling above him; there was fire noted on the side of his bed. V4 said she screamed, help, fire! fire! as she was pulling R1's bed away from the ceiling. V4 said V5 (Certified Nursing Assistant-CNA) came to help pull R1 away from the fire. 911 was called. R1 was sent to the ER. R1 came back to the facility with second degree burns.On 11/18/25 at 1:36 PM, V5 (CNA) said that day (10/6/25) he was collecting breakfast trays from rooms as breakfast was just finishing, when he heard loud screams coming from R1's room. V5 said he ran towards R1's room, the Nurse (V4) was already there pulling R1 in his bed for safety away from the ceiling. A ceiling tile fell on top of R1, smoke was noted in the ceiling, fire sparks were noted inR1's covers. R1 was shocked and confused. R1 was noted to have burned areas in his right upper arm. 911 was called. A fire extinguisher was used to spray the ceiling to stop the fire. On 11/18/25 at 11 AM, V7 (Maintenance Director) said it was around 8:30 in the morning on 10/6/25, a code red was initiated indicating a fire on the 4th floor. V7 said he hurriedly went to 4th floor, staff have extinguished the fire. At this time, the fire alarm had been activated, and Fire Department arrived (EMS). EMS cleared the code red. R1 was transported to the hospital via 911. V7 said investigation shows the cause of the fire was a light fixture in the ceiling. There was a loose contact that caused overheating and fire. The light fixture was still the original one years ago. V7 said prior to the incident, the preventive maintenance was just to go around looking for broken bulbs and replacing them. After this incident, (when R1 sustaining second degree burns) all the light fixtures have been checked. All light fixtures have been replaced with LED lights. V7 said an Electrician Company came to check the facility.An electrician report, dated 10/6/25, showed, Called to the facility why a light fixture caught on fire. Noticed that the plastic covering on the LED T8 bulb was melted and the end of the lamp was burnt (sic). We walked through the other residence (sic) room and took note of lamps that were not working but did not notice any arcing or discoloration on any of the other light fixture.On 11/19/25 at 9:30 AM, V1 (Administrator) said all lights were now in good working order and continue to educate staff to report any defective light fixture. V1 also said a reportable was sent to the state agency.The Facility Reported Incident sent to the state agency as final, dated 10/10/5, documents: On 10/6/25 at 8:30 AM, code red was initiated indicating a fire, staff immediately responded to the 4th floor room [ROOM NUMBER] (R1's room) During the code, staff retrieved fire extinguisher and put out the small flame. 911 was notified, fire department responded cleared the code red. (R1) was transported to the local hospital. Initial root cause analysis showed the light fixture malfunction in (R1's) room, light fixture melted onto the bed of (R1). Ballast connection to the light bulb became too hot and sparked. All preventive maintenance was reviewed and note that there were no issues with any light bulb in the building, staff educated on what to do if observing a malfunctioning light fixture.The Facility Policy on Environmental Services, (undated) documents, to ensure that the facility is designed, equipped and maintained in accordance with all governing rules and regulations and standards.

Based on observation, interview, and record review, the facility failed to ensure a resident (R112) receiving tube feedings had their weight monitored. This failure resulted in R112 sustaining a significant weight loss. This applies to 1 of 6 residents (R112) reviewed for weight loss in the sample of 32. The findings include. R112's Physician Order Sheet (POS), printed on 1/14/25, showed R112 has diagnoses that include difficulty swallowing due to stroke, and gastrostomy. The same POS showed R112 has an order of tube feedings with Glucerna 1.5 at 60 milliliters (ml) per/hour x 10 hours (on at 8PM off 6AM) date of order 11/4/24. R112 was also on general diet mechanical soft with nectar thick fluids. R112's Progress notes by V13 (Dietitian), dated 11/4/24, recommends reinstate Glucerna 1.5 run x 75 ml/hr x hours .Monitor weight x 4 more weeks . No weekly weights were done in November 2024. R112's progress notes, dated 12/22/24, by V12 (another facility Dietitian) showed, Dec (December) weight pending. Nov (November) weight 173 lbs .General diet mechanical soft texture. TF (Tube feeding Glucerna 1.5 60 ml/hour x 10 hours (on 8PM of 6AM) .continue with present management pending present weight. Please weigh resident. R112's progress notes, dated 1/2/25, by V12 (another facility Dietitian) showed Dec weight pending. Nov weight 173# (pounds). General diet mechanical soft texture. TF (Tube feeding Glucerna 1.5 60 ml/hour x 10 hours (on 8PM of 6AM) .continue with present management pending present weight. Please weigh resident. R112's careplan, dated 1/2/25, shows, Requires enteral feedings as a supplement to oral feeding that puts resident at risk for: Aspiration, Malnutrition, Dehydration, and Intolerance. R112's Weights and Vitals Summary printed on 1/14/25 showed weights of: January 6, 2025 -156.6 pounds (lbs). December 2024 - No weights. November 16, 2024 -173 lbs. A weight loss of 17 lbs or 9.36% weight loss (from November 2024 and January 2025 weight.) On 1/13/25 at 12:30 PM, R112 was being fed lunch. V7 (Registered Nurse) said R112's food intake varies. R112 was also on tube feeding. On 1/14/25 at 1:00 PM, V13 (Dietitian) said last November 2024, she was informed R112's food intake was poor. R112's weight at that time was 173 lbs. V13 said she reinstated R112's tube feeding order of Glucerna 1.5 to 75 ml x 10 hours, continued R112's food intake by mouth general mechanical soft, thickened liquids. R112's weight was to be monitored. This month (January 2025), R112 had a significant weight loss from November 2024. R112 weight last 1/6/25 was 156.8 lbs from 173 lbs last 11/16/24. (R112 had no weight in December.) V13 said she also saw a Nurse Practitioner (NP) note that R112 needed reweighed dated 1/9/25. V13 said R112 was not reweighed until today, 1/14/25. R112's latest weight was 161.2 lbs, still an 11.2 lbs weight loss or 6.82% weight loss in 2 months. V13 said today she increased R112's tube feeding rate (from 60 ml to 75 ml) and R112, was now put on weekly weights. V13 said tube feeding residents should not be losing weight. On 1/15/25 at 11:20 AM, V25 (R112's Physician) said for residents who are on tube feeding, their weight should be monitored closely. At least a monthly weight should be done to identify weight loss and nutritional risks. If there was a weight loss, weekly weights can be done. V25 said he was not aware R112's December weight was not done. The facility policy on Weights, dated 11/14/12, showed, 1. All residents shall be weight on admission and monthly 2. Residents identified at nutritional risks may be weighed weekly or bi weekly as per physician pr interdisciplinary team.4. Reweigh should be taken as soon as possible after an unanticipated weight change is noted .usually within 72 hours.

Based on observation, interview, and record review, the facility failed to provide adequate hand and nail care to 1 of 3 (R1) dependent residents with a hand contracture who were reviewed for improper nursing care; failed to follow facility policies for nail care, morning/nighttime care, and for bed baths. This failure resulted in R1 having a foul odor to her left hand and obtaining an open wound to the palm of her contracted hand that required immediate treatment by the facility's wound care team. Findings include: Review of R1's medical record showed she admitted to the facility on [DATE], and has a past medical history not limited to: encephalopathy, traumatic subdural hemorrhage, acute respiratory failure, obesity, and fractures to base of skull, nasal bones, and multiple cervical vertebrae. Review of R1's restorative observation, dated 08/19/2024, documented she is dependent on staff assist for activities of daily living (ADL'S), transfers, and mobility, and is total hands on assist to keep clean and dry with bowel and bladder. Range of motion services were offered and refused, noted with facial grimacing and shaking her head no. Review of R1's Minimum Data Set (MDS) Section C for Cognitive Patterns, dated 08/21/2024, showed Brief Interview for Mental Status (BIMS) score of 99, indicating interview could not be conducted due to cognitive impairment. MDS Section GG for functional abilities and goals, dated 08/21/2024, showed she was dependent of two or more staff for showers/bathing and personal hygiene. Review of R1's care plan documented she would benefit from an active assistive range of motion program because she is at risk for developing contractures/has actual contractures related to physical inactivity with date initiated of 11/14/2024; has the potential for/a cognitive problem related to BIMS score, staff assessment, difficulty making decisions, head injury, impaired decision making, and encephalopathy with date initiated of 08/27/2024; Resident is at risk for alteration in skin integrity related to: Anemia, Braden Scale Score, Impaired mobility, Incontinence of Bowel, Incontinence of Urine, Malnutrition, Medical Devices (c-collar, gastrostomy), Pneumonia, fractures, dysphagia, subdural hemorrhage, encephalopathy, respiratory failure, fractures, on anticoagulants with date initiated of 07/17/2024 and an intervention to monitor skin during care and report any changes. On 11/14/2024 at 11:43 AM, V3 (Licensed Practical Nurse) said grooming and nail trimming is done by the aides, mainly on their shower days. She added the aides are to complete a shower skin that documents type of bath given, added cares provided, and if there was any skin redness or open areas, they should be communicated to the nurse. V3 then said if a resident has a contracted hand, then the hand should be washed daily, and any issues or concerns should be communicated to the nurse. On 11/14/2024 at 11:53 AM, R1 was awake and lying in bed. R1 was non-verbal. Noted a foul odor within the room and near her bed. R1 was moving and turning her arms /hands around, and surveyor observed contractures to both hands, with all her fingers touching the palm. The length of R1's fingernails to both hands extended approximately 5-6 millimeters in length past the tip of her fingers. Beneath R1's middle finger was what appeared to be a small piece of dry and discolored skin flap that was visibly protruding from beneath the tip of her finger. A moderate amount of light brown colored build-up that was foul smelling covered the lateral side of R1's index finger and along the medial aspect of the thumb to her left hand. On 11/14/2024 at 11:56 AM, V4 (Licensed Practical Nurse/LPN) assessed R1's hands. V4 said resident fingernails are normally trimmed on their shower days and R1's nails should not be the length that they were, then said it looked like the nail is digging into her skin that has caused an injury to her hand. V4 (LPN) then said hand care should be done daily to a contracted hand, and said she has not provided hand care to either of R1's contracted hands. V4 indicated there was a foul odor present to R1's left hand. At 12:02 PM, V4 showed surveyor completed shower/bath sheets dated from November 1st through the 12th for the third floor shower book, with no shower/bath sheet found for R1. V4 said there should be shower/bath sheets for R1 during that timeframe. Review of shower skin notification sheet showed options for shower, bed bath, or refused, and listed care areas to be addressed for hair, face, torso, oral care, feet, legs, shave, fingernails, peri area, buttocks and under breasts. Form also provided area to document skin characteristics, and aide/nurse signatures. On 11/14/2024 at 12:07 PM, V5 (Certified Nursing Assistant/CNA) said she gave R1 a bed bath before breakfast. V5 added she washed R1's upper body and private areas, but did not attempt to wash R1's hands today because she usually flinches in pain then pulls her hands away. At 12:44 PM, V7 (CNA) working on first floor said hand care should be provided daily with a contracture, and she usually trims a resident's fingernails weekly if needed. On 11/14/2024 at 12:51 PM, V2 (Director of Nursing/DON) said on a resident's shower or bed bath day, the aides are to complete a bathing sheet and document electronically, then report any issues to the nurse who is to assess the resident. V2 added when completing a shower skin sheet, all areas on the form must be addressed to ensure that all residents received their scheduled shower or bed bath, and what additional care was provided to the resident. V2 said if a resident has a contracture, hand/nail care is provided during their scheduled shower or bed bath, and fingernails should be trimmed per patient preference if verbal, and trimmed weekly or biweekly depending on the length if non-verbal. V2 also said he believed the facility protocol is to place a towel or foam hand roll to a contracted hand when there is not an order for a hand splint to prevent skin breakdown. At 1:45 PM, V2 said R1 was found to have long fingernails and a cut to the palm of her left hand, which the treatment team is preparing to assess. On 11/14/2024 at 1:51 PM, V8 (Wound Nurse) stood in the doorway of R1's room and in front of a treatment cart. A foul odor was present at the doorway of R1's room. V8 said he had just washed R1's hand and trimmed the fingernails to both of her hands. V8 added the foul odor came from washing the build-up of sweat and debris trapped within the skin folds of R1's contracted hand. V8 said he trimmed R1's fingernail because a nail was digging into her left hand that caused a cut to her palm. On 11/14/2024 at 1:53 PM, V9 (Nurse Practitioner) assessed R1 left hand. V9 said R1 sustained an open wound to the palm of her left hand, caused by her long and sharp fingernail. Surveyor observed an actively bleeding open wound to the R1's left palm that measured in centimeters (cm) approximately 1.00 x 1.00 (length x width). V9 added she will order a topical triple antibiotic ointment and the placement of a hand roll to R1's contracted hands. V9 also said R1 had not recently received hand care, and was previously placed on the monthly podiatrist list. Review of Wound Assessment Details Report, with assessment time and date of 11/14/2024 at 2:29 PM, documented the following: Facility-acquired, traumatic abrasion identified on 11/14/2024 that measures 1.00 x 1.00 x 0.10 (L x W x D) in centimeters. Last Braden Score of 12 (High Risk) dated 10/14/2024 indicated R1 is at high risk of developing pressure ulcers. Review of Nurse Practitioner Progress Notes, with effective time and date of 11/14/2024 at 2:44 PM (14:44), documented the following: Per nurse, patient has a wound on her left palm, as her contracted fingers are always in contact with that aspect of her hand. Patient examined in her room with wound registered nurses. She has a shallow puncture wound, just right up to the first layer of the epidermis, at the stratum granulosum, to be exact, measuring less than 1cm in diameter, circular shape, new from either today or yesterday, as the visible stratum granulosum appears very fresh. Wound registered nurse trimmed her nails, as podiatry hasn't been by. She has a standing order for podiatry consult. Wound cleaned, and applied with topical antimicrobial agent, and covered with gauze to prevent further abrasion of the wound bed. Temporary grip rolls are applied to both hands. Will update restorative nursing. On 11/14/2024 at 2:52 PM, V10 (Restorative Director) said R1 was added to restorative today for range of motion because she was not previously on a program, due to noted pain when assessing her hands. Review of R1's Order Summary Report for Active Orders, dated 11/15/2024, showed the following: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete Nursing Skin Assessment Form every day and evening shift every Tuesday, Thursday, Saturday for Weekly Showers/Skin Assessment with a start date of 07/18/2024; Bacitracin Ointment 500 UNIT/GRAM-apply to left hand topically every day shift and as needed for wound care. Cleanse with normal saline prior to application. Pat to dry. Cover/top with rolled gauze/kerlix with order date or 11/14/2024. On 11/14/2024, requested from V2 (DON) R1's shower sheets for the last thirty days, podiatry notes for the last three months, and R1's aide bath charting for the last thirty days. None were provided. Review of Nail Care policy, last revised 01/25/2018, documented to observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails. Review of Morning Care (A.M. Care) policy, last revised 01/31/2018, reads: Purpose: To promote comfort, cleanliness and dignity. Guidelines: Explain procedure to resident and bring equipment to bedside or to bathroom. Provide privacy. Prepare water to wash, offer washcloth to wash hands. Allow/assist resident with cleansing body, face, hands, arms, underarms and perineum. Observe for skin problems. Report any abnormal findings such as bruising, reddened areas or breakdown. Document care and assistance provided in electronic record. Review of Bedtime Care (HS Care) ) policy, last revised 01/24/2018, reads: Purpose: To promote comfort and relaxation before sleep. Guidelines: Offer washcloth to wash hands and face, assist as needed. Document care and assistance provided. Review of Complete Bed Bath policy, last revised 01/31/2018, reads: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. Procedure: Explain procedure, provide privacy. Drape resident to maintain dignity by not exposing body and to keep resident warm. Place towel under far arm. Wash, rinse and pat dry hand, arm, shoulder and underarm. Repeat for the other arm. Call for nurse to report any reddened areas, skin discoloration or breakdown. Document bathing task and assistance provided in the electronic record.

Based on observation, interview, and record review, the facility failed to ensure an X-ray was completed and reported in a timely manner, and failed to ensure there was not a delay in treatment after a fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 4. This failure resulted in an almost 24 hour delay in emergency care, and R1 experiencing pain. The findings include: On 10/16/24 at 1:22 PM, R1 was lying on her back, in bed. R1 said she did fall, but was unable to provide any further details of the fall. R1 said her right leg hurt when she had to move. R1's Risk Management, dated 10/8/24, showed, Nursing supervisor noted resident lying on the floor on the right side of her bed during rounds. Resident dressed with non-skid socks on. (R1's) wheelchair noted to be on the left side of the bed. (The) resident stated, I fell , I don't remember. This document showed R1 had facial grimacing and moaning when right leg moved after the fall. This form showed R1's pain was rated at a 5 on a scale from 1-10 (10 being the worst pain). The Facility's Fall investigation provided to the surveyor on 10/16/24 showed the following statements. V13 (Registered Nurse - RN) said he was passing medications when the nursing supervisor noted R1 lying on the floor on the right side of her bed. A head to toe assessment was completed with full ROM (Range of Motion) present. R1 complained of pain later on during the evening to her right leg. There was no swelling or bruising noted at this time. The NP (Nurse Practitioner) was notified and orders were received for X-rays of the right leg. Pain medications was administered. This form showed V15 (Certified Nursing Assistant - CNA's) statement was that she did not see R1 on the floor 10/8/24. This form showed V11 (Nursing Supervisor's) statement was he saw R1 on the floor, during rounds. V11 said R1 was lying on her right side, on the right side of her bed and her wheelchair was on the opposite side of the bed. R1's Facesheet, dated 10/16/24, showed diagnoses to include, but not limited to: displaced interrogate right femur fracture; stage 2 CKD (chronic kidney disease); hemiplegia and hemiparesis following a stroke; dysphagia; dysarthria; severe-protein calorie malnutrition, vascular dementia, and anxiety. R1's Physician Order Sheet, dated 10/17/24, showed orders for X-rays of the right hip, knee, ankle, and foot were ordered on 10/8/24. R1's Order Audit Report, dated 10/17/24, showed the order was entered on 10/8/24 at 5:32 PM by V13 (RN). This order type was entered as Standard Diagnostic. (The order type should show STAT if order was requested to be completed immediately.). R1's X-ray Report, dated 10/8/24, showed R1 had an acute intertrochanteric fracture of the proximal right femur with mild varus deformity (an excessive inward angulation of the distal segment of the bone). This X-ray was digitally signed by the Radiologist on 10/8/24 at 8:10 PM. This document showed the X-ray was reviewed by V4 (Assistant Director of Nursing - ADON) on 10/9/24 at 2:57 PM. R1 fell at 4:00 PM. The X-ray was read by the radiologist at 8:10 PM, but the facility did not review the results and transfer R1 to the hospital until the afternoon of 10/9/24, over 20 hours after the unwitnessed fall. R1's has no progress notes from 10/7/24 at 1:24 PM until 10/9/24 at 2:12 AM, that demonstrates continued monitoring of pain and the resident's condition. This note showed, The resident was sent to (local emergency room ) via ambulance at 2:12 PM. (This note was entered by V6 (Licensed Practical Nurse - LPN) and she worked 7 AM to 3 PM on 10/9/24; she wasn't in the building at the time of this note entry. R1's Change in Condition noted, dated 10/9/24 at 12:50 PM, showed R1 had decreased mobility, pain, and X-ray results showed she had an acute fracture. This note showed R1 a non-emergent ambulance was contacted with an ETA (estimated time of arrival) in 30 minutes. R1's Radiology Note, dated 10/9/24 at 12:50 PM, showed R1's X-ray results were received, relayed to the doctor, and orders were given to send R1 to the hospital for an acute intertrochanteric fracture of the proximal right femur with mild varus deformity. R1's Hospital Records showed she was admitted on [DATE] at 2:45 PM (22 hours after R1's unwitnessed fall that resulted in a right hip fracture).These records showed R1 was presented to the hospital after a fell yesterday evening at the facility. R1's X-ray showed an acute intertrochanteric fracture of the right femur. R1 had pain with movement of her right leg. R1 was admitted for orthopedic evaluation. R1 was a poor surgical candidate and returned to the facility on [DATE] with non-weight bearing (NWB) status to her right leg. On 10/16/24 at 12:51 PM, V6 (LPN) said she wasn't working when R1 fell (10/8/24 at 4 PM), but she was the nurse that sent R1 to the hospital on 10/9/24. V6 said she sent R1 to the emergency room around mid-day 10/9/24 because her X-ray showed a fracture. V6 said R1 is alert to person/place and can tell you what she needs/wants. V6 said R1's voice is very quiet, but she can answer questions. V6 said R1 complained of right leg pain (10/9/24) and she notified V3 (DON) and V4 (ADON). V6 said the decision was made to send R1 to the hospital. On 10/16/24 at 1:54 PM, V3 (Director of Nursing/DON) said he was off when R1 fell (10/8/24), and when she was sent to the hospital (10/9/24). V3 said he got a phone call from V11 (Nursing Supervisor). V3 said V11 told him that he was doing rounds and found R1 on the floor. V3 said an hour later he got a call from V13 (R1's RN), and he said R1 was having pain, the doctor was called, and an order for an X-ray was obtained. V3 said it was about 5:30 PM. V3 said he would have expected the nurses to enter the X-ray orders as STAT. V3 said he would have to review the X-ray order to see how it was entered. V3 reviewed the report and said the Order Type was standard or routine, not STAT. V3 said the X-ray should have been ordered STAT to ensure the results were received in a timely manner and any injuries could be treated properly and timely. V3 said the X-ray results weren't received until close to noon on 10/9/24. V3 said the X-ray showed R1 had an acute right hip fracture, the provider was notified, and she was sent to the emergency room . V3 said after the X-ray was completed, then he expects the nurses will watch the chart for the results and relay the results to the provider as soon as possible. V3 said R1's X-ray showed she had a fracture and it's important to get her to the hospital for an appropriate evaluation and treatment of the injury. V3 said it shouldn't have taken so long to get R1's X-ray results, but they have had issues with the company that completes their X-rays. On 10/18/24 at 8:23 AM, V19 (RN) said she worked as the Nursing Supervisor on 10/8/24 from 11PM to 7 AM. V19 said she was told R1 fell on ,d+[DATE] shift and wasn't acting like herself. V19 said she remembered seeing R1 was weak and complaining of pain. V19 said she wasn't sure what time the X-ray was completed, but she did not receive the results. V19 said she did not review R1's chart for the X-ray results. V19 said on 10/9/24 when she gave report, she notified the on-coming supervisor to watch for the X-ray results. V19 said she checked with V20 (R1's nurse 10/8/24 11P-7A) and she said she didn't have results. V19 said there have been problems with the X-ray company and there sometimes are delays in the report times. On 10/18/24 at 8:59 AM, V17 (Certified Nursing Assistant/CNA) said she was R1's CNA from 11 PM to 7 AM on 10/8/24. V17 said she provided care to R1 2-3 times during her shift. V17 said R1 was grimacing, wincing, and moaning whenever she had to turn her to provide care. V17 said it seemed like R1 was having pain in her right hip. V17 said she reported it to V20 (R1's nurse) and she said that she knew about it. V17 said R1 stayed in the bed all night. On 10/18/24 at 9:05 AM, V20 (LPN) said she was the only nurse working R1's floor 11 PM to 7 AM on 10/8/24. V20 said R1 fell on ,d+[DATE] shift and stayed in bed all night. V20 said she did get report that R1 complained of pain in her right leg. V20 said she was told an X-ray was done and they were waiting on the results. V20 said she didn't get any calls from the X-ray company about R1's X-ray results. V20 said she notified the day shift nurse to follow-up on the X-ray results. On 10/18/24 at 9:59 AM, V22 (Nurse Practitioner/NP) said R1 was not one of her regular residents, but she was covering for another NP. V22 said she received an urgent call form the facility on 10/8/24 that R1 had fallen, her leg was swollen, and they were requesting X-ray orders. V22 said she gave orders for immediate X-rays and she didn't hear anything back from the facility until the next day. V22 said when a STAT order is given, she would expect the results to be received quickly. V22 said sometimes the X-ray company will call the results, but not always. V22 said it's been a problem, but the nurse should also be watching for the X-ray results in the computer. V22 said she would check her messages to determine the time she was notified. V22 said she received a message from V4 (Asssistant Director of Nursing/ADON) at 9:37 AM regarding R1's X-ray showing a fracture. V22 said R1's doctor was also notified, and he gave orders to send her to the hospital. V22 said she had no idea R1's X-ray results were available the night before. V22 said if she would have received the results then, R1 would have been sent to the hospital sooner. V22 stated, They didn't communicate with me. The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results Policy, revised 3/14/18, showed, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care . Guidelines for Reporting Abnormal Results: .X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: pneumonia, new fracture . The licensed nurse is responsible for documenting the notification of results in the clinical record. The facility's Physician-Family Notification-Change in Condition Policy, reviewed 7/8/24, showed, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a resident at high risk for falling for 1 of 3 residents (R1) reviewed for falls in the sample of 4. This failure resulted in R1 experiencing an unwitnessed fall and sustaining a right hip fracture. The findings include: R1's Facesheet, dated 10/16/24, showed diagnoses to include, but not limited to: displaced interrogate right femur fracture; stage 2 CKD (chronic kidney disease); hemiplegia and hemiparesis following a stroke; dysphagia; dysarthria; severe-protein calorie malnutrition, vascular dementia, and anxiety. R1's facility assessment, dated 8/30/24, showed she had moderate cognitive impairment; and required partial to moderate assistance with eating, bed mobility, and transfers. R1's Fall Risk Assessment completed 7/3/24 showed R1 was at High Risk for Falling. R1's Care Plan, initiated 4/18/24, showed R1 was at high risk for falls related to confusion and gait/balance problems. On 10/16/24 at 1:22 PM, R1 was lying on her back, in bed. R1 said she did fall, but was unable to provide any further details of the fall. R1 said her right leg hurt when she had to move. R1's Risk Management, dated 10/8/24, showed, Nursing supervisor noted resident lying on the floor on the right side of her bed during rounds. Resident dressed with non-skid socks on. (R1's) wheelchair noted to be on the left side of the bed. (The) resident stated, I fell , I don't remember. This document showed R1 had facial grimacing and moaning when right leg moved after the fall. This form showed R1's pain was rated at a 5 on a scale from 1-10 (10 being the worst pain). The Facility's Fall investigation provided showed the following statements. V13 (Registered Nurse - RN) said he was passing medications when the nursing supervisor noted R1 lying on the floor on the right side of her bed. A head to toe assessment was completed with full ROM (Range of Motion) present. R1 complained of pain later on during the evening to her right leg. There was no swelling or bruising noted at this time. The NP (Nurse Practitioner) was notified and orders were received for X-rays of the right leg. Pain medications was administered. This form showed V15 (Certified Nursing Assistant - CNA's) statement was that she did not see R1 on the floor 10/8/24. This form showed V11 (Nursing Supervisor's) statement was he saw R1 on the floor, during rounds. V11 said R1 was lying on her right side, on the right side of her bed and her wheelchair was on the opposite side of the bed. R1's Care Plan, initiated 10/15/24 (after R1's fall), showed R1 required the use of a full body lift for transfer secondary to NWB (non-weight bearing) status to her right leg. R1's X-ray Report, dated 10/8/24, showed R1 had an acute intertrochanteric fracture of the proximal right femur with mild varus deformity (an excessive inward angulation of the distal segment of the bone). R1's has no progress notes from 10/7/24 at 1:24 PM until 10/9/24 at 2:12 AM, that demonstrates continued monitoring of pain and the resident's condition. This note showed, The resident was sent to (local emergency room ) via ambulance at 2:12 PM. This note was entered by V6 (Licensed Practical Nurse - LPN and she worked 7 AM to 3 PM on 10/9/24; she wasn't in the building at the time of this note entry. R1's Change in Condition note, dated 10/9/24 at 12:50 PM, showed R1 had decreased mobility, pain, and X-ray results showed she had an acute fracture. This note showed R1 a non-emergent ambulance was contacted with an ETA (estimated time of arrival) in 30 minutes. R1's Radiology Note, dated 10/9/24 at 12:50 PM, showed R1's X-ray results were received, relayed to the doctor, and orders were given to send R1 to the hospital for an acute intertrochanteric fracture of the proximal right femur with mild varus deformity. R1's Hospital Records showed she was admitted on [DATE] at 2:45 PM (22 hours after R1's unwitnessed fall that resulted in a right hip fracture).These records showed R1 was presented to the hospital after a fell yesterday evening at the facility. R1's X-ray showed an acute intertrochanteric fracture of the right femur. R1 had pain with movement of her right leg. R1 was admitted for orthopedic evaluation. R1 was a poor surgical candidate and returned to the facility on [DATE] with non-weight bearing (NWB) status to her right leg. R1's October 2024 MAR (Medication Administration Record) showed she had pain at a level 5 on 10/8/24 at 9:52 PM and was administered Tylenol. This document showed R1 required Norco (opioid pain medication) after her fall. On 10/15/24 and 10/16/24 R1 was administered Norco for pain levels of 5 and 7. On 10/16/24 at 12:51 PM, V6 (Licensed Practical Nurse/LPN) said she wasn't working when R1 fell (10/8/24 at 4 PM), but she was the nurse that sent R1 to the hospital on 10/9/24. V6 said she sent R1 to the emergency room around mid-day 10/9/24 because her X-ray showed a fracture. V6 said R1 is alert to person/place and can tell you what she needs/wants. V6 said R1's voice is very quite, but she can answer questions. V6 said R1 complained of right leg pain (10/9/24) and she notified V3 (DON) and V4 (ADON). V6 said the decision was made to send R1 to the hospital. V6 said R1 had been staying in bed since she returned from the hospital. On 10/16/24 at 1:07 PM, V7 (CNA) said he hadn't been assigned to R1 for a month or two, but R1 was able to ambulate with a walker and standby assistance. V7 said now R1 is in bed or the wheelchair. On 10/16/24 at 1:54 PM, V3 (Director of Nursing/DON) said he was off when R1 fell (10/8/24) and when she was sent to the hospital (10/9/24). V3 said he got a phone call from V11 (Nursing Supervisor). V3 said V11 told him that he was doing rounds and found R1 on the floor. V3 said an hour later he got a call from V13 (R1's RN), and he said R1 was having pain, the doctor was called, and an order for an X-ray was obtained. V3 said it was about 5:30 PM. V3 said he conducted interviews with the staff regarding R1's fall. V3 said prior to R1's fall she was walking with a walker. V3 said R1 had some weakness from a previous stroke, but she was able to ambulate with minimal assistance. V3 said since R1 returned from the hospital she required a total lift and was NWB to her right leg. On 10/16/24 at 2:55 PM, V11 (Nursing Supervisor) said he was doing rounds on 10/8/24 and found R1 on the floor, on the right side of her bed. V11 said it was approximately 4 PM. V11 said R1 was lying on her right side and her wheelchair was on the left side of the bed. V11 said R1 said she fell , but couldn't provide details of what happened. V11 said completed a head to toe assessment, reported the fall to V13 (R1's RN), and assisted him to use the total lift to transfer R1 back to bed. V11 said he didn't make any phone calls, but provided V13 (R1's nurse) with reminders to complete all the proper documentation and make phone calls to the provider and resident's family. On 10/18/24 at 8:23 AM, V19 (RN) said she worked as the Nursing Supervisor on 10/8/24 from 11PM to 7 AM. V19 said she was told R1 fell on ,d+[DATE] shift and wasn't acting like herself. V19 said she remembered seeing R1 was weak and complaining of pain. On 10/18/24 at 8:59 AM, V17 (CNA) said she was R1's CNA from 11 PM to 7 AM on 10/8/24. V17 said she provided care to R1 2-3 times during her shift. V17 said R1 was grimacing, wincing, and moaning whenever she had to turn her to provide care. V17 said it seemed like R1 was having pain in her right hip. V17 said she reported it to V20 (R1's nurse) and she said that she knew about it. V17 said R1 stayed in the bed all night. On 10/18/24 at 9:59 AM, V22 (NP) said R1 was not one of her regular residents, but she was covering for another NP. V22 said she received an urgent call form the facility on 10/8/24 that R1 had fallen, her leg was swollen, and they were requesting X-ray orders. V22 said she gave orders for immediate X-rays and she didn't hear anything back from the facility until the next day. V22 said R1's right hip fracture was caused by the unwitnessed fall. The facility's Fall Prevention Program, revised 11/21/17, showed, Purpose: 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 .

Based on interview and record review, the facility failed to have an effective process in place for staff to quickly identify a resident's code status. The facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R1) found not breathing and pulseless, whose POLST (Physician Orders for Life-Sustaining Treatment) form showed the resident was a Full Code. These failures led to a delay in R1 receiving CPR and R1 dying in the facility. These failures apply to 1 of 6 residents (R1) reviewed for deaths in the facility in the sample of 6. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when facility staff failed to immediately initiate CPR on R1, when he was found unresponsive and pulseless, due to facility staff not being able to quickly identify R1's code status. These failures resulted in R1 dying in the facility on [DATE]. The Immediate Jeopardy was identified on [DATE]. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 2:27 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE]; however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's care plan, dated [DATE], showed R1 was a cognitively impaired resident with diagnoses of dementia, cerebral infarction (stroke), dysphagia, and schizophrenia. R1 was dependent on staff for all cares. The care plan showed R1 was a Full Code and wanted full treatment/CPR in the event of a cardiac arrest. The plan showed R1 wishes for full code status, as specified in their advanced directive documents, will be honored and clearly delineated in the medical record . R1's POLST form, dated [DATE], showed R1 was a Full Code. Staff were to attempt CPR and provide all indicated treatments to R1 in the event of a cardiac arrest. The form was signed by V6 (R1's Physician) and R1's legal guardian. A physician order for R1, dated [DATE], showed R1 was a Full Code. R1's nurses note, dated [DATE], showed R1 was found unresponsive and pulseless in his room by staff at 6:29 PM. V7, Registered Nurse (RN), started CPR on R1 and 911 was called. EMS (Emergency Medical Services) arrived at the facility at 6:35 PM and took over providing CPR to R1. R1 was pronounced dead in the facility at 7:10 PM. R1's death certificate, dated [DATE], showed R1's cause of death as cardiopulmonary arrest. On [DATE] at 9:45 AM, V5, Certified Nursing Assistant (CNA), stated she fed R1 dinner on the evening of [DATE]. V5 stated, (R1) was fine at dinner. I fed him in his room while he seated upright in his Geri Chair (reclining wheelchair). When I went back to check on him, about a half hour later, he didn't look right. He was still sitting in his chair. His eyes were open. I called out his name and he didn't respond. He didn't look at me. I didn't check to see if he was breathing. I don't know if he had a pulse. I didn't know what to do. I left the room to go find the nurse (V7, RN). I found the nurse (V7) in another resident's room and asked him to come look at (R1). (V7) walked down to (R1's) room with me. He checked for a pulse on (R1) and tried to get (R1) to respond. (V7) then walked out of (R1's) and said he had to go check to see what (R1's) code status was. (V7) went to the nurses station and checked (R1's) code status on the computer. (R7) came back into the room and started CPR on (R1) because he said (R1) was a Full Code. V5 stated she was CPR certified, but did not check R1 for a pulse or yell for help when she found R1 unresponsive because, I didn't know what to do. I was nervous. V5 stated from the time she entered R1's room and found him unresponsive, to the time V7 (RN) started CPR on R1, was probably at least a few minutes. We had to get (R1) up out of his chair to do CPR. When V5 was asked how to quickly identify a resident's code status, V5 stated, I don't know. I would have to ask the nurse. On [DATE] at 10:21 AM, V7, RN, stated on [DATE], he was in another resident's room when V5 (CNA) came to find him. V7 (RN) stated, (V5) asked me to come look at (R1) because she said he didn't look right. I got up and went down to (R1's) room. He was up in his wheelchair. He was not responding to me. I tried to feel for a pulse on him, but I couldn't feel one. I didn't know if he was a Full Code or not, so I went out to a computer at the nurses station to check. I saw in the computer (R1) was a Full Code. I went back in to his room and tried to feel for a pulse again. I didn't feel a pulse on (R1), so I called a code and started CPR on him. V7 stated, If I don't know a resident's code status, I have to check their medical record on the computer at the nurses station. On [DATE] at 9:59 AM, V6 (R1's Physician) stated, If a resident, that is a full code, is found pulseless and not breathing, staff are to start CPR on the resident immediately. V6 stated a delay in CPR could cause death. V6 stated he did not know any details surrounding R1's death in the facility, but stated, I just know he died of cardiac arrest. On [DATE] at 11:20 AM, V3 (Director of Nursing/DON) stated, If staff find a resident unresponsive and the resident is a Full Code, they should check for a pulse and start CPR immediately. Staff are not to leave the resident. They are supposed to shout for help. V3 stated, There really isn't a quick way to verify the code status of a resident. Staff either have to check the chart in the computer or check the DNR (do not resuscitate) lists we have located in the binders on the crash carts on the floors. On [DATE], V4, Licensed Practical Nurse (LPN), V8 (LPN), and V9 (LPN) each stated the only way to verify a resident's code status is by leaving the resident's room to check their electronic medical record via computers located at the nurses stations. On [DATE], V10 and V12 (CNAs) each stated they did not know how to check a resident's code status. V10 and V12 each stated they would have to ask a nurse to verify a resident's code status. The facility's Cardiopulmonary-CPR policy, dated [DATE], showed, The facility will provide basic life support, including CPR, when a resident requires such care, prior to arrival of EMS, subject to physician order, and resident choice indicated in the resident's advanced directives .CPR Procedure: Check for resident response while simultaneously assessing the resident for breathing and pulse for 10 seconds. Shout for help and activate the emergency response system by announcing overhead, 3 times, code blue and the location of the code . The facility presented an abatement plan to remove the immediacy on [DATE] at 8:08 AM. This surveyor reviewed the abatement plan and was able to accept the plan to remove the immediacy on [DATE]. The Immediate Jeopardy that began on [DATE] was removed [DATE] when the facility took the following actions to remove the immediacy: 1. R1 expired in the facility [DATE] after a code blue was initiated by staff and four rounds of epinephrine was administered by 911 EMS services. 2. On [DATE] at 3:30 PM, Social Services Director and Director of Nursing completed full facility audit of DNR (do not resuscitate) status to ensure all POLST forms are in place and match code status in PCC (computer charting/medical records). 3. Facility staff were educated on where resident code status is available via PCC as well as POLST binders located at each crash cart on each unit to quickly identify a resident's CPR/code status. 4. Staff educated on facility's Code Blue Policy and process on what do to should a resident be found unresponsive and pulseless to ensure not delay in CPR including but not limited to (see attachment A): a. Assess for pulse and respirations b. Verify code status/advanced directives c. If a resident is a Full Code, announce Code Blue via overhead paging-give specific location d. Licensed nurses and other staff will respond e. Call 911 f. CPR started by first person on scene. CPR will be alternated between the nursing staff until the ambulance arrives. 5. Education on Code Blue policy and POLST binders location on each crash cart to quickly identify code status has been included in facility new hire orientation process and annually for all staff. 6. Based on facility staffing roster as of [DATE] at 11:00 PM, education has been provided to all RNs, LPNs, and CNAs staff currently present in the facility and all staff not present in the facility, have been in-serviced over the phone and will be re-inserviced before the start of their next shift. 7. Emergency QA meeting conducted on [DATE] at 7:35 PM with facility Medical Director. 8. The Director Of Nursing/DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure staff is able to state facility's Code Blue Policy, how to quickly identify a resident's code status, and immediately initiate CPR as/when indicated. 9. The DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure they are aware of the POLST binders located on each crash cart in the facility for quick identification of code status. 10. Social Services will conduct audits of POLST binders, 2 times a week for 3 months, to ensure the binders are up to date with the latest POLST information.

Based on interview and record review, the facility failed to ensure a resident was treated in a dignified manner for 1 of 3 residents (R1) reviewed for dignity in the sample of 3. This failure resulted in R1 being ignored, left naked, and crying after the insertion of a permacath. The findings include: R1's Physician Order Sheet shows R1 has diagnosis of chronic kidney disease and dependent on dialysis. The same POS shows R1 has a Permacath Insertion ( access line insertion) for dialysis access. The Facility Reported Incident as Final, dated 1/10/24, (with incident date of 1/5/24) documents, (R1), 75 y/o alert and oriented x 3 -on 1/5/24 it was reported to the facility Administrator that resident (R1) was left in an undignified manner after care was provided and talked to inappropriately by a nurse. Nurse identified within the investigation was an (outside Vascular) Nurse conducting a permacath ( access line insertion) insertion. Facility contacted the (outside Vascular Company) regarding the concern . (V4, Licensed Practical Nurse/LPN), (R1's) nurse on 1/5/24 said she was informed by (R1) that the (outside Vascular) nurse (V7) conducting the procedure told (R1) she was difficult to deal with. After the procedure, (R1) was bloody, naked, and the Vascular Company left needles on the floor. Per (R1) when she asked questions the (outside Vascular) nurse (V7) ignored her. R1's progress notes, dated 1/5/24 by V2 (Director of Nursing), shows, (R1) was upset after permacath insertion. (R1) was in tears when this writer went into her room. Per resident she did not like how the female nurse treated her during the procedure, she (R1) was asking questions and was purposely ignored. Per (R1), she asked to be turned but was ignored by the female nurse and she was left with no sheets to cover her. On 1/22/24 at 9:42 AM, V3 (Assistant Director of Nursing) said R1's dialysis access was clogged. R1 had an order for an in house permacath insertion by an outside Vascular Company on 1/5/24. On 1/22/24 at 10:25AM, R1 was alert and pleasant and receiving treatment in dialysis. When asked about the incident on 1/5/24, R1 stated, They did me wrong! A follow up interview was done at 12:30 PM, R1 was now in bed alert and stated, The female nurse ignored me, won't answer my questions and won't cover me up. On 1/22/24 at 10:10 AM, V6 (Nurse Supervisor) said on 1/5/24, she saw R1's call light on. She went and checked R1. The 2 Vascular staff (male and female) were in the process of inserting the permacath. (R1) was asking to be turned, and she was being ignored. (R1) was also naked; (R1's) breast was exposed, (curtains were pulled), there was an incision in (R1's) chest for the permacath, and the staff were now trying to insert the permacath in (R1's) femoral artery (leg). On 1/22/24 at 10 AM, V5 (Certified Nursing Assistant-CNA) said she was R1's CNA on 1/5/24. V5 said she was in the room taking care of another resident (R1's roomate) when R1 was having the dialysis procedure. V5 said she could hear R1 crying, but the curtains were pulled. V5 said later, she saw the staff (Vascular staff male and female) at the elevator leaving the floor, so she went and checked R1. R1 was crying, R1 had no covers, and blood spots were on R1's linens. V5 said she asked R1 what happened; R1 told her They just left me like this, (naked) and left without saying anything. V5 said she went and told R1's nurse (V4, Licensed Practical Nurse/LPN). On 1/22/24 at 12:18 PM, V4 (License Practical Nurse- LPN) said on 1/5/24, she was told R1 was crying after the dialysis procedure. R1 told her the female nurse was rude and was ignoring R1, and wouldn't answer any of her questions. V4 said residents should be treated with respect and take time to answer their questions. On 1/22/24 at 12:05 PM, V8 (CEO of the Vascular Access Company) said, We are a Vascular Access Company that goes to the facility for insertion procedure for dialysis access. On 1/5/24, we were at the facility to insert (R1's) dialysis access (permacath). V8 said he was with her female Vascular Nurse assistant (V7). V8 said they were focused on inserting a dialysis access to R1, and were not aware that was how R1 perceived them. V8 said they will have to be careful next time. On 1/22/24 at 1:45 PM, both V1 (Administrator) and V2 (Director of Nursing/DON) said residents should be treated with respect and dignity. The facility policy entitled Dignity, dated 4/23/18, shows, The facility shall promote care for resident in a manner and in an environment that maintain or enhances each resident's dignity and respect and in full recognition of his or her individuality.

Based on observation, interview and record review the facility failed to turn and reposition a resident (R2) in a safe manner to avoid injury. This failure contributed to a fracture of R2's left upper arm (humerus). This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 6. The findings include: R2's care plan dated January 29, 2020 showed R2 was nonverbal with a [MEDICAL CONDITION] in place and is severely cognitively impaired. R2 is unable to move his extremities independently related to his [DIAGNOSES REDACTED]. The care plan also showed R2 required total assistance of 2 staff for bed mobility and transfers as well as use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R2's resident assessment dated [DATE] showed R2 was totally dependent on 2+ persons for bed mobility. R2's Injury of Unknown Origin report dated February 27, 2020 (untimed) showed R2 was found to have discoloration and swelling to his left shoulder. R2's hospital Emergency Documentation dated February 27, 2020 at 9:34 PM showed R2 was sent to the hospital for an evaluation due to bruising of his left shoulder/upper arm area. R2's left shoulder radiology findings dated February 27, 2020 at 9:57 PM showed, 1. Acute mildy impacted fracture of left humeral neck. 2. Acute mildly displaced oblique fracture through the proximal left humeral diaphysis. On March 2, 2020 at 9:20 AM, R2 was lying in bed with a splint under his left upper arm that was wrapped with cotton padding and an elastic wrap. R2's left shoulder was swollen with areas of scattered purple bruising noted across and around R2's left shoulder and left upper arm. R2's eyes remained closed with no voluntary or involuntary movement noted of R2's extremities. On March 2, 2020 at 12:00 PM, V6, V7, V8 and V9 Certified Nursing Assistants (CNA) were interviewed and they all stated R2 does not move at all without assistance and he requires 2 staff to reposition him in bed. V6 CNA stated, We haven't gotten (R2) out of bed in months per his family's request. We need two people to reposition him and we bathe him in bed. On March 2, 2020 at 12:10 PM, V9 stated, I took care of (R2) on the day shift on February 26th (2020). We never got him out of bed and it took 2 of us to roll him. He didn't have any swelling or bruising to his left shoulder then. On March 2, 2020 at 2:45 PM, V19 CNA stated, I took care of (R2) from 11:00 PM on February 26 (2020) until 7:00 AM on February 27. I don't recall seeing anything wrong with (R2's) shoulder in the beginning, but later in my shift, I did notice some discoloration to his left shoulder. V19 stated she told the night nurse about R2's left shoulder discoloration, but V19 was unable to recall the nurse's name. When V19 CNA was asked which staff member assisted her in repositioning R2 during the night shift on February 26, V19 CNA replied, I repositioned him myself every 2 hours. I am not sure how many times that was. When V19 CNA was asked if she usually repositions R2 in bed, by herself, V19 stated, Yes, I can do it. On March 2, 2020 at 10:25 AM, V4 Registered Nurse (RN) stated he cared for R2 on February 27, 2020 from 7:00 AM-3:00 PM. V4 stated, I noticed (R2's) left shoulder was swollen and bruised and immediately reported it to (V2 Director of Nursing) and (V3 Nurse Practitioner/NP). That shoulder swelling was new for him and I got no report of an injury or swelling to (R2's) left shoulder from the night nurse that morning. We ordered an X-ray right away. On March 2, 2020 at 11:20 AM, V3 Nurse Practitioner stated, I was asked to see (R2) on February 27, 2020 because of the swelling to his left shoulder. Upon examinination, (R2's) left shoulder and upper arm was swollen with bruising noted to his left shoulder and armpit area so I ordered a STAT (immediate) X-ray of his shoulder. The X-ray showed a fracture but I believe (R2) has some bone density disease. (R2) has never had a fracture like this before. I have never seen him move his arms or legs at all. Usually some force has to be applied to cause a fracture like this (impacted, displaced) even if the resident has some type of bone density disease. I don't know what happened to him. On March 2, 2020 at 1:10 PM, V10 Family of R2 stated, (R2) hasn't gotten out of bed in years. We stopped getting him up years ago. I got a call from (V2 Director of Nursing) and she told me his shoulder fracture happened because he has brittle bones and has been in the nursing home for 5 years. My concern is that something happened when they were moving him in bed because he doesn't move himself at all. They are supposed to reposition him with 2 people and they usually have just one person roll him because they are always short staffed. I have seen this happen many times when visiting (R2). On March 3, 2020 at 2:10 PM, V21 Orthopedic Physician Assistant stated, (R2) is osteopenic. With that said, it would take some type of force applied to (R2's) left shoulder to have caused the fracture. That force could have easily been from just from repositioning him in bed. V21 stated he would refer to and follow the facility's assessments and recommendations completed on that resident to ensure that resident was transferred and repositioned in a safe manner.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident who requires supervision with smoking. This failure resulted in R4 being outside on the patio unknown to staff at approximately 3:00 AM, wearing oxygen, lighting a cigarette and sustaining second degree facial burns. These failure resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 24, 2019 when R4 was outside un-supervised lighting a cigarette with his oxygen on. On (MONTH) 19, 2019 at 12:15 PM, V1 (Administrator) was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 16, 2019. While the immediacy was removed, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 7. The findings include: The Final Incident Investigation Report dated (MONTH) 29, 2019 documents, R4 is a [AGE] year old male with a [DIAGNOSES REDACTED]. R4 stated he was outside on the patio the morning on (MONTH) 24, 2019, when he lit his cigarette and caught his long beard on fire. The Emergency report dated (MONTH) 24, 2019 documents R4 presented with facial injuries that happened in the early morning hours. R4 was smoking with his oxygen on when it caught on fire and injured his face .R4 sustained 2nd [MEDICAL CONDITION] his left cheek, lower nose, and the soot on his nares . V5's (Nurse Practitioner) progress note dated (MONTH) 25, 2019 documents R4 was sent to the emergency roiagnom on (MONTH) 24, 2019 for treatment of [REDACTED]. V5 documents R4 reported to R7 (R4's brother/POA/roommate) he picked up a cigarette butt on the patio and lit it while wearing his oxygen causing a flame that burned some areas on the left side of his face. Half of the left eyebrow burned, his left upper eyelid had greyish discoloration, and the left cheek area with greyish black streak, R4's nares had blackish burnt tissues. The physician's orders [REDACTED]. The Minimum Data Set assessment dated (MONTH) 21, 2019 shows R4 is cognitively intact. R4's Smoking Safety Risk Observation dated (MONTH) 3, 2019 shows R4 requires supervision with smoking. The same report shows R4 scored a risk of having a moderate problem in these areas: general awareness and orientation, including the ability to understand the facility safe smoking policy, potential for causing injury to himself or others from smoking in unauthorized areas or careless using smoking materials and R4 has a history of hazardous behavior, begs borrows, trades items, and panhandles for smoking materials. R4's wound report dated (MONTH) 25, 2019, shows pictures of [MEDICAL CONDITION] R4's face. R4's left eyebrow was burned with grayish black discoloration to the left side of his eye/face. An imprint of the oxygen tubing was on the left side of his face. Both of R4's nostrils are blackened with some skin burned off and R4 had burn discoloration to his upper lip. The same report documents these wounds as facility acquired full thickness burns. On (MONTH) 16, 2019 at 12:07 PM, R4 was lying in bed with his oxygen on. R4's left eye had redness with part of his left eyebrow having little hair. His left eyelashes appeared singed with redness to his cheeks, nose, and upper lip. R4 said on (MONTH) 24, 2019 he went outside around 3:00 AM. He took the elevator across from the nurse's station to the basement. R4 said there was no staff at the nurse's station at this time. He went through the double doors in the basement dining room then outside the patio door. R4 said there is no lock or alarm on the doors. R4 said he found a cigarette butt outside and lit up the cigarette while wearing his oxygen and then his face caught on fire. R4 said he slapped his face with his hands multiple times to extinguish the fire. On (MONTH) 16, 2019 at 12:24 PM, R7 (R4's POA/roommate) said in the morning on (MONTH) 24, 2019, V9 (RN) and V14 (Nurse Supervisor) woke him sometime after 7:00 AM, and said his brother (R4) got into a fight. R7 said he looked at his brother's face and said his brother's left eye was black and swollen. R7 saw imprint of R4's nasal cannula tubing on his face, part of his mustache was gone and both of his nostrils were pitch black. R7 said he talked to his brother and R4 told him he caught himself on fire lighting a cigarette outside by himself while wearing his oxygen. R7 said you could tell R4 sustained a burn. R7 said Now facility staff put a lock on the cigarette butt receptacles since this happened. On (MONTH) 16, 2019 at 12:36 PM, V9 (RN) said R4 came up to nurse's station around 7:30 AM asking for coffee. He had bruising and redness to his face. He first told me he got into a fight, then told me he was outside and caught his face on fire while wearing his oxygen. I could not tell he [MEDICAL CONDITION] his face. On (MONTH) 16, 2019 at 12:53 PM, this surveyor opened the patio doors. They were unlocked and did not alarm. V10 (Activity Aide) said Residents can get outside anytime. There is no alarm or lock on the double doors that enter the dining room or the patio doors. At 12:55 PM, V11 (Outside Contractor) was installing a lock mechanism on the double doors that enter the basement dining room. V11 said This door will automatically lock now at 8:00 PM and unlock at 7:00 AM. I'm installing an egress/fire exit on this door. On (MONTH) 17, 2019 at 1:15 PM, R6 said he was outside around 3:00 AM on (MONTH) 24, 2019, smoking a cigarette without staff. R6 said R4 was outside on the patio at the same time. R6 said when he got done smoking he went back into the building while R4 was still outside. R6 said there is no lock or alarm on the double doors to the dining room or on the patio doors. R6 said he has seen R4 outside un-supervised in the past. On (MONTH) 17, 2019 at 1:45 PM, V 12 (LPN) said she was R4's nurse on (MONTH) 24, 2019. V12 said I don't know how R4 got outside without supervision. I don't know if the basement doors are locked or alarmed. I've never been down there. On (MONTH) 17, 2019 at 10:45 AM, V7 (Maintenance Director) said Since R4 sneaked outside with his oxygen and lit a cigarette and caught himself on fire, we have installed new locking mechanisms on the double doors that enter the dining room onto the patio. Before the incident residents could exit anytime thru both sets of doors. On (MONTH) 18, 2019 at 9:10 AM, V5 (Nurse Practitioner) said R4 sustained [MEDICAL CONDITION] lighting a cigarette and wearing his oxygen. R4 is not safe to be outside by himself and needs supervision with smoking. I have seen R4 outside unsupervised in the past and escorted him back inside the building. R7 (R4's POA) reported R4 will pick up cigarette butts from outside. The facility's Smoking Program document states, To provide a safe and healthy living environment with respect for the health and well-being needs of each resident . Guidelines: Community will assign staff to monitor residents during the designated smoking times, Assigned staff will remain in the designated area during the entire scheduled smoking time, .A Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking .Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is prohibited . The undated Resident's Smoking Club report shows the smoking location is on the Patio with the smoking times: 9:00 AM, 11:30 AM, 1PM, 4PM, 6PM, and 7:30 PM. Through observation, interview and record review on (MONTH) 19, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy: 1.) There are 27 residents identified in the Smoking Club. On (MONTH) 16, 2019 all smoking assessments were reviewed for accuracy to identify resident risk level. All smoking materials are now locked in the Activity Room. All residents will only be allowed to smoke at designated times with activity staff with supervision. Completion Date: (MONTH) 16, 2109. 2.) On (MONTH) 16, 2019, re-education was immediately started with facility staff which includes CNA's, Nurses, and all other staff involved on the smoking policy/procedures by the DON and designated staff: Completion date: (MONTH) 16, 2019. 3.) All Ash receptacles had locks installed on (MONTH) 24, 2019- to prevent residents removing cigarette butts from the ashtrays. 4.) The Facility took immediate action to ensure implement measures to ensure residents who require supervision are not able to exit patio doors with staff knowledge. Magnetic locks were installed on (MONTH) 16, 2019. Completion date: (MONTH) 16, 2019 5.) The facility immediately reviewed and revised R4's smoking assessment. All residents who smoke will be supervised by activity staff, regardless of risk level. Completion Date: (MONTH) 16, 2019.

Based on interview, and record review the facility failed to protect a resident (R5) from sexual abuse and two residents (R2, R4) from verbal abuse for 3 of 6 residents reviewed for resident to resident abuse in the sample of 6. The findings include: 1. The facility's Preliminary 24-hour Incident Investigation Report showed on On 9/24/19 (Date is incorrect. Incident was faxed to the Local State Agency on 9/23/19) at around 11:15 PM it was reported to the Administrator that one of the Nurses had witnessed (R6, male) touch (R5, female) inappropriately by the nursing station . The facility's investigation showed a 9/25/19 statement from V11 Licensed Practical Nurse (LPN) as follows, I witnessed (R6) and (R5) sitting next to the Nursing station having a conversation. I looked down for no longer than 30 seconds and (R6) had his hand on (R5) and was touching her inappropriately . On 9/26/19 at 10:05 AM, V11 stated he observed R6 with one of his hands under R5's gown. V11 denied being aware of any inappropriate sexual behaviors regarding R6. V11 stated, I haven't been on that floor a lot .I am not aware of any behaviors he (R6) has .I was not aware of any previous sexual behavior. I've never heard of him making inappropriate comments to staff or residents. V17 Local Police Department Officer summary statement showed, On 09-23-19 at approximately 2314 hours (11:14 PM), I (V17) responded to (the facility) .in reference to a sexual assault between 2 patients. Upon my arrival, I met with the facility administrator (V1) and nurse (V11) . (V1) informed me that a dementia patient had touched the vaginal area of another patient who is diagnosed with [REDACTED]. (V1) Informed me that the offender, (R6) has a history of making inappropriate sexual remarks towards other patients .(V1) informed me that (V11) witnessed (R6) touching the vaginal area of (R5) earlier .(R5) appeared to have the speech pattern of a young child, but did state that (R6) tries to touch her breasts often. (R5) stated that she repeatedly tells him to leave her alone which he does not comply with. (R5) stated that her and (R6) are not and have never been in a relationship with each other. (R5) stated she remembered (R6) touching her today, but did not state where he touched her. (R5) stated she tells him to stay away from her vagina and does not let him touch her there. (R5) stated she wanted (R6) arrested for bothering her and trying to touch her breasts .V11 stated that today, while he was charting at the main nurses station on the 4th floor both (R5) and (R6) were sitting near each other. (V11) stated that he had to turn away for a moment and when he returned he saw (R6's) hands under (R5's) gown in the area of the vagina .we returned to (V1's) office where I learned that they had reported a similar incident earlier this year between (R6) and another female patient . On 9/25/19 at 10:30 AM, the facility's 9/23/19 security footage was reviewed, with V1, for the fourth floor nursing station. The video showed at 7:39 PM (V1 stated the date and time stamp was accurate) V11 sitting at the nurses station. To V11's right, R5 was sitting in a chair in the hallway and she was facing V11. V11 appeared to be looking down at the desk. At approximately 7:40 PM, R6 was observed self propelling in a wheelchair towards R5. R6 moved to a position directly infront of and facing R5. V11 did not intervene when he moved in front of her. In the camera angle, R5 is facing the camera and R6 had his back to the camera. R6's position obscured vision of R5's lower half and where he was placing his hands. Shortly after R6 maneuvered his chair in front of R5, he leaned towards R5. At approximately 7:42 PM, V11 looked around the nursing station desk, stood up, and separated R6 from R5. On 9/25/19 at 10:45 AM, R5 stated, in regards to the 9/23/19 incident, (R6) touched me all over. R5 said, It felt terrible. I'm scared of him he touched me at the nurses station. On 9/25/19 at 11:10 AM, V14 Certified Nursing Assistant stated R6 likes to grab females in the chest and bottom. V14 stated, He does it as often as he wants when he thinks no one is watching .He's had those behaviors as long as I've worked here. V14 stated, she has worked at the facility for approximately one year. On 9/26/19 at 1:45 PM, V17 stated during his interview of R5 he had no reason to believe R5 was fabricating her recollection of the incident on 9/23/19; I had no reason to not believe her. She answered matter of factly and did not pause during her statement like she was formulating a plan. The facility's Preliminary 24-Hour Incident Investigation Report showed R^ was involved in previous resident to resident incident. The report dated (MONTH) 7, 2019 showed staff has witnessed resident (R6) allegedly touched (R10) inappropriately on the top of her clothing . The facility's investigation showed a statement taken on 4/7/19 by V1 from a facility staff member as follows, .(R6) approached (R10) in the hallway and touched her inappropriately on top of her clothes in her private areas . R6's Care Plan created on 12/18/17 and revised on 9/24/19 showed, (R6) exhibits sexually inappropriate behavioral symptoms as manifested by making crude, sexually-oriented and/or suggestive remarks towards females .these symptoms may be related to dx of mild cognitive impairment and poor impulse control . The care plan showed an intervention initiated on 9/24/19, Resident will be admitted to a (local area hospital) for evaluation of sexually inappropriate behavior towards a female resident . R6's 8/23/19 Psychiatry/Mental Health note showed, Patient was seen this morning due to behavioral disinhibition. Per medical staff, patient continues to make derogatory statements towards staff and other residents. Difficult to redirect. Verbally inappropriate . The facility's Abuse Prevention and Reporting police revised on 1-22-19 showed, The resident has the right to be free from sexual abuse . The policy continues, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Sexual abuse is non-consensual sexual contact of any type with a resident. 2. The facility assessment dated [DATE] shows R2 is alert and oriented. On 9/24/19 at 12:43 PM, R2 said that on 9/20/19 around lunch time while waiting to ride in the elevator, a male resident (R3) threatened to hit her. R2 said R3 also called her a name fuxx-ing fat. R2 said she reported the incident to V9 (Social Worker) and V1 (Administrator) when the incident happened. R2 said nothing has been done to R3 going around verbally abusing residents. R2 said R3 was also verbally abusive to R4. On 9/25/19 at 10:15 AM, R3 (alert and oriented per facility assessment dated [DATE]) when asked about R2, R3 stated, That fat lady tried to ride with me in the elevator? Yes I called her fat! Why? On 9/25/19 at 12:11 PM, V9 said R2 reported to her that last Friday (9/20/19) R2 was down by the elevator and R3 made inappropriate comments to R2. V9 said it was concerning enough that V9 reported the incident to V1. V9 said V1 is the abuse coordinator of the facility. On 9/25/19 at 2:15 PM, V1 (Administrator) said there was no investigation done regarding R2's allegation of R3 being verbally abusive. The facility's Abuse Prevention and Reporting policy revised on 1/22/19 showed, Abuse is the willful infliction of injury, inreasonable confinement, intimidation .It includes verbal abuse . 3. The facility assessment dated [DATE] shows R4 is alert and oriented. R4 has [MEDICAL CONDITION] and is legally blind. On 9/24/19 at 12:40 PM, R4 said he was blind and would at times bump into R3. R4 said R3 punched him in his upper arm a couple of months ago. R4 said he reported the incident to V9 (Social Worker). R4 also stated {R3} call me names, threatens me, I can't help it. At times I do bump into him but that does not give him the right to hit me or call me names. On 9/24/19 at 2:10 PM by the 2nd floor nurses station, R8 and R9, both said R3 is really mean to R4. R3 calls R4 the N word and nothing is being done about it. Both R8 and R9 said they feel sorry for R4. On 9/25/19 at 10:15 AM, R3 stated I threatened him (R4) He kept bumping into me, he better stay away from me. On 9/25/19 at 12:11 PM, V9 (Social Worker) said she cannot recall anything specific relating to R3 and R4. On 9/25/19 at 2:15 PM, V1 said R3 acts like that due to his cognition. (Facility assessment shows R3 is alert and oriented)

Based on observation, interview and record review the facility failed to ensure a mechanical lift sling was the correct size to accommodate a resident's weight and in good repair before transferring a resident. These failures resulted in two of the sling attachment straps to rip apart, resulting in R1 falling to the floor on (MONTH) 27, (YEAR). R1 sustained a fractured right leg requiring surgical repair. These failures contribute to R1's fear and anxiety about using the mechanical lift device again. This applies to 1 of 4 residents (R1) reviewed for transfers in the sample of 6. The findings include: R1's Minimum Data Set assessment dated (MONTH) 8, (YEAR) shows that her cognition is intact and she is totally dependent on two persons for transfer. R1's undated Face Sheet shows a [DIAGNOSES REDACTED]. R1's Final Incident Report dated (MONTH) 7, (YEAR) shows that on (MONTH) 27, (YEAR), staff were transferring R1 from her bed to her chair when two of the mechanical lift slings (attachment loops) snapped during the transfer process. On (MONTH) 7, (YEAR) at 12:50 PM, R1 said that she was being transferred with a mechanical lift and the top right loop and bottom right loop of the sling broke during her transfer. R1 said that she fell to the floor and broke her right leg and had to have surgery. R1 said that she got back from the hospital 2 days ago (March 5) and has not gotten up out of bed yet because she is too nervous and scared that it will happen again. R1 said that the pain in her leg is sometimes a 10 on a pain scale of 0-10. R1' s hospital records dated (MONTH) 27, (YEAR) show, Fracture of right tibia and fibula with right tibia intramedullary nailing .Patient complains of pain after surgery . On (MONTH) 7, (YEAR) at 12:00 PM, V9, Certified Nursing Assistant (CNA) said that she went into R1's room and put a mechanical lift sling under her. V9 said that the slings do not have sizes on them, they just know what sizes need to be used for what resident. V9 said that slings come in two sizes, R1 requires the bigger size (extra large) due to her weight. V9 said that the sling was hooked to the mechanical lift and when (V9) moved R1 off of the bed, R1 just fell to the floor. V9 said that the right purple and right green loop split in half. On (MONTH) 7, (YEAR) at 10:30 AM, V1 (Administrator) said that they no longer have the sling that broke during the transfer of R1. On (MONTH) 7, (YEAR) at 2:00 PM, V9 brought the surveyor a sling that was a blue cloth material and said this sling is the exact fabric and size of sling that she used to transfer R1. At 2:15 PM, V1 (Administrator) brought in a sling that was a blue cloth material and said that it was the cloth type of sling that was used to transfer R1 but it was a size large and not extra large. V1 said that she could not find any extra large slings. The two slings were compared and they were the same in size. Both slings had a tag on the fabric. One tag was unreadable due to fading and the other tag was ripped and missing pieces. A sling tag on another sling was then observed and the size and washing instructions could be read. On (MONTH) 7, (YEAR) at 2:58 PM, V2 (Director of Nursing) said that if a resident is above 300 pounds, an extra large sling should be used. V2 said that the tag on R1's sling was faded and unable to be read. V2 said that sometimes the tags get faded with washing. V2 said that they did a mass order of slings one year ago. On (MONTH) 7, (YEAR) at 2:10 PM, V3 (Restorative Nurse) said that the size of sling that is used is according to the residents size and weight. They have size large and extra large slings and the size is indicated on the slings. V3 said that R1 would require an extra large sling. V3 said that there is not a list of what size sling each resident needs, the CNAs just decide which size to use. R1's Care Plan dated (MONTH) 12, 2108 shows, R1 requires use of full body lift for transfer. [DIAGNOSES REDACTED]. The facility undated Patient Sling Reference Guide shows that a resident would need a size extra large sling if they are 360 pounds. The facility undated Mechanical Lift Transfer Policy shows, Follow manufactures recommendations. The policy does not show how to select a sling for the size and weight of a resident. The policy does not include inspecting the sling for wear prior to use. On (MONTH) 7, (YEAR) at 12:00 PM, V9 said that slings are used once by each resident and when it is taken off, it is put in the laundry and a new one is found the next time that the resident needs to get up. On (MONTH) 7, (YEAR) at 1:08 PM, V1 said that they purchased a bunch of new extra large slings about 1 year ago. The slings were not numbered or logged when they came in. V1 said that the facility does random audits for wear and tear but does not have any documentation of these inspections. A packing list dated (MONTH) 21, (YEAR) shows that 7 extra large slings were ordered. On (MONTH) 7, (YEAR) at 11:15 AM, V11 (housekeeping manager) said that slings are supposed to be washed using chemical number 8. At 2:00 PM, V11 said that slings should be washed using chemical formula number 1. At 1:50 PM, V13 (laundry) said that she does not know how to wash slings or what number to put the machine on. At 2:15 PM, V14 (laundry) said that she would put slings on formula number 7. There was a sign on the wash machine that had a list that showed different linen types and what formula should be used. Slings were not listed on this list. V11 said that slings are inspected after each wash but they are currently not logged. An email from the wash formula vendor dated (MONTH) 7, (YEAR) shows that five of the eight wash formulas dispense bleach. The email also shows, All formulas are washed at 150 degree temperature. The facility provided manufacturer information states, Useful life of this product is six months from date of purchase under normal use, however, heavy use or excessive washing may reduce the useful life of the product .This warranty does not cover device failure due to owner misuse or negligence .excessive washing or incorrect washing and drying hand wash only in water temperature of not more than 120 degrees. Do not use bleach; bleach will damage the integrity of the sling and strap materials which may result in failure causing injury or death to the patient .

Based on interview and record review, the facility failed to continue basic life support measures for a resident after R1 choked on food. The facility discontinued the cardiac compressions prior to emergency rescue team arriving. This failure contributed to R1 going for a period of 6 minutes without cardiac compression until initiated immediately by the paramedics. R1 later expired at the hospital. The immediate jeopardy began on (MONTH) 19, (YEAR) when R1 became unresponsive and not breathing at 7:10 PM. CPR was initiated but was stopped by the facility at 7:18 PM. Emergency Medical Services (EMS) arrived to R1 at 7:24 PM; (6 minutes later) on arrival of the paramedics; R1 was unresponsive, without a pulse and not breathing. EMS initiated CPR 6 minutes after the facility had stopped. On (MONTH) 28, (YEAR) at 10:00 AM, E1 (Administrator) was informed of the immediate jeopardy related to the facility discontinuing life saving efforts for R1 while waiting for emergency rescue to arrive. While the immediacy was removed on (MONTH) 29, (YEAR), the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 18 residents (R1) reviewed for necessary care and services related to basic life support in the sample of 18. The findings include: R1's physician order [REDACTED]. The same POS shows R1 is on a mechanical soft diet and thin liquids. The same POS shows R1 is a full code. R1's Minimum Data Set Assessment (MDS) dated (MONTH) 12, (YEAR) shows R1 has severe cognitive impairment. The same MDS shows R1 needs extensive physical assist of 1 staff for eating. R1's careplan dated (MONTH) 6, (YEAR) shows R1 was on aspiration precautions but it does not include specific interventions if R1 should aspirate. R1's careplan did not include R1 needed supervision/assist at mealtimes. R1's careplan did not include R1 had no teeth and did not include R1 was on mechanical soft (diet). Daily nursing assignment sheet dated (MONTH) 19, (YEAR) shows R1 requires supervision/assistance at mealtimes. E13 was assigned to assist R1 with meals. On (MONTH) 20, (YEAR) at 1:36 PM, E13 (CNA) said he served R1's evening tray on (MONTH) 19, (YEAR). R1 was served mechanical soft diet. E13 said he did not stay with R1 continuously during meals. E13 stated sometimes I would get up and leave R1 alone. On (MONTH) 16, (YEAR), Z5 (family member) said she would visit during meals. R1 would be feeding herself without staff assistance. On (MONTH) 16, (YEAR) at 3:41 PM, E24 (3rd floor nurse supervisor) said that on (MONTH) 19, (YEAR), E24 saw R1 feeding herself the evening meal in the hallway by the nurse's station. E24 said there was no staff assisting R1. E24 said I went to R1 and asked her if she was doing ok. On (MONTH) 13, (YEAR) at 3:11 PM, E15 (Certified Nursing Assistant- CNA) said on (MONTH) 19, (YEAR), she was walking in the hallway on 3rd floor right across from where R1 was sitting. R1 waved at her and then pointed to her throat. E15 said she asked R1 if she was choking, R1 nodded (unable to speak) and then R1 turned gray. E15 alerted E14 (Registered Nurse) then E15 went to R1 to perform the [MEDICATION NAME] maneuver. R1 was trying to cough but nothing was coming out. She had R1 in her arms when R1 became unresponsive. E15 lowered R1 to the floor and E14 (Nurse Supervisor- trainee) started CPR. 911 was called. On (MONTH) 13, (YEAR) at 11:16 AM, E14 said on (MONTH) 19, (YEAR) she was alerted by E15 (CNA) that R1, was choking, I ran over to (R1), and asked her if she was choking? She shook her head no, R1 was unable to speak. E14 said she visually checked R1's mouth and said she did not see any food particles. E14 said that E15 (CNA) proceeded to perform the [MEDICATION NAME] maneuver to be sure but nothing came out of R1's mouth. A few seconds later, R1 slumped over, became unresponsive, had no pulse and a code blue was initiated. The paramedics arrived and R1 was transported to the hospital where R1 expired. On (MONTH) 13, (YEAR) at 10:48 AM, E16 (CNA) said that on (MONTH) 19, (YEAR) at about 6:30 PM, she was coming from another hall when she heard E15 say R1 was choking. E14 (RN) then called code blue. A facility incident report dated (MONTH) 20, (YEAR) (written a day after the incident happened) shows that on (MONTH) 19, (YEAR) at approximately 7:08 PM, R1 was sitting in her wheelchair in front of the nurses' station. R1 was pale but able to respond and nod head. At 7:10 PM, R1 became unresponsive and code blue initiated. R1 was stabilized on the floor. Checked for airway, breathing and circulation, reflexes and pupil response. Vital signs taken, 911 called. Noted no pulse, ambubagging initiated. Pulse noted. (No pulse rate was documented) EMS arrived, treated resident and stabilized. Resident was transferred to the hospital. R1's progress notes dated (MONTH) 19, (YEAR) written by E18 (Registered Nurse) shows a timeline: 7:10 PM-R1 non responsive code blue initiated. 7:11 PM-CPR started 7:15 PM-Ambubagging initiated 7:18 Pulse noted (no pulse rate, no description of pulse) 7:40 PM-BP- ,[DATE] Pulse-74 (E18 did not verify the accuracy of these readings) The EMS report dated (MONTH) 19, (YEAR) documents R1 was pulseless from the time of arrival to the facility to ER transport-7:24 PM to 7:58PM) On (MONTH) 20, (YEAR) at 9:45 AM, E18 (RN) said she was R1's nurse. She said on (MONTH) 19, (YEAR) she was assigned to observe and document while CPR was ongoing. CPR was performed on R1; CPR was stopped when one of the staff said R1 had a pulse (7:18 PM). E18 said she did not confirm whether there was a pulse. E18 said R1's pulse was not rechecked after 7:18 PM. E18 also said she documented the blood pressure and pulse recordings (7:40 PM) that she copied from the electronic blood pressure equipment but did not verify the accuracy of the recording or the time the readings were made by the machine. The local Fire Department Patient Care Report dated (MONTH) 19, (YEAR) signed by Z3 (paramedic) shows that paramedics arrived to the patient at 7:24 PM. (6 minutes after facility stopped CPR) Upon arrival (R1) on floor unresponsive and not breathing. CPR was initiated immediately by EMS. (R1) appeared to have choked on food. Food was removed with forceps and suction. Pt was asystole (no heart beat) upon arrival and then (PEA) pulseless electrical activity. Pulse -0, Respirations-0, T-0, BP-,[DATE] SP,[DATE]% at 19:31 Pulse-0 Resp-0 Temp-,[DATE] SP,[DATE]%. Cap refill-0%. R1 was transported to the local hospital. The Emergency Department Triage note dated (MONTH) 19, (YEAR) showed (R1) was witnessed to choke on food. (R1) has been in asystole or PEA since the medics responded (At 7:24 PM-7:58 PM= 34 minutes with no pulse). Z4's Emergency Physician Documentation dated (MONTH) 19, (YEAR) shows: R1 witnessed choke on food, witnessed arrested. (R1) had been asystole (no cardiac activity) or PEA (pulseless, unresponsiveness and lack of palpable pulse) since the medic responded in the facility at (at 7:24 PM.) EMS reports pulling out of food out of R1's trachea. On (MONTH) 15, (YEAR) at 8:05AM, Z3 (paramedic) said when EMS arrived on the floor where R1 was, R1 was lying on the floor by the elevator. R1 was pulseless and not breathing. There was no staff providing CPR. EMS initiated CPR immediately. We removed chunks of food from R1 using forceps and suction. The facility said that R1 was in her wheelchair eating and became unresponsive and stopped breathing. Z3 said food from trachea can indicate R1 had choked and can cause respiratory arrest. Z3 said if R1 had a weak pulse (per facility) the facility should have continued CPR until EMS arrived. Z3 said R1 had been asystole and EPA since they arrived in the facility to transport to ER. Z3 said if patient had a pulse after doing CPR, they should have more constant monitoring like oxygen saturations or continue CPR until EMS/paramedics arrives. On (MONTH) 16, (YEAR) at 3:20PM, E25 (Registered Nurse) said she felt a pulse on R1 and also used stethoscope to check apical pulse (but can't remember pulse rate and characteristics of pulse) I stopped the compression but not sure if ambu bagging was still ongoing. On (MONTH) 20, (YEAR) at 10:15 PM, E26 (respiratory therapist) said he was doing the compression when a staff said there was a pulse but it was weak/faint. CPR was stopped by one of the nurses. On (MONTH) 16, (YEAR) at 3:41 PM, E24 (3rd floor supervisor) said she also felt a pulse in R1's arm and neck (carotid) but could not remember the pulse rate. On (MONTH) 20, (YEAR) at 11:25 AM, E2 (Director of Nursing-DON) said if R1 had a weak pulse, they should have continued CPR until paramedics arrived to the patient. An undated facility document entitled code blue showed 3. (In bold letters) continues CPR if still absence of pulse or still thready/weak . (In bold print) DO NOT STOP UNLESS PULSE IS STRONG AND BOUNDING . On (MONTH) 16, (YEAR) at 7:14 PM, Z4 (emergency room Physician) said R1 was dead when she arrived in the ER. R1 was pronounced dead on 7:58PM. Z4 said it was reported by the paramedics that R1 had a choking episode in the facility; EMS removed a lot of food from her trachea. R1 was already intubated by paramedics when R1 arrived in the ER. Z4 said food in the trachea may cause choking and respiratory arrest. On (MONTH) 20, (YEAR) at 11:30 AM, E1 (Administrator) said R1 should have been supervised and a staff should have been with her during meals to keep an eye on R1. On (MONTH) 13, (YEAR) at 8:51 AM, Z6 (Coroner's office) said an autopsy was performed on R1's death due to witnessed choking and EMS reports removing lots of food in her trachea. The National Institutes of Health Medline plus shows CPR is an emergency life-saving procedure that is done when someone breathing and heartbeat has stopped. CPR combines rescue breathing and chest compression. Chest compression keeps oxygen heart-rich blood flowing until the heartbeat and breathing can be restored. Permanent brain damage begins after only 4 minutes or death can occur ,[DATE] minutes if blood flow stops. Therefore it is important that blood flow continues until trained medical help arrives. Through observation, interview and record review, the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. 1. The facility ensured that Physician order [REDACTED]. 2. All direct care staff received inservice on Code Blue/CPR, aspiration policy completed on (MONTH) 29, (YEAR). 3. The director of nursing and designee will review discharges/transfers to ensure CPR was initiated as ordered by (MONTH) 29, (YEAR). 4. The facility updated the Code Blue policy that included continuing CPR until EMS arrives. This was completed by (MONTH) 29, (YEAR). 5. The Director of Nursing or designee shall be responsible for ensuring continued compliance of this abatement plan by (MONTH) 29, (YEAR).

Based on interview and record review the facility failed to supervise and assist a resident who required assistance to eat, and was at risk for choking. This failure contributed to R1 choking and experiencing respiratory arrest on (MONTH) 19, (YEAR). This applies to 1 of 18 residents (R1) reviewed for safety and supervision during meals in the sample of 18. The findings include: 1. R1's physician's orders [REDACTED]. The same POS shows R1 receives a mechanical soft diet and thin liquids. R1's Minimum Data Set Assessment (MDS) dated (MONTH) 12, (YEAR) shows R1 has severe cognitive impairment and requires extensive physical assistance of one staff for eating. R1's Occupational Therapy note dated (MONTH) 6, (YEAR) shows R1 requires contact guard assist during meals (staff providing hands on assist at mealtimes.) R1's care plan dated (MONTH) 6, (YEAR) shows R1 is at risk for aspiration. R1's care plan did not include specific interventions that should be done in the event of R1 choking. R1's care plan did not include the need for assistance and supervision at mealtimes. R1's care plan did not include that R1 does not have teeth and is on a mechanical soft diet. The facility's daily nursing assignment sheet dated (MONTH) 19, (YEAR) shows R1 requires supervision/assistance at mealtimes. On (MONTH) 20, (YEAR) at 1:36 PM, E13 (Certified Nursing Assistant-CNA) said he served R1's evening tray on (MONTH) 19, (YEAR). E13 said he did not stay with R1 continuously during the meal. E13 stated sometimes I would get up and leave R1 alone. On (MONTH) 16, (YEAR), Z5 (family member) said she would often visit during mealtimes and R1 would be feeding herself. Staff were not paying attention to R1. On (MONTH) 16, (YEAR) at 3:41 PM, E24 (3rd floor nurse supervisor) said that on (MONTH) 19, (YEAR), E24 saw R1 feeding herself the evening meal in the hallway by the nurse's station. E24 said there was no staff assisting R1. E24 said I went to R1 and asked her if she was doing ok. On (MONTH) 13, (YEAR) at 11:16 AM, E14 (Nurse supervisor-trainee) said she was alerted by E15 (CNA) that R1, was choking. E14 said, she ran over to (R1), and asked her if she was choking. She (R1) shook her head no. R1 was unable to speak. E14 said she checked R1's mouth and did not see any food particles. E15 (CNA) proceeded to perform the [MEDICATION NAME] maneuver to be sure but nothing came out of R1's mouth. A few seconds later, R1 slumped over, became unresponsive, had no pulse and a code blue was initiated. The paramedics arrived and R1 was transported to the hospital where she expired. A facility incident report dated (MONTH) 20, (YEAR) (written a day after the incident happened) shows that on (MONTH) 19, (YEAR) at approximately 7:08 PM, R1 was sitting in her wheelchair in front of the nurses' station. R1 was pale but able to respond and nod head. At 7:10 PM, R1 became unresponsive and code blue initiated. R1 was stabilized on the floor. Checked for airway, breathing and circulation, reflexes and pupil response. Vital signs taken, 911 called. Noted no pulse, ambu bagging initiated. Pulse noted. (No pulse rate was documented) EMS arrived, treated resident and stabilized. Resident was transferred to the hospital. Z4's Emergency Physician Documentation dated (MONTH) 19, (YEAR) shows: R1 witnessed choking on food, witnessed arrested. (R1) had been asystole (no cardiac activity) or PEA (pulseless, unresponsiveness and lack of palpable pulse) since the medic responded in the facility at (at 7:24 PM.) EMS reports pulling out of food out of her trachea. On (MONTH) 15, (YEAR) at 8:05AM, Z3 (paramedic) said when EMS arrived , R1 was lying on the floor by the elevator. R1 was pulseless and not breathing. We removed chunks of food from ( R1) using forceps and suction. The facility said that ( R1) was in her wheelchair eating and became unresponsive and stopped breathing. Z3 said food from the trachea can indicate R1 had choked and can cause respiratory arrest. On (MONTH) 16, (YEAR) at 7:14 PM. Z4 (emergency room Physician) said R1 was dead when she arrived in the ER. R1 was pronounced dead at 7:58PM. Z4 said it was reported by the paramedics that R1 had a choking episode in the facility; EMS removed a lot of food from her trachea. Z4 said food in the trachea may cause choking and respiratory arrest. On (MONTH) 20, (YEAR) at 11:30 AM, E1 (Administrator) said R1 should have been supervised, a staff should have been with her during meals to keep an eye on her. The facility policy on resident care dated (MONTH) 2006 shows 3. During mealtimes, staff should observe for difficulty swallowing, chewing, coughing, choking, and changes in intake.

Based on observation, interview and record review the facility failed to identify that a resident was at high risk for developing pressure ulcers, failed to document the location of reddened and open areas, failed to follow-up on identified skin concerns, and failed to identify pressure ulcers upon readmission to the facility. This applies to 1 of 6 residents (R27) reviewed for pressure ulcers in the sample of 30. These failures resulted in a delay in treatment to R27's unstageable pressure ulcer on her right heel and stage II pressure ulcer on her sacral. The findings include: R27 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Section M0150 of the 8/7/12 MDS shows that R27 was admitted to the facility with zero pressure ulcers. R27 is assessed at low risk for pressure ulcer development according to the facility's pressure ulcer assessments dated 11/8/12 and 12/12/12. R27 has a [DIAGNOSES REDACTED]. On 12/20/12 at 11:15 AM, E8 (Treatment Nurse) stated that R27 was at high risk for pressure ulcer development because she is highly compromised due to R27's [MEDICAL CONDITION] and [MEDICAL CONDITION]. E8 said that the pressure ulcer assessments dated 11/8/12 and 12/12/12 were not accurate. E8 stated "high risk residents should have a skin assessment done everyday." R27's Restraint Care Plan dated 10/29/12 states an intervention to "Provide skin checks daily." The Diabetes Care Plan dated 10/31/12 documents to "Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness. Notify nurse and physician as needed." There is no documentation that daily skin checks or daily foot inspections were done on R27, per review of the clinical record and electronic medical record. R27 had a "Red Area" (location not documented) on 12/6/12 and an "Open Area" (location not documented) on 12/8/12 according to CNA (Certified Nursing Aide) charting in the electronic medical record. No other documentation regarding these skin concerns could be found in the clinical or electronic record. On 12/19/12 at 3:20 PM, E2 (Director of Nursing) stated that there was no other documentation regarding these skin concerns and no documentation of daily skin checks. E2 said "we chart by exception." E2 said that the CNA's should have documented the location of the red and open skin areas and should have told the nurse about them. On 12/19/12 at 4:10 PM, E8 and E10 (Treatment Nurses) stated that they were not informed about R27's red and open areas identified by the CNA 12/6/12 and 12/8/12. E8 and E10 stated that any open areas should be reported to the treatment nurse. E8 and E10 stated that they were not aware of any skin concerns identified for R27 prior to her going out of the facility on 12/11/12. On 12/11/12 R27 went out of the facility to have a port-a-cath placed, according to Daily Nursing Progress Note documentation dated 12/11/12 5:30 AM. On 12/11/12 R27 was admitted to the hospital for observation status [REDACTED]. R27 had a stage II pressure ulcer on her sacral measuring 3 X 2 centimeters (cm) according to the hospital Present on Admission physician progress notes [REDACTED]. The Present on Admission physician progress notes [REDACTED]. However, according to interview with Z1 (R27's physician) an unstageable pressure ulcer was present on R27's right heel on 12/11/12 at the hospital, (interviewed 12/19/12). (This is also documented by Z1 in the facility's Progress Note dated 12/19/12). There is no documentation that R27's skin was checked prior to going out on 12/11/12, according to review of the clinical record. On 12/19/12 at 2:30 PM, E9 (Nurse) stated that R27's skin was not checked prior to R27 being sent out for the port-a-cath placement on 12/11/12. On 12/20/12, E2 (Director of Nursing) stated that R27 developed the stage II sacral wound and the unstageable heel wound on 12/11/12 while at the surgical center having the port-a-cath placed and due to complication of pneumothorax. E2 surmises that R27 was on a cart/gurney for 11 hours while at the surgical center and hospital. R27 had a stage II pressure ulcer upon discharge from the hospital on [DATE] at 4:15 PM, according to the hospital Discharge/Patient Transfer Referral Form. The Discharge form does not document the presence of a left heel unstageable wound. Readmission Daily Nursing Progress Note dated 12/12/12 and signed by E7 (Nurse) states "skin is intact." Additionally, "Intact" is check-marked under the section labeled Skin on the Daily Nursing Progress Note dated 12/12/12 (the alternative word "Wounds" was not check-marked). The facility's electronic admission nursing assessment dated [DATE] also documents "skin is intact" under section M.1. on page 10. The hard copy of the electronic admission nursing assessment dated [DATE] has hand written documentation of a stage II pressure ulcer to the sacral and a right heel "NUC." These entries are not dated or initialed. E2 (Director of Nursing) stated that she does not know who hand wrote this information on the electronic copy or when it was written. E6's (Nurse) electronic signature appears on the form. On 12/19/12 at 4:45 PM, E6 (Nurse) stated that he was not the nurse for R27 upon her readmission on 12/12/12 but he entered the information into the computer for R27's nurse (E7) because E7 did not have a password. E6 stated that E7 did not report any skin issues other than a chest porta cath, which is what he typed into the computer. E6 said he did not hand write anything on the hard copy of the electronic nursing admission form dated 12/12/12. On 12/19/12 at 4:40 PM E7 (Nurse) stated that she was the nurse for R27 when R27 was re-admitted on [DATE]. E7 said that she assessed R27's skin upon re-admission and that R27 did not have any skin concerns. E7 stated "her skin was intact." E7 said that she did not hand write "sacral stage II" or "Rt heel" on the hard copy electronic nursing assessment. E7 confirmed that E6 had typed the information into the system for her because she did not have a password. The facility's Wound Documentation form dated 12/13/12 shows that R27 had a stage II pressure ulcer measuring 2.0 X 1.5 X 0.1 on the sacral, and an unstageable pressure ulcer measuring 4.0 X 4.0 (100% necrotic) on the right heel. Physician orders [REDACTED]. There is no identification of these pressure ulcers and no measurements, treatments or physician's orders [REDACTED]. On 12/19/12 at approximately 2:00 PM, R27's skin was assessed with [REDACTED]. R27 was noted to have a stage II pressure ulcer measuring 2.0 X 2.0 X 0.1 cm on her sacral, left of crease. R27 was observed to have an unstageable right heel wound measuring 5.2 X 5.5 cm, black in color. On 12/20/12, R27 was assessed by the Wound Care doctor (Z6). Z6 stated that R27 had strong anterior pulse in the right foot and a weaker posterior pulse. Z6 said that the strong pulse will compensate for the weaker pulse. Z6 stated that R27 had a Deep Tissue Injury in her right heel.